hospital_name,last_updated_on,version,location_name,hospital_address,license_number|MA,type_2_npi,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name
Brigham and Women's Faulkner Hospital,2026-03-27,3.0.0,Brigham and Women's Faulkner Hospital,1153 Centre St Boston MA 02130-3446,2048,1578677811,true,Daniel Morash
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","modifiers","setting","drug_unit_of_measurement","drug_type_of_measurement","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|min","standard_charge|max","standard_charge|methodology","additional_generic_notes"
"1 25 Dihydroxy Inc Fraction","PX-30000412","CDM","82652","CPT","0301","RC","","","","both","","","325.00","243.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","237.25","73","","179.17","179.17","179.17","1 through 10","37.73","237.25","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","237.28","58.3","","74.28","74.28","74.28","22","83.7","407","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.11","73","","891.32","891.32","891.32","1 through 10","83.7","407","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","both","","","407.00","305.25","WELLPOINT [1015]","HB CH WELLPOINT","317.09","77.91","","103.18","103.18","103.18","449","83.7","407","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.71","49.07","","294.83","131.00","707.60","714","199.71","5129.31","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","203.91","50.1","","370.90","370.90","370.90","1 through 10","199.71","5129.31","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","203.91","50.1","","412.11","259.50","1211.00","505","199.71","5129.31","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.35","59.3","","1842.36","383.83","7058.19","61","199.71","5129.31","percent of total billed charges",""
"1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes","PX-98300811","CDM","99221","CPT","0983","RC","","","","outpatient","","","407.00","305.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","319.29","78.45","","503.55","503.55","503.55","1 through 10","199.71","5129.31","percent of total billed charges",""
"Abdomen Peritoneum Omentum Unlstd","PX-75000344","CDM","49999","CPT","0361","RC","","","","both","","","6749.00","5061.75","WELLPOINT [1015]","HB CH WELLPOINT","5258.15","77.91","","3449.15","3449.15","3449.15","1 through 10","1057.74","6418.3","percent of total billed charges",""
"Abdominal Pain,MAJOR","251","DRG","","","","","","","","inpatient","","","24665.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19030.99","","Standard inlier is a Case rate ($19,030.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,171, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,701.52) for the length of stay and the standard reimbursement.","18166.19","18166.19","18166.19","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","24050.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11992.50","","Standard inlier is a Case rate ($11,992.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,100, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,702.29) for the length of stay and the standard reimbursement.","11447.67","11447.67","11447.67","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","24050.10","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8074.7544","","Fee schedule rate ($11,226.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8074.7544","10794.28","10794.28","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","24050.10","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5955.87","","Fee schedule rate ($5,955.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5955.87","5955.87","5955.87","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MINOR","251","DRG","","","","","","","","inpatient","","","24050.10","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4618.59","","Case rate ($5,106.64). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,536.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5105.39","5105.39","5105.39","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24416.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14417.27","","Standard inlier is a Case rate ($14,417.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,100, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,046.59) for the length of stay and the standard reimbursement.","14417.27","14417.27","14417.27","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24416.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8074.7544","","Fee schedule rate ($17,443.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8074.7544","11226.88","11226.88","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24416.98","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5450.23","","Case rate ($6,026.16). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,456.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8323.03","8323.03","8323.03","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24416.98","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5450.23","","Case rate ($6,026.16). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,456.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6024.69","6024.69","6024.69","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Pain,MODERATE","251","DRG","","","","","","","","inpatient","","","24416.98","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5450.23","","Case rate ($6,026.16). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,456.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6024.69","6024.69","6024.69","1 through 10","4618.59","28780.99","case rate",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","AETNA [1001]","HB CH AETNA HMO / PPO","1254.62","58.3","","1186.73","1186.73","1186.73","1 through 10","761.55","1676.62","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1972.41","1972.41","1972.41","1 through 10","761.55","1676.62","other","Multiple Surgery"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","MEDICARE [2001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","989.36","1113.41","23","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.54","1098.54","3295.62","1 through 10","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.15","969.58","1098.65","23","761.55","1676.62","other","OPPS APC"
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","both","","","2152.00","1614.00","WELLPOINT [1015]","HB CH WELLPOINT","1676.62","77.91","","1648.45","1648.45","2093.00","1 through 10","761.55","1676.62","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1257.55","1231.42","1257.55","21","761.55","1873.9","other","ASC "
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.29","1233.17","1259.29","14","761.55","1873.9","other","ASC "
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1276.14","59.3","","1226.50","1226.50","1226.50","1 through 10","761.55","1873.9","percent of total billed charges",""
"Abdominal Paracentesis W/ Imaging","PX-75000278","CDM","49083","CPT","0761","RC","","","","outpatient","","","2152.00","1614.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","1789.64","1789.64","1 through 10","761.55","1873.9","other","Multiple Surgery"
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","AETNA [1001]","HB CH AETNA HMO / PPO","1912.97","58.3","","1634.24","1004.95","1718.99","42","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2395.31","73","","2123.89","1900.92","2123.89","1 through 10","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1912.97","58.3","","3729.00","1254.19","3729.00","1 through 10","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1739.06","53","","939.37","939.37","5593.65","1 through 10","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2789.06","85","","2323.25","1864.50","2882.25","16","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3281.25","100","","2909.44","1772.40","10952.08","45","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3281.25","100","","2323.25","2323.25","2323.25","1 through 10","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3281.25","100","","2882.25","1772.40","10169.17","187","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2395.31","73","","1659.41","1659.41","1659.41","1 through 10","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","both","","","3281.25","2460.94","WELLPOINT [1015]","HB CH WELLPOINT","2556.42","77.91","","2050.91","1468.48","2902.83","52","1458.52","3281.25","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3281.25","2460.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","1945.78","59.3","","1548.60","1092.60","3613.79","82","1640.63","2574.14","percent of total billed charges",""
"ACETABULAR AUGMENT 10MM SIZE 50 ZIMMER TRABECULAR METAL 22","SUP-ITM-10019435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3281.25","2460.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2574.14","78.45","","2085.51","998.68","6202.11","56","1640.63","2574.14","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"ACETABULAR AUGMENT 10X50 52MM GRIPTION TF REVISION TI TRUEBOND LOCKING SLOT 21","SUP-ITM-10118696","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1634.24","1004.95","1718.99","42","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2123.89","1900.92","2123.89","1 through 10","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","3729.00","1254.19","3729.00","1 through 10","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","939.37","939.37","5593.65","1 through 10","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","2323.25","1864.50","2882.25","16","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","2909.44","1772.40","10952.08","45","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","2323.25","2323.25","2323.25","1 through 10","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","2882.25","1772.40","10169.17","187","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","1659.41","1659.41","1659.41","1 through 10","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","2050.91","1468.48","2902.83","52","1066.8","2400","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1548.60","1092.60","3613.79","82","1200","1882.8","percent of total billed charges",""
"ACETABULAR CUP 48MM RESTORATION ADM SHELL RT 09","SUP-ITM-10073228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","2085.51","998.68","6202.11","56","1200","1882.8","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","AETNA [1001]","HB CH AETNA HMO / PPO","3191.34","58.3","","1634.24","1004.95","1718.99","42","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3996.02","73","","2123.89","1900.92","2123.89","1 through 10","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3191.34","58.3","","3729.00","1254.19","3729.00","1 through 10","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2901.22","53","","939.37","939.37","5593.65","1 through 10","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4652.90","85","","2323.25","1864.50","2882.25","16","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5474.00","100","","2909.44","1772.40","10952.08","45","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5474.00","100","","2323.25","2323.25","2323.25","1 through 10","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5474.00","100","","2882.25","1772.40","10169.17","187","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3996.02","73","","1659.41","1659.41","1659.41","1 through 10","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","both","","","5474.00","4105.50","WELLPOINT [1015]","HB CH WELLPOINT","4264.79","77.91","","2050.91","1468.48","2902.83","52","2433.19","5474","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5474.00","4105.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3246.08","59.3","","1548.60","1092.60","3613.79","82","2737","4294.35","percent of total billed charges",""
"ACETABULAR CUP 58MM SHELL COBALT HA COATING POROUS IMPACTOR","SUP-ITM-10019768","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5474.00","4105.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4294.35","78.45","","2085.51","998.68","6202.11","56","2737","4294.35","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1634.24","1004.95","1718.99","42","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2123.89","1900.92","2123.89","1 through 10","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","3729.00","1254.19","3729.00","1 through 10","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","939.37","939.37","5593.65","1 through 10","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","2323.25","1864.50","2882.25","16","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","2909.44","1772.40","10952.08","45","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","2323.25","2323.25","2323.25","1 through 10","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","2882.25","1772.40","10169.17","187","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","1659.41","1659.41","1659.41","1 through 10","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","2050.91","1468.48","2902.83","52","400.05","900","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1548.60","1092.60","3613.79","82","450","706.05","percent of total billed charges",""
"ACETABULAR INSERT 22MM 10DEG LINER TRIDENT CROSSFIRE POLYETHYLENE SIZE C","SUP-ITM-10034879","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","2085.51","998.68","6202.11","56","450","706.05","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1634.24","1004.95","1718.99","42","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2123.89","1900.92","2123.89","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","3729.00","1254.19","3729.00","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","939.37","939.37","5593.65","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","2323.25","1864.50","2882.25","16","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","2909.44","1772.40","10952.08","45","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","2323.25","2323.25","2323.25","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","2882.25","1772.40","10169.17","187","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","1659.41","1659.41","1659.41","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","2050.91","1468.48","2902.83","52","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1548.60","1092.60","3613.79","82","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 28MM 0DEG SIZE D TRIDENT POLYETHYLENE","SUP-ITM-10016790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","2085.51","998.68","6202.11","56","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1634.24","1004.95","1718.99","42","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","2123.89","1900.92","2123.89","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","3729.00","1254.19","3729.00","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","939.37","939.37","5593.65","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1785.00","85","","2323.25","1864.50","2882.25","16","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2100.00","100","","2909.44","1772.40","10952.08","45","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2100.00","100","","2323.25","2323.25","2323.25","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2100.00","100","","2882.25","1772.40","10169.17","187","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","1659.41","1659.41","1659.41","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","2050.91","1468.48","2902.83","52","933.45","2100","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1548.60","1092.60","3613.79","82","1050","1647.45","percent of total billed charges",""
"ACETABULAR INSERT 28X60MM RESTORATION CROSSLINKED POLYETHYLENE DUAL MOBILITY","SUP-ITM-10086319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","2085.51","998.68","6202.11","56","1050","1647.45","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR INSERT 28X61MM 0DEG CONSTRAINED PLASTIC","SUP-ITM-10002178","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1634.24","1004.95","1718.99","42","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2123.89","1900.92","2123.89","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","3729.00","1254.19","3729.00","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","939.37","939.37","5593.65","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","2323.25","1864.50","2882.25","16","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","2909.44","1772.40","10952.08","45","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","2323.25","2323.25","2323.25","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","2882.25","1772.40","10169.17","187","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","1659.41","1659.41","1659.41","1 through 10","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","2050.91","1468.48","2902.83","52","733.43","1650","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1548.60","1092.60","3613.79","82","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 32MM 10DEG TRIDENT POLYETHYLENE SIZE D","SUP-ITM-10016632","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","2085.51","998.68","6202.11","56","825","1294.43","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","AETNA [1001]","HB CH AETNA HMO / PPO","1339.73","58.3","","1634.24","1004.95","1718.99","42","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1677.54","73","","2123.89","1900.92","2123.89","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1339.73","58.3","","3729.00","1254.19","3729.00","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1217.94","53","","939.37","939.37","5593.65","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1953.30","85","","2323.25","1864.50","2882.25","16","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2298.00","100","","2909.44","1772.40","10952.08","45","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2298.00","100","","2323.25","2323.25","2323.25","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2298.00","100","","2882.25","1772.40","10169.17","187","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1677.54","73","","1659.41","1659.41","1659.41","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","WELLPOINT [1015]","HB CH WELLPOINT","1790.37","77.91","","2050.91","1468.48","2902.83","52","1021.46","2298","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1362.71","59.3","","1548.60","1092.60","3613.79","82","1149","1802.78","percent of total billed charges",""
"ACETABULAR INSERT 32X46 48MM 10DEG LINER SHELL ECCENTRIC POLYETHYLENE","SUP-ITM-10016847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1802.78","78.45","","2085.51","998.68","6202.11","56","1149","1802.78","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1634.24","1004.95","1718.99","42","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","2123.89","1900.92","2123.89","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","610.40","58.3","","3729.00","1254.19","3729.00","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","939.37","939.37","5593.65","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","889.95","85","","2323.25","1864.50","2882.25","16","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1047.00","100","","2909.44","1772.40","10952.08","45","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1047.00","100","","2323.25","2323.25","2323.25","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1047.00","100","","2882.25","1772.40","10169.17","187","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","1659.41","1659.41","1659.41","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","2050.91","1468.48","2902.83","52","465.39","1047","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1548.60","1092.60","3613.79","82","523.5","821.37","percent of total billed charges",""
"ACETABULAR INSERT 32X54 56MM 10DEG LINER CROSSFIRE SERIES II HIGHLY CROSSLINKED POLYETHYLENE","SUP-ITM-10006911","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","2085.51","998.68","6202.11","56","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","161.55","62.25","161.55","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","52.44","22.90","505.57","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","889.95","85","","68.52","68.52","68.52","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1047.00","100","","62.20","62.19","81.17","14","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1047.00","100","","43.22","31.95","953.91","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","63.92","25.16","245.73","18","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 28X46MM PLUS 4 10DEG PINNACLE ALTRX POLYETHYLENE","SUP-ITM-10042870","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","97.25","24.56","207.80","18","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","AETNA [1001]","HB CH AETNA HMO / PPO","1340.61","58.3","","1634.24","1004.95","1718.99","42","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1678.64","73","","2123.89","1900.92","2123.89","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1340.61","58.3","","3729.00","1254.19","3729.00","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1218.74","53","","939.37","939.37","5593.65","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1954.58","85","","2323.25","1864.50","2882.25","16","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2299.50","100","","2909.44","1772.40","10952.08","45","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2299.50","100","","2323.25","2323.25","2323.25","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2299.50","100","","2882.25","1772.40","10169.17","187","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1678.64","73","","1659.41","1659.41","1659.41","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","WELLPOINT [1015]","HB CH WELLPOINT","1791.54","77.91","","2050.91","1468.48","2902.83","52","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1548.60","1092.60","3613.79","82","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 32MM SIZE E G7 POLYETHYLENE ARCOMXL HIGH WALL","SUP-ITM-10132566","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1803.96","78.45","","2085.51","998.68","6202.11","56","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","AETNA [1001]","HB CH AETNA HMO / PPO","1406.72","58.3","","1634.24","1004.95","1718.99","42","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1761.42","73","","2123.89","1900.92","2123.89","1 through 10","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1406.72","58.3","","3729.00","1254.19","3729.00","1 through 10","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1278.84","53","","939.37","939.37","5593.65","1 through 10","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2050.97","85","","2323.25","1864.50","2882.25","16","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2412.90","100","","2909.44","1772.40","10952.08","45","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2412.90","100","","2323.25","2323.25","2323.25","1 through 10","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2412.90","100","","2882.25","1772.40","10169.17","187","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1761.42","73","","1659.41","1659.41","1659.41","1 through 10","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","both","","","2412.90","1809.67","WELLPOINT [1015]","HB CH WELLPOINT","1879.89","77.91","","2050.91","1468.48","2902.83","52","1072.53","2412.9","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2412.90","1809.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1430.85","59.3","","1548.60","1092.60","3613.79","82","1206.45","1892.92","percent of total billed charges",""
"ACETABULAR LINER 32MM SZ C CONSTRAINED G7 VITAMIN FREEDOM","SUP-ITM-10308050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2412.90","1809.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1892.92","78.45","","2085.51","998.68","6202.11","56","1206.45","1892.92","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1634.24","1004.95","1718.99","42","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","2123.89","1900.92","2123.89","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","610.40","58.3","","3729.00","1254.19","3729.00","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","939.37","939.37","5593.65","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","889.95","85","","2323.25","1864.50","2882.25","16","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1047.00","100","","2909.44","1772.40","10952.08","45","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1047.00","100","","2323.25","2323.25","2323.25","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1047.00","100","","2882.25","1772.40","10169.17","187","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","1659.41","1659.41","1659.41","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","2050.91","1468.48","2902.83","52","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1548.60","1092.60","3613.79","82","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 32X46MM R3 0DEG XLPE","SUP-ITM-10297353","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","2085.51","998.68","6202.11","56","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","AETNA [1001]","HB CH AETNA HMO / PPO","1339.73","58.3","","1634.24","1004.95","1718.99","42","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1677.54","73","","2123.89","1900.92","2123.89","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1339.73","58.3","","3729.00","1254.19","3729.00","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1217.94","53","","939.37","939.37","5593.65","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1953.30","85","","2323.25","1864.50","2882.25","16","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2298.00","100","","2909.44","1772.40","10952.08","45","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2298.00","100","","2323.25","2323.25","2323.25","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2298.00","100","","2882.25","1772.40","10169.17","187","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1677.54","73","","1659.41","1659.41","1659.41","1 through 10","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","both","","","2298.00","1723.50","WELLPOINT [1015]","HB CH WELLPOINT","1790.37","77.91","","2050.91","1468.48","2902.83","52","1021.46","2298","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1362.71","59.3","","1548.60","1092.60","3613.79","82","1149","1802.78","percent of total billed charges",""
"ACETABULAR LINER 32X52MM PLUS 4 10DEG PINNACLE ESC CONSTRAINED","SUP-ITM-10019565","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2298.00","1723.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1802.78","78.45","","2085.51","998.68","6202.11","56","1149","1802.78","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","AETNA [1001]","HB CH AETNA HMO / PPO","1340.61","58.3","","1634.24","1004.95","1718.99","42","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1678.64","73","","2123.89","1900.92","2123.89","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1340.61","58.3","","3729.00","1254.19","3729.00","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1218.74","53","","939.37","939.37","5593.65","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1954.58","85","","2323.25","1864.50","2882.25","16","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2299.50","100","","2909.44","1772.40","10952.08","45","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2299.50","100","","2323.25","2323.25","2323.25","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2299.50","100","","2882.25","1772.40","10169.17","187","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1678.64","73","","1659.41","1659.41","1659.41","1 through 10","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","both","","","2299.50","1724.62","WELLPOINT [1015]","HB CH WELLPOINT","1791.54","77.91","","2050.91","1468.48","2902.83","52","1022.13","2299.5","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1363.60","59.3","","1548.60","1092.60","3613.79","82","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 36 MMF G7 POLYETHYLENE NEUTRAL","SUP-ITM-10132557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2299.50","1724.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1803.96","78.45","","2085.51","998.68","6202.11","56","1149.75","1803.96","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 36/48 OR3O DUAL MOBILITY","SUP-ITM-10280254","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","AETNA [1001]","HB CH AETNA HMO / PPO","640.92","58.3","","1634.24","1004.95","1718.99","42","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","802.53","73","","2123.89","1900.92","2123.89","1 through 10","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","640.92","58.3","","3729.00","1254.19","3729.00","1 through 10","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","582.66","53","","939.37","939.37","5593.65","1 through 10","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","934.45","85","","2323.25","1864.50","2882.25","16","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1099.35","100","","2909.44","1772.40","10952.08","45","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1099.35","100","","2323.25","2323.25","2323.25","1 through 10","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1099.35","100","","2882.25","1772.40","10169.17","187","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","802.53","73","","1659.41","1659.41","1659.41","1 through 10","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","WELLPOINT [1015]","HB CH WELLPOINT","856.50","77.91","","2050.91","1468.48","2902.83","52","488.66","1099.35","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.91","59.3","","1548.60","1092.60","3613.79","82","549.68","862.44","percent of total billed charges",""
"ACETABULAR LINER 36X50 54MM IMPLANT MODULAR CUP NEUTRAL LONGEVITY HIGHLY CROSSLINKED STANDARD POLYETHYLENE 10 BX/1EA","SUP-ITM-10007871","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.44","78.45","","2085.51","998.68","6202.11","56","549.68","862.44","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1634.24","1004.95","1718.99","42","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","2123.89","1900.92","2123.89","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","610.40","58.3","","3729.00","1254.19","3729.00","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","939.37","939.37","5593.65","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","889.95","85","","2323.25","1864.50","2882.25","16","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1047.00","100","","2909.44","1772.40","10952.08","45","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1047.00","100","","2323.25","2323.25","2323.25","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1047.00","100","","2882.25","1772.40","10169.17","187","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","1659.41","1659.41","1659.41","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","2050.91","1468.48","2902.83","52","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1548.60","1092.60","3613.79","82","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 36X50 TO 52MM 20DEG REFLECTION XLPE POLYETHYLENE MICROSTABLE SIZE E","SUP-ITM-10016580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","2085.51","998.68","6202.11","56","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","1634.24","1004.95","1718.99","42","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","2123.89","1900.92","2123.89","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","610.40","58.3","","3729.00","1254.19","3729.00","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","939.37","939.37","5593.65","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","889.95","85","","2323.25","1864.50","2882.25","16","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1047.00","100","","2909.44","1772.40","10952.08","45","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1047.00","100","","2323.25","2323.25","2323.25","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1047.00","100","","2882.25","1772.40","10169.17","187","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","1659.41","1659.41","1659.41","1 through 10","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","2050.91","1468.48","2902.83","52","465.39","1047","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","1548.60","1092.60","3613.79","82","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 36X52MM PLUS 4 NEUTRAL MARATHON CROSS-LINKED POLYETHYLENE","SUP-ITM-10019280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","2085.51","998.68","6202.11","56","523.5","821.37","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 42/54 OR3O DUAL MOBILITY","SUP-ITM-10280251","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","AETNA [1001]","HB CH AETNA HMO / PPO","1775.85","58.3","","1634.24","1004.95","1718.99","42","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2223.62","73","","2123.89","1900.92","2123.89","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1775.85","58.3","","3729.00","1254.19","3729.00","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1614.41","53","","939.37","939.37","5593.65","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2589.14","85","","2323.25","1864.50","2882.25","16","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3046.05","100","","2909.44","1772.40","10952.08","45","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3046.05","100","","2323.25","2323.25","2323.25","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3046.05","100","","2882.25","1772.40","10169.17","187","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2223.62","73","","1659.41","1659.41","1659.41","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","WELLPOINT [1015]","HB CH WELLPOINT","2373.18","77.91","","2050.91","1468.48","2902.83","52","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1548.60","1092.60","3613.79","82","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 42MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10171241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2389.63","78.45","","2085.51","998.68","6202.11","56","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 44/56 OR3O DUAL MOBILITY","SUP-ITM-10280250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","AETNA [1001]","HB CH AETNA HMO / PPO","1775.85","58.3","","1634.24","1004.95","1718.99","42","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2223.62","73","","2123.89","1900.92","2123.89","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1775.85","58.3","","3729.00","1254.19","3729.00","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1614.41","53","","939.37","939.37","5593.65","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2589.14","85","","2323.25","1864.50","2882.25","16","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3046.05","100","","2909.44","1772.40","10952.08","45","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3046.05","100","","2323.25","2323.25","2323.25","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3046.05","100","","2882.25","1772.40","10169.17","187","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2223.62","73","","1659.41","1659.41","1659.41","1 through 10","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","both","","","3046.05","2284.54","WELLPOINT [1015]","HB CH WELLPOINT","2373.18","77.91","","2050.91","1468.48","2902.83","52","1353.97","3046.05","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","1806.31","59.3","","1548.60","1092.60","3613.79","82","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR LINER 46MM COMPONENT DUAL MOBILITY G7","SUP-ITM-10170721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3046.05","2284.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2389.63","78.45","","2085.51","998.68","6202.11","56","1523.03","2389.63","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"ACETABULAR SHELL 28X45MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"ACETABULAR SHELL 28X46MM RINGLOC BIPOLAR COBALT ALLOY ARTICULATING","SUP-ITM-10122823","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","AETNA [1001]","HB CH AETNA HMO / PPO","1138.60","58.3","","1634.24","1004.95","1718.99","42","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1425.69","73","","2123.89","1900.92","2123.89","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1138.60","58.3","","3729.00","1254.19","3729.00","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1035.09","53","","939.37","939.37","5593.65","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1660.05","85","","2323.25","1864.50","2882.25","16","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1953.00","100","","2909.44","1772.40","10952.08","45","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1953.00","100","","2323.25","2323.25","2323.25","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1953.00","100","","2882.25","1772.40","10169.17","187","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1425.69","73","","1659.41","1659.41","1659.41","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","WELLPOINT [1015]","HB CH WELLPOINT","1521.58","77.91","","2050.91","1468.48","2902.83","52","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1158.13","59.3","","1548.60","1092.60","3613.79","82","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 38MM HOLE PINNACLE BANTAM POROUS MULTIPLE HOLE","SUP-ITM-10013114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1532.13","78.45","","2085.51","998.68","6202.11","56","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 40MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10116890","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 44MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10114166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","AETNA [1001]","HB CH AETNA HMO / PPO","2326.17","58.3","","1634.24","1004.95","1718.99","42","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","2123.89","1900.92","2123.89","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2326.17","58.3","","3729.00","1254.19","3729.00","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.70","53","","939.37","939.37","5593.65","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3391.50","85","","2323.25","1864.50","2882.25","16","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3990.00","100","","2909.44","1772.40","10952.08","45","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3990.00","100","","2323.25","2323.25","2323.25","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3990.00","100","","2882.25","1772.40","10169.17","187","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","1659.41","1659.41","1659.41","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB CH WELLPOINT","3108.61","77.91","","2050.91","1468.48","2902.83","52","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.07","59.3","","1548.60","1092.60","3613.79","82","1995","3130.16","percent of total billed charges",""
"ACETABULAR SHELL 48MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10090308","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","2085.51","998.68","6202.11","56","1995","3130.16","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","AETNA [1001]","HB CH AETNA HMO / PPO","1652.81","58.3","","1634.24","1004.95","1718.99","42","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2069.55","73","","2123.89","1900.92","2123.89","1 through 10","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1652.81","58.3","","3729.00","1254.19","3729.00","1 through 10","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1502.55","53","","939.37","939.37","5593.65","1 through 10","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2409.75","85","","2323.25","1864.50","2882.25","16","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2835.00","100","","2909.44","1772.40","10952.08","45","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2835.00","100","","2323.25","2323.25","2323.25","1 through 10","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2835.00","100","","2882.25","1772.40","10169.17","187","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2069.55","73","","1659.41","1659.41","1659.41","1 through 10","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","both","","","2835.00","2126.25","WELLPOINT [1015]","HB CH WELLPOINT","2208.75","77.91","","2050.91","1468.48","2902.83","52","1260.16","2835","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1681.16","59.3","","1548.60","1092.60","3613.79","82","1417.5","2224.06","percent of total billed charges",""
"ACETABULAR SHELL 50MM IMPLANT CUP MODULAR TRABECULAR METAL POROUS CLUSTER HOLED 08 BX/1EA","SUP-ITM-10011570","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2224.06","78.45","","2085.51","998.68","6202.11","56","1417.5","2224.06","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","AETNA [1001]","HB CH AETNA HMO / PPO","2326.17","58.3","","1634.24","1004.95","1718.99","42","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","2123.89","1900.92","2123.89","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2326.17","58.3","","3729.00","1254.19","3729.00","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.70","53","","939.37","939.37","5593.65","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3391.50","85","","2323.25","1864.50","2882.25","16","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3990.00","100","","2909.44","1772.40","10952.08","45","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3990.00","100","","2323.25","2323.25","2323.25","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3990.00","100","","2882.25","1772.40","10169.17","187","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","1659.41","1659.41","1659.41","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB CH WELLPOINT","3108.61","77.91","","2050.91","1468.48","2902.83","52","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.07","59.3","","1548.60","1092.60","3613.79","82","1995","3130.16","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE MULTIHOLE","SUP-ITM-10076215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","2085.51","998.68","6202.11","56","1995","3130.16","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","AETNA [1001]","HB CH AETNA HMO / PPO","1138.60","58.3","","1634.24","1004.95","1718.99","42","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1425.69","73","","2123.89","1900.92","2123.89","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1138.60","58.3","","3729.00","1254.19","3729.00","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1035.09","53","","939.37","939.37","5593.65","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1660.05","85","","2323.25","1864.50","2882.25","16","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1953.00","100","","2909.44","1772.40","10952.08","45","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1953.00","100","","2323.25","2323.25","2323.25","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1953.00","100","","2882.25","1772.40","10169.17","187","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1425.69","73","","1659.41","1659.41","1659.41","1 through 10","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","both","","","1953.00","1464.75","WELLPOINT [1015]","HB CH WELLPOINT","1521.58","77.91","","2050.91","1468.48","2902.83","52","868.11","1953","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1158.13","59.3","","1548.60","1092.60","3613.79","82","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 52MM PINNACLE POROCOAT","SUP-ITM-10006204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1532.13","78.45","","2085.51","998.68","6202.11","56","976.5","1532.13","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1634.24","1004.95","1718.99","42","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2123.89","1900.92","2123.89","1 through 10","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","939.37","939.37","5593.65","1 through 10","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","2323.25","1864.50","2882.25","16","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","2909.44","1772.40","10952.08","45","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","2323.25","2323.25","2323.25","1 through 10","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","2882.25","1772.40","10169.17","187","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","1659.41","1659.41","1659.41","1 through 10","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","2050.91","1468.48","2902.83","52","1466.85","3300","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1548.60","1092.60","3613.79","82","1650","2588.85","percent of total billed charges",""
"ACETABULAR SHELL 52MM REDAPT MODULAR","SUP-ITM-10280269","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","2085.51","998.68","6202.11","56","1650","2588.85","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","AETNA [1001]","HB CH AETNA HMO / PPO","2326.17","58.3","","1634.24","1004.95","1718.99","42","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","2123.89","1900.92","2123.89","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2326.17","58.3","","3729.00","1254.19","3729.00","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.70","53","","939.37","939.37","5593.65","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3391.50","85","","2323.25","1864.50","2882.25","16","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3990.00","100","","2909.44","1772.40","10952.08","45","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3990.00","100","","2323.25","2323.25","2323.25","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3990.00","100","","2882.25","1772.40","10169.17","187","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","1659.41","1659.41","1659.41","1 through 10","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB CH WELLPOINT","3108.61","77.91","","2050.91","1468.48","2902.83","52","1773.56","3990","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.07","59.3","","1548.60","1092.60","3613.79","82","1995","3130.16","percent of total billed charges",""
"ACETABULAR SHELL 54MM PINNACLE GRIPTION MULTIHOLE","SUP-ITM-10025832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","2085.51","998.68","6202.11","56","1995","3130.16","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"ACETABULAR SHELL 56MM SIZE E TRIDENT TRITANIUM PRIMARY HEMISPHERICAL CLUSTER HOLE","SUP-ITM-10042537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","AETNA [1001]","HB CH AETNA HMO / PPO","1195.53","58.3","","1634.24","1004.95","1718.99","42","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1496.97","73","","2123.89","1900.92","2123.89","1 through 10","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1195.53","58.3","","3729.00","1254.19","3729.00","1 through 10","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1086.84","53","","939.37","939.37","5593.65","1 through 10","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1743.05","85","","2323.25","1864.50","2882.25","16","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2050.65","100","","2909.44","1772.40","10952.08","45","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2050.65","100","","2323.25","2323.25","2323.25","1 through 10","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2050.65","100","","2882.25","1772.40","10169.17","187","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1496.97","73","","1659.41","1659.41","1659.41","1 through 10","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","both","","","2050.65","1537.99","WELLPOINT [1015]","HB CH WELLPOINT","1597.66","77.91","","2050.91","1468.48","2902.83","52","911.51","2050.65","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1216.04","59.3","","1548.60","1092.60","3613.79","82","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM HOLE TRILOGY TIVANIUM TITANIUM ALLOY POROUS CLUSTER BX/1EA","SUP-ITM-10001729","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2050.65","1537.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1608.73","78.45","","2085.51","998.68","6202.11","56","1025.33","1608.73","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM PINNACLE SECTOR GRIPTION COATING","SUP-ITM-10077063","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","AETNA [1001]","HB CH AETNA HMO / PPO","2121.10","58.3","","1634.24","1004.95","1718.99","42","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2655.92","73","","2123.89","1900.92","2123.89","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2121.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1928.27","53","","939.37","939.37","5593.65","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3092.51","85","","2323.25","1864.50","2882.25","16","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3638.25","100","","2909.44","1772.40","10952.08","45","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3638.25","100","","2323.25","2323.25","2323.25","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3638.25","100","","2882.25","1772.40","10169.17","187","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2655.92","73","","1659.41","1659.41","1659.41","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","WELLPOINT [1015]","HB CH WELLPOINT","2834.56","77.91","","2050.91","1468.48","2902.83","52","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1548.60","1092.60","3613.79","82","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 58MM SIZE G G7 OSSEOTI MULTI HOLE","SUP-ITM-10170720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2854.21","78.45","","2085.51","998.68","6202.11","56","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL 60MM CUP GAP II RESTORATION RIGHT","SUP-ITM-10007471","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL 62MM IMPLANT HEMISPHERICAL REVISION TRIDENT TITANIUM 08","SUP-ITM-10019574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1634.24","1004.95","1718.99","42","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","2123.89","1900.92","2123.89","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","3729.00","1254.19","3729.00","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","939.37","939.37","5593.65","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1785.00","85","","2323.25","1864.50","2882.25","16","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2100.00","100","","2909.44","1772.40","10952.08","45","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2100.00","100","","2323.25","2323.25","2323.25","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2100.00","100","","2882.25","1772.40","10169.17","187","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","1659.41","1659.41","1659.41","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","2050.91","1468.48","2902.83","52","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1548.60","1092.60","3613.79","82","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT HEMISPHERICAL MULTIHOLE SIZE","SUP-ITM-10030811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","2085.51","998.68","6202.11","56","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1634.24","1004.95","1718.99","42","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","2123.89","1900.92","2123.89","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","3729.00","1254.19","3729.00","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","939.37","939.37","5593.65","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1785.00","85","","2323.25","1864.50","2882.25","16","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2100.00","100","","2909.44","1772.40","10952.08","45","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2100.00","100","","2323.25","2323.25","2323.25","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2100.00","100","","2882.25","1772.40","10169.17","187","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","1659.41","1659.41","1659.41","1 through 10","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","2050.91","1468.48","2902.83","52","933.45","2100","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1548.60","1092.60","3613.79","82","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL F 56MM TRIDENT TITANIUM HYDROXYAPATITE HEMISPHERICAL CLUSTER HOLE SIZE","SUP-ITM-10019379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","2085.51","998.68","6202.11","56","1050","1647.45","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","AETNA [1001]","HB CH AETNA HMO / PPO","2121.10","58.3","","1634.24","1004.95","1718.99","42","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2655.92","73","","2123.89","1900.92","2123.89","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2121.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1928.27","53","","939.37","939.37","5593.65","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3092.51","85","","2323.25","1864.50","2882.25","16","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3638.25","100","","2909.44","1772.40","10952.08","45","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3638.25","100","","2323.25","2323.25","2323.25","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3638.25","100","","2882.25","1772.40","10169.17","187","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2655.92","73","","1659.41","1659.41","1659.41","1 through 10","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","WELLPOINT [1015]","HB CH WELLPOINT","2834.56","77.91","","2050.91","1468.48","2902.83","52","1617.2","3638.25","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1548.60","1092.60","3613.79","82","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SHELL SZ 60 MULTIHOLEMM LINER G 08","SUP-ITM-10192419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2854.21","78.45","","2085.51","998.68","6202.11","56","1819.13","2854.21","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","1634.24","1004.95","1718.99","42","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2123.89","1900.92","2123.89","1 through 10","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","3729.00","1254.19","3729.00","1 through 10","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","939.37","939.37","5593.65","1 through 10","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","2323.25","1864.50","2882.25","16","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","2909.44","1772.40","10952.08","45","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","2323.25","2323.25","2323.25","1 through 10","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","2882.25","1772.40","10169.17","187","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","1659.41","1659.41","1659.41","1 through 10","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","2050.91","1468.48","2902.83","52","133.35","300","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","1548.60","1092.60","3613.79","82","150","235.35","percent of total billed charges",""
"ACETABULAR SPACER 0MM PLUS 12/14 ARTICUL/EZE MODULAR CATHCART UNIPOLAR TAPERED","SUP-ITM-10013166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","2085.51","998.68","6202.11","56","150","235.35","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","both","","","82.00","61.50","AETNA [1001]","HB CH AETNA HMO / PPO","47.81","58.3","","45.36","45.36","45.36","1 through 10","8.01","59.86","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","82.00","61.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.63","59.3","","46.88","46.88","46.88","1 through 10","8.44","64.33","percent of total billed charges",""
"Acetone/Ketones Serum Qn","PX-30000275","CDM","82010","CPT","0301","RC","","","","outpatient","","","82.00","61.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","64.33","78.45","","61.50","61.50","61.50","1 through 10","8.44","64.33","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","157.00","117.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","99.54","63.4","","101.44","101.44","101.44","1 through 10","18.03","149.31","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","both","","","157.00","117.75","WELLPOINT [1015]","HB CH WELLPOINT","122.32","77.91","","273.50","273.50","273.50","1 through 10","18.03","149.31","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","90.59","57.7","","92.26","92.26","92.26","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","94.99","60.5","","96.85","96.85","96.85","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Binding Antibody","PX-30003820","CDM","86041","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","117.63","117.63","117.63","1 through 10","46.11","123.17","percent of total billed charges",""
"Acetylcholine Receptor Modulating Antibody","PX-30003822","CDM","86043","CPT","0302","RC","","","","both","","","104.00","78.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","74.98","72.1","","76.15","76.15","76.15","1 through 10","11.81","98.9","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","AETNA [1001]","HB CH AETNA HMO / PPO","220.37","58.3","","209.79","209.79","209.79","1 through 10","162.16","378","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","321.30","85","","80.38","80.38","80.38","1 through 10","162.16","378","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","378.00","100","","78.03","78.03","78.03","1 through 10","162.16","378","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","378.00","100","","100.27","100.27","100.27","1 through 10","162.16","378","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","both","","","378.00","283.50","WELLPOINT [1015]","HB CH WELLPOINT","294.50","77.91","","134.12","134.12","134.12","1 through 10","162.16","378","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","378.00","283.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","185.48","49.07","","99.45","99.45","99.45","1 through 10","151.2","296.54","percent of total billed charges",""
"Acth Stimulation Panel Adrenal","PX-30000040","CDM","80400","CPT","0300","RC","","","","outpatient","","","378.00","283.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.38","50.1","","99.45","99.45","99.45","1 through 10","151.2","296.54","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","1 through 10","11.81","93.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","both","","","98.00","73.50","WELLPOINT [1015]","HB CH WELLPOINT","76.35","77.91","","74.82","74.82","74.82","1 through 10","11.81","93.2","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","55.67","1 through 10","29.02","76.88","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","56.55","57.7","","57.29","57.29","57.29","1 through 10","29.02","76.88","percent of total billed charges",""
"Actin Smooth Muscle Antibody Each","PX-30003761","CDM","86015","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","59.29","60.5","","62.99","62.99","62.99","1 through 10","29.02","76.88","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","125.00","93.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.13","59.3","","71.49","71.49","71.49","1 through 10","14.72","98.06","percent of total billed charges",""
"Activated Protein C Resistance","PX-30001077","CDM","85307","CPT","0305","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.06","78.45","","93.79","93.79","119.05","1 through 10","14.72","98.06","percent of total billed charges",""
"ACTIVATOR PATIENT REACTIV8","SUP-ITM-10283221","CDM","C1787","HCPCS","0270","RC","","","","both","","","3453.45","2590.09","WELLPOINT [1015]","HB CH WELLPOINT","2690.58","77.91","","2948.77","2948.77","2948.77","1 through 10","1830.33","3453.45","percent of total billed charges",""
"ACTIVATOR PATIENT REACTIV8","SUP-ITM-10283221","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3453.45","2590.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","2047.90","59.3","","4673.98","4673.98","4673.98","1 through 10","1535.06","2709.23","percent of total billed charges",""
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","26918.48","20188.86","MEDICARE [2001]","HB BWF MEDICARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","9718.69","728.09","9782.96","1 through 10","186.24","9479.5954","other","Inpatient Psych"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","26918.48","20188.86","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8794.09","8794.09","8794.09","1 through 10","186.24","9479.5954","other","Inpatient Psych"
"Acute Adjustment Reaction And Psychosocial Dysfunction","880","MS-DRG","","","","","","","","inpatient","","","26918.48","20188.86","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","10381.74","10381.74","10381.74","1 through 10","186.24","9479.5954","other","Inpatient Psych"
"Acute And Subacute Endocarditis,MAJOR","193","DRG","","","","","","","","inpatient","","","36442.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","37918.33","","Standard inlier is a Case rate ($37,918.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $47,859, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,382.35) for the length of stay and the standard reimbursement.","36194.76","36194.76","36194.76","1 through 10","2383","85024.2","case rate",""
"Acute And Subacute Endocarditis,MODERATE","193","DRG","","","","","","","","inpatient","","","47151.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28627.69","","Standard inlier is a Case rate ($28,627.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,987, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,063.58) for the length of stay and the standard reimbursement.","20317.89","20317.89","20317.89","1 through 10","2383","85024.2","case rate",""
"Acute Bronchitis And Related Symptoms,MODERATE","145","DRG","","","","","","","","inpatient","","","22741.59","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4778.52","","Case rate ($5,283.47). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,713.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5282.18","5282.18","5282.18","1 through 10","4778.52","14979.36","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","81482.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","42035.87","","Standard inlier is a Case rate ($42,035.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,771, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,967.16) for the length of stay and the standard reimbursement.","42035.87","42035.87","42035.87","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,EXTREME","469","DRG","","","","","","","","inpatient","","","81482.48","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","21839.75","","Case rate ($24,147.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $66,577.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24141.68","24141.68","24141.68","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","40154.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22468.00","","Standard inlier is a Case rate ($22,468.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,189.42) for the length of stay and the standard reimbursement.","22467.99","22467.99","22467.99","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","40154.88","","MASSHEALTH [3001]","HB BWF MEDICAID","9656.42","","Case rate ($10,676.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,106.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10674.21","10674.21","10674.21","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","40154.88","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10781.78","","Fee schedule rate ($10,781.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10781.78","10781.78","10781.78","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","40154.88","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9656.42","","Case rate ($10,676.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,106.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10674.21","10674.21","10674.21","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MAJOR","469","DRG","","","","","","","","inpatient","","","40154.88","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9656.42","","Case rate ($10,676.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,106.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10674.21","1287.10","24186.11","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MINOR","469","DRG","","","","","","","","inpatient","","","10496.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11100.39","","Standard inlier is a Case rate ($11,100.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,035, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,575.74) for the length of stay and the standard reimbursement.","11100.39","11100.39","11100.39","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MINOR","469","DRG","","","","","","","","inpatient","","","10496.78","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4097.67","","Case rate ($4,530.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,960.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","777.29","777.29","777.29","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21670.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14395.21","","Standard inlier is a Case rate ($14,395.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,035, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,043.46) for the length of stay and the standard reimbursement.","13741.06","13741.06","14395.20","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21670.42","","MASSHEALTH [3001]","HB BWF MEDICAID","5403.39","","Case rate ($5,974.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,404.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5972.91","5972.91","5972.91","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21670.42","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5403.39","","Case rate ($5,974.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,404.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5972.91","5972.91","6087.38","1 through 10","4097.67","48189.51","case rate",""
"Acute Kidney Injury,MODERATE","469","DRG","","","","","","","","inpatient","","","21670.42","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5403.39","","Case rate ($5,974.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,404.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6331.29","6331.29","6331.29","1 through 10","4097.67","48189.51","case rate",""
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","27851.02","20888.26","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","9065.87","","Case rate ($8,801.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,815.62, add-ons for qualifying new technology services are included. If operating cost exceeds $54,339.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,210.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,812.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,476.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.77. The transfer capital threshold is the transfer adjustment factor * $649.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7440.11","7440.11","7440.11","1 through 10","8625.78","9610.92","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","27851.02","20888.26","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8625.78","","Case rate ($8,801.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,815.62, add-ons for qualifying new technology services are included. If operating cost exceeds $54,339.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,210.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,812.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,476.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.77. The transfer capital threshold is the transfer adjustment factor * $649.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18314.34","18314.34","18314.34","1 through 10","8625.78","9610.92","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","27851.02","20888.26","MEDICARE [2001]","HB BWF MEDICARE","9610.92","","Case rate ($9,610.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,815.62, add-ons for qualifying new technology services are included. If operating cost exceeds $54,339.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,210.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,621.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,476.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.77. The transfer capital threshold is the transfer adjustment factor * $649.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9355.26","986.81","9417.07","14","8625.78","9610.92","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With Cc","281","MS-DRG","","","","","","","","inpatient","","","27851.02","20888.26","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8625.78","","Case rate ($8,801.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,815.62, add-ons for qualifying new technology services are included. If operating cost exceeds $54,339.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,210.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,812.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,476.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.77. The transfer capital threshold is the transfer adjustment factor * $649.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8480.27","8480.27","8480.27","1 through 10","8625.78","9610.92","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","15562.22","","Case rate ($15,108.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,635.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","15626.80","15626.80","15626.80","1 through 10","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","16521.06","","Case rate ($16,521.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,047.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14925.08","14925.08","14966.53","1 through 10","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14806.77","","Case rate ($15,108.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,635.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14841.40","14841.40","14841.40","1 through 10","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","MEDICARE [2001]","HB BWF MEDICARE","16521.06","","Case rate ($16,521.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,047.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16462.30","0.03","16572.36","55","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","16521.06","","Case rate ($16,521.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,047.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14917.66","14917.66","14917.66","1 through 10","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14806.77","","Case rate ($15,108.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,635.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10959.70","10959.70","10959.70","1 through 10","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14806.77","","Case rate ($15,108.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,635.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17067.10","17067.10","17067.10","1 through 10","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive With McC","280","MS-DRG","","","","","","","","inpatient","","","46710.68","35033.01","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14806.77","","Case rate ($15,108.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,133.01, add-ons for qualifying new technology services are included. If operating cost exceeds $60,656.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,635.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,793.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.03. The transfer capital threshold is the transfer adjustment factor * $1,134.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14883.18","14841.40","14922.20","11","14806.77","16521.06","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","15588.56","11691.42","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7207.09","","Case rate ($6,997.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,008.01, add-ons for qualifying new technology services are included. If operating cost exceeds $52,531.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,071.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,146.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,668.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $511.20. The transfer capital threshold is the transfer adjustment factor * $511.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7079.12","7079.12","7079.12","1 through 10","6857.23","7207.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","15588.56","11691.42","MEDICARE [2001]","HB BWF MEDICARE","6997.17","","Case rate ($6,997.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,008.01, add-ons for qualifying new technology services are included. If operating cost exceeds $52,531.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,071.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,146.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,668.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $511.20. The transfer capital threshold is the transfer adjustment factor * $511.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","7412.56","1 through 10","6857.23","7207.09","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","15588.56","11691.42","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6857.23","","Case rate ($6,997.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,008.01, add-ons for qualifying new technology services are included. If operating cost exceeds $52,531.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,071.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,146.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,668.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $511.20. The transfer capital threshold is the transfer adjustment factor * $511.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6701.71","6701.71","6701.71","1 through 10","6857.23","7207.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Discharged Alive Without Cc/McC","282","MS-DRG","","","","","","","","inpatient","","","15588.56","11691.42","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6857.23","","Case rate ($6,997.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,008.01, add-ons for qualifying new technology services are included. If operating cost exceeds $52,531.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,071.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,146.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,668.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $511.20. The transfer capital threshold is the transfer adjustment factor * $511.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6719.46","6719.46","6719.46","1 through 10","6857.23","7207.09","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","38411.60","28808.70","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","19134.72","","Case rate ($18,577.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,607.12, add-ons for qualifying new technology services are included. If operating cost exceeds $64,130.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,961.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $16,837.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,267.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.35. The transfer capital threshold is the transfer adjustment factor * $1,400.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","18606.28","18606.28","18606.28","1 through 10","18205.85","19336.9506","other","Inpatient DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","38411.60","28808.70","MEDICARE [2001]","HB BWF MEDICARE","18577.40","","Case rate ($18,577.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,607.12, add-ons for qualifying new technology services are included. If operating cost exceeds $64,130.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,961.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $16,837.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,267.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.35. The transfer capital threshold is the transfer adjustment factor * $1,400.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19563.50","19563.50","19563.50","1 through 10","18205.85","19336.9506","other","Inpatient Replacement Plans DRG"
"Acute Myocardial Infarction, Expired With McC","283","MS-DRG","","","","","","","","inpatient","","","38411.60","28808.70","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","18205.85","","Case rate ($18,577.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,607.12, add-ons for qualifying new technology services are included. If operating cost exceeds $64,130.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,961.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $16,837.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,267.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,400.35. The transfer capital threshold is the transfer adjustment factor * $1,400.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17682.67","17682.67","17682.67","1 through 10","18205.85","19336.9506","other","Inpatient DRG"
"Acute Myocardial Infarction,MAJOR","190","DRG","","","","","","","","inpatient","","","21137.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27916.67","","Fee schedule rate ($27,916.67). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,230.12) multiplied by length of stay and the outlier percent (100%).","3962.65","3962.65","3962.65","1 through 10","2586","27916.67","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","12377.24","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19995.41","","Standard inlier is a Case rate ($19,995.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,745, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,838.26) for the length of stay and the standard reimbursement.","2838.26","2838.26","2838.26","1 through 10","2586","27916.67","case rate",""
"Acute Myocardial Infarction,MINOR","190","DRG","","","","","","","","inpatient","","","12377.24","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4532.91","","Case rate ($5,011.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,441.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,403.90 and the sum of the standard inlier and any outlier amount.","5010.68","5010.68","5010.68","1 through 10","2586","27916.67","case rate",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Adalimumab Ab, S","PX-30003604","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","both","","","215.00","161.25","AETNA [1001]","HB CH AETNA HMO / PPO","125.35","58.3","","121.91","121.91","121.91","1 through 10","18.27","156.95","percent of total billed charges",""
"Adalimumab Qn","PX-30003603","CDM","80299","CPT","0301","RC","","","","outpatient","","","215.00","161.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","168.67","78.45","","165.29","165.29","165.29","1 through 10","14.12","168.67","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","121.91","121.91","121.91","1 through 10","18.27","486.18","percent of total billed charges",""
"Adalimumab Qn With Reflex to Ab, S","PX-30003495","CDM","80299","CPT","0301","RC","","","","outpatient","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","522.48","78.45","","165.29","165.29","165.29","1 through 10","14.12","522.48","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","AETNA [1001]","HB CH AETNA HMO / PPO","411.02","58.3","","1634.24","1004.95","1718.99","42","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","2123.89","1900.92","2123.89","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","411.02","58.3","","3729.00","1254.19","3729.00","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.65","53","","939.37","939.37","5593.65","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","599.25","85","","2323.25","1864.50","2882.25","16","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","705.00","100","","2909.44","1772.40","10952.08","45","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","705.00","100","","2323.25","2323.25","2323.25","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","705.00","100","","2882.25","1772.40","10169.17","187","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","1659.41","1659.41","1659.41","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","WELLPOINT [1015]","HB CH WELLPOINT","549.27","77.91","","2050.91","1468.48","2902.83","52","313.37","705","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","418.07","59.3","","1548.60","1092.60","3613.79","82","352.5","553.07","percent of total billed charges",""
"ADAPTER BOLT FEMORAL IMPLANT PFC SIGMA NEUTRAL KNEE 15C","SUP-ITM-10029450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","553.07","78.45","","2085.51","998.68","6202.11","56","352.5","553.07","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","AETNA [1001]","HB CH AETNA HMO / PPO","1173.58","58.3","","1634.24","1004.95","1718.99","42","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1469.49","73","","2123.89","1900.92","2123.89","1 through 10","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1173.58","58.3","","3729.00","1254.19","3729.00","1 through 10","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1066.89","53","","939.37","939.37","5593.65","1 through 10","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1711.05","85","","2323.25","1864.50","2882.25","16","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2013.00","100","","2909.44","1772.40","10952.08","45","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2013.00","100","","2323.25","2323.25","2323.25","1 through 10","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2013.00","100","","2882.25","1772.40","10169.17","187","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1469.49","73","","1659.41","1659.41","1659.41","1 through 10","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","both","","","2013.00","1509.75","WELLPOINT [1015]","HB CH WELLPOINT","1568.33","77.91","","2050.91","1468.48","2902.83","52","894.78","2013","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2013.00","1509.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1193.71","59.3","","1548.60","1092.60","3613.79","82","1006.5","1579.2","percent of total billed charges",""
"ADAPTER FEMORAL 5.0DEG IMPLANT KNEE PFC SIGMA 25","SUP-ITM-10020721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2013.00","1509.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1579.20","78.45","","2085.51","998.68","6202.11","56","1006.5","1579.2","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","1634.24","1004.95","1718.99","42","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","2123.89","1900.92","2123.89","1 through 10","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1661.55","58.3","","3729.00","1254.19","3729.00","1 through 10","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","939.37","939.37","5593.65","1 through 10","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2422.50","85","","2323.25","1864.50","2882.25","16","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2850.00","100","","2909.44","1772.40","10952.08","45","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2850.00","100","","2323.25","2323.25","2323.25","1 through 10","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2850.00","100","","2882.25","1772.40","10169.17","187","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","1659.41","1659.41","1659.41","1 through 10","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","2050.91","1468.48","2902.83","52","1266.83","2850","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","1548.60","1092.60","3613.79","82","1425","2235.83","percent of total billed charges",""
"ADAPTER HUMERAL 36MM SHOULDER AEQUALIS REVERSED II 02","SUP-ITM-10042400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","2085.51","998.68","6202.11","56","1425","2235.83","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","AETNA [1001]","HB CH AETNA HMO / PPO","1364.22","58.3","","1634.24","1004.95","1718.99","42","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1708.20","73","","2123.89","1900.92","2123.89","1 through 10","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1364.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1240.20","53","","939.37","939.37","5593.65","1 through 10","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1989.00","85","","2323.25","1864.50","2882.25","16","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2340.00","100","","2909.44","1772.40","10952.08","45","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2340.00","100","","2323.25","2323.25","2323.25","1 through 10","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2340.00","100","","2882.25","1772.40","10169.17","187","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1708.20","73","","1659.41","1659.41","1659.41","1 through 10","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","WELLPOINT [1015]","HB CH WELLPOINT","1823.09","77.91","","2050.91","1468.48","2902.83","52","1040.13","2340","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1387.62","59.3","","1548.60","1092.60","3613.79","82","1170","1835.73","percent of total billed charges",""
"ADAPTER OFFSET 2.0MM KNEE MODULAR COBALT JAM NUT","SUP-ITM-10035430","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1835.73","78.45","","2085.51","998.68","6202.11","56","1170","1835.73","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","AETNA [1001]","HB CH AETNA HMO / PPO","205.68","58.3","","1634.24","1004.95","1718.99","42","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","257.54","73","","2123.89","1900.92","2123.89","1 through 10","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","205.68","58.3","","3729.00","1254.19","3729.00","1 through 10","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.98","53","","939.37","939.37","5593.65","1 through 10","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","299.88","85","","2323.25","1864.50","2882.25","16","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","352.80","100","","2909.44","1772.40","10952.08","45","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","352.80","100","","2323.25","2323.25","2323.25","1 through 10","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","352.80","100","","2882.25","1772.40","10169.17","187","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","257.54","73","","1659.41","1659.41","1659.41","1 through 10","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","both","","","352.80","264.60","WELLPOINT [1015]","HB CH WELLPOINT","274.87","77.91","","2050.91","1468.48","2902.83","52","156.82","352.8","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","209.21","59.3","","1548.60","1092.60","3613.79","82","176.4","276.77","percent of total billed charges",""
"ADAPTER SHOULDER TAPER VERSA DIAL TITANIUM STANDARD 03","SUP-ITM-10100164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","352.80","264.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.77","78.45","","2085.51","998.68","6202.11","56","176.4","276.77","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","AETNA [1001]","HB CH AETNA HMO / PPO","411.02","58.3","","1634.24","1004.95","1718.99","42","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","2123.89","1900.92","2123.89","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","411.02","58.3","","3729.00","1254.19","3729.00","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.65","53","","939.37","939.37","5593.65","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","599.25","85","","2323.25","1864.50","2882.25","16","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","705.00","100","","2909.44","1772.40","10952.08","45","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","705.00","100","","2323.25","2323.25","2323.25","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","705.00","100","","2882.25","1772.40","10169.17","187","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","1659.41","1659.41","1659.41","1 through 10","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","both","","","705.00","528.75","WELLPOINT [1015]","HB CH WELLPOINT","549.27","77.91","","2050.91","1468.48","2902.83","52","313.37","705","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","418.07","59.3","","1548.60","1092.60","3613.79","82","352.5","553.07","percent of total billed charges",""
"ADAPTER SIGMA 2.0MM STEM FEMORAL KNEE PFC BOLT PLUS MINUS","SUP-ITM-10020722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","553.07","78.45","","2085.51","998.68","6202.11","56","352.5","553.07","percent of total billed charges",""
"ADAPTER SPINE 55CM PRECISION M8 STIMULATION LEAD","SUP-ITM-10191375","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","1830.28","315.58","1830.28","1 through 10","900.11","2025","percent of total billed charges",""
"ADAPTER SPINE 55CM PRECISION M8 STIMULATION LEAD","SUP-ITM-10191375","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","4170.85","4170.85","4170.85","1 through 10","900.11","2025","percent of total billed charges",""
"ADAPTER SPINE 55CM PRECISION M8 STIMULATION LEAD","SUP-ITM-10191375","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","649.55","649.55","649.55","1 through 10","900.11","2025","percent of total billed charges",""
"ADAPTER SPINE 55CM PRECISION M8 STIMULATION LEAD","SUP-ITM-10191375","CDM","C1889","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","8998.38","2542.37","8998.38","20","900.11","2025","percent of total billed charges",""
"ADAPTER SPINE 55CM PRECISION M8 STIMULATION LEAD","SUP-ITM-10191375","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","1891.61","1609.14","3664.18","25","1012.5","1588.61","percent of total billed charges",""
"ADAPTER SPINE 55CM PRECISION M8 STIMULATION LEAD","SUP-ITM-10191375","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","1470.68","1310.06","2481.69","19","1012.5","1588.61","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","AETNA [1001]","HB CH AETNA HMO / PPO","495.84","58.3","","1634.24","1004.95","1718.99","42","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","620.87","73","","2123.89","1900.92","2123.89","1 through 10","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","495.84","58.3","","3729.00","1254.19","3729.00","1 through 10","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","450.77","53","","939.37","939.37","5593.65","1 through 10","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","722.93","85","","2323.25","1864.50","2882.25","16","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","850.50","100","","2909.44","1772.40","10952.08","45","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","850.50","100","","2323.25","2323.25","2323.25","1 through 10","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","850.50","100","","2882.25","1772.40","10169.17","187","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","620.87","73","","1659.41","1659.41","1659.41","1 through 10","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","both","","","850.50","637.87","WELLPOINT [1015]","HB CH WELLPOINT","662.62","77.91","","2050.91","1468.48","2902.83","52","378.05","850.5","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","850.50","637.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","504.35","59.3","","1548.60","1092.60","3613.79","82","425.25","667.22","percent of total billed charges",""
"ADAPTER TAPER 25MM MINI COMPREHENSIVE VRS","SUP-ITM-10240115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","850.50","637.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","667.22","78.45","","2085.51","998.68","6202.11","56","425.25","667.22","percent of total billed charges",""
"Adapter/Extension Lead T1","PX-27000166","CDM","C1883","HCPCS","0278","RC","","","","both","","","1047.50","785.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","555.18","53","","1892.10","1892.10","1892.10","1 through 10","555.18","1047.5","percent of total billed charges",""
"Adapter/Extension Lead T2","PX-27000167","CDM","C1883","HCPCS","0278","RC","","","","both","","","3487.50","2615.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1848.38","53","","1892.10","1892.10","1892.10","1 through 10","1848.38","3487.5","percent of total billed charges",""
"Adapter/Extension Lead T3","PX-27000168","CDM","C1883","HCPCS","0278","RC","","","","both","","","6280.00","4710.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3328.40","53","","1892.10","1892.10","1892.10","1 through 10","3328.4","6280","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Adenovrs Quant Real Time Pcr","PX-30001659","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Adjustment Gastric Band, via Port Injection/Aspiration","PX-76002982","CDM","43999","CPT","0761","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","2383.28","2383.28","2383.28","1 through 10","109.4","1146.7","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Admark Phosphotau Anls 83520","PX-30003305","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Admin Hepatitis B Vaccine No Fee","PX-77100011","CDM","G0010","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","51.85","1 through 10","14.16","147.35","other","OPPS APC"
"Admin Hepatitis B Vaccine No Fee","PX-77100012","CDM","G0010","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","51.85","1 through 10","14.16","147.35","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","53.35","53.35","53.35","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","50.81","50.81","50.81","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","54.79","207.40","16","14.67","168.39","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Flumist Influenza Vaccine","PX-77100017","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","54.79","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","53.35","53.35","53.35","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","50.81","50.81","50.81","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","54.79","207.40","16","14.67","168.39","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100007","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","54.79","1 through 10","14.67","168.39","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","53.35","53.35","53.35","1 through 10","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","50.81","50.81","50.81","1 through 10","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","54.79","207.40","16","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","1 through 10","14.67","147.35","other","OPPS APC"
"Admin of Influenza Vaccine","PX-77100008","CDM","G0008","HCPCS","0771","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","54.79","1 through 10","14.67","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100009","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","60.44","","APC Price ($58.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","14.16","147.35","other","OPPS APC"
"Admin of Pneumococcal Vaccine","PX-77100010","CDM","G0009","HCPCS","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","60.44","","APC Price ($58.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","14.16","147.35","other","OPPS APC"
"Adrenal Procedures,MINOR","401","DRG","","","","","","","","inpatient","","","28248.94","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11189.47","","Case rate ($12,371.89). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,801.89, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12368.85","12368.85","12368.85","1 through 10","11189.47","40849.92","case rate",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","both","","","326.00","244.50","AETNA [1001]","HB CH AETNA HMO / PPO","190.06","58.3","","179.74","179.74","179.74","1 through 10","37.85","237.98","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","326.00","244.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.32","59.3","","185.76","185.76","185.76","1 through 10","39.83","255.75","percent of total billed charges",""
"Adrenocorticotropic (Acth)","PX-30000279","CDM","82024","CPT","0301","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","255.75","78.45","","243.71","243.71","243.71","1 through 10","39.83","255.75","percent of total billed charges",""
"Aftercare, Musculoskeletal System And Connective Tissue With McC","559","MS-DRG","","","","","","","","inpatient","","","39308.62","29481.46","MEDICARE [2001]","HB BWF MEDICARE","17510.24","","Case rate ($17,510.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,538.23, add-ons for qualifying new technology services are included. If operating cost exceeds $63,061.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,879.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,852.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,198.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,318.41. The transfer capital threshold is the transfer adjustment factor * $1,318.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18584.75","18584.75","26023.02","1 through 10","17160.04","18356.9507","other","Inpatient Replacement Plans DRG"
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/McC","561","MS-DRG","","","","","","","","inpatient","","","52603.32","39452.49","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7586.30","","Case rate ($7,741.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,753.18, add-ons for qualifying new technology services are included. If operating cost exceeds $53,276.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,129.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,833.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,413.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $568.33. The transfer capital threshold is the transfer adjustment factor * $568.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8566.50","8566.50","8566.50","1 through 10","7586.3","8085.2464","other","Inpatient DRG"
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","both","","","53.00","39.75","AETNA [1001]","HB CH AETNA HMO / PPO","30.90","58.3","","29.48","29.48","29.48","1 through 10","7.62","41.31","percent of total billed charges",""
"Albumin Qn Urine or Other Source","PX-30000282","CDM","82042","CPT","0301","RC","","","","outpatient","","","53.00","39.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.43","59.3","","30.47","30.47","30.47","1 through 10","5.34","41.58","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","14","4.85","32.44","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","both","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18.67","44.45","","18.41","18.41","18.41","1 through 10","4.85","32.44","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","72.09","23","5.11","32.95","percent of total billed charges",""
"Albumin Serum/Plasma/Blood","PX-30000281","CDM","82040","CPT","0301","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","18.68","31.53","19","5.11","32.95","percent of total billed charges",""
"Albumin Vl 25% 50ml","PX-63600341","CDM","P9047","HCPCS","0636","RC","","","","outpatient","","","586.00","439.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","305.89","52.2","","74.41","74.41","74.41","1 through 10","91.7","354.53","percent of total billed charges",""
"Albumin Vl 25% 50ml","PX-63600341","CDM","P9047","HCPCS","0636","RC","","","","outpatient","","","586.00","439.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","338.12","57.7","","52.45","52.45","52.45","1 through 10","91.7","354.53","percent of total billed charges",""
"Alcohol (Quantitative Alcohols)","PX-30002837","CDM","80320","CPT","0301","RC","","","","both","","","85.00","63.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","62.05","73","","47.06","47.06","47.06","1 through 10","37.78","445.13","percent of total billed charges",""
"Alcohol Abuse And Dependence,EXTREME","775","DRG","","","","","","","","inpatient","","","48312.04","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","25402.31","","Fee schedule rate ($25,402.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24662.61","24662.61","24662.61","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","23908.34","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","30086.74","","Fee schedule rate ($30,086.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30086.74","30086.74","30086.74","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MAJOR","775","DRG","","","","","","","","inpatient","","","23908.34","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8005.33","","Fee schedule rate ($8,005.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8005.33","8005.33","8005.33","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26885.60","","Standard inlier is a Case rate ($26,885.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,784, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,816.52) for the length of stay and the standard reimbursement.","6852.00","5316.00","11991.00","11","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28880.50","","Standard inlier is a Case rate ($28,880.50). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,230, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,099.46) for the length of stay and the standard reimbursement.","5289.00","3526.00","10578.00","17","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","FALLON HEALTH [1008]","HB BWF MEDICAID","6166.49","","Case rate ($6,818.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,248.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6816.44","6816.44","10251.18","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12385.72","","Fee schedule rate ($12,385.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11190.00","4646.64","11190.00","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13004.94","","Fee schedule rate ($13,004.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5595.00","5097.00","10147.47","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","MASSHEALTH [3001]","HB BWF MEDICAID","6166.49","","Case rate ($6,818.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,248.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3707.84","855.88","9486.72","18","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","6166.49","","Case rate ($6,818.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,248.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3759.18","695.29","6391.75","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5769.11","","Fee schedule rate ($5,769.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5769.11","5769.11","5769.11","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12296.59","","Fee schedule rate ($12,296.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12296.59","12296.59","12296.59","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6166.49","","Case rate ($6,818.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,248.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6816.44","1037.68","6816.44","34","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","6166.49","","Case rate ($6,818.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,248.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6816.44","325.04","6816.44","1 through 10","880.94","105986.03","case rate",""
"Alcohol Abuse And Dependence,MODERATE","775","DRG","","","","","","","","inpatient","","","17795.49","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6166.49","","Case rate ($6,818.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,248.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6816.44","695.29","6816.44","34","880.94","105986.03","case rate",""
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Age >21 Without McC","898","TRIS-DRG","","","","","","","","inpatient","","","22694.08","","TRICARE [160005]","HB BWF TRICARE","5537.11","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,649.25). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $51,470.69 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($1,821.25), capped at $7,000.32. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $51,470.69 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","3145.72","3145.72","3145.72","1 through 10","5537.11","5537.11","other","Inpatient DRGs"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","181.06","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16940.19","16885.00","16981.52","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","17671.15","17671.15","17671.15","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16080.95","16080.95","16230.98","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","HUMANA [1012]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","480.59","480.59","480.59","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","MEDICARE [2001]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8805.12","0.03","17958.49","14","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","10142.89","10142.89","10142.89","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","17994.14","17994.14","17994.14","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC","896","MS-DRG","","","","","","","","inpatient","","","23299.16","17474.37","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16103.45","16103.45","16103.45","1 through 10","172.44","17913.45","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","172.01","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","4728.70","4275.64","8495.17","16","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8158.31","8136.07","8878.93","1 through 10","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8112.82","5438.08","12988.38","24","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","HUMANA [1012]","HB BWF MEDICARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","5208.02","1600.87","9202.72","1 through 10","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","MEDICARE [2001]","HB BWF MEDICARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","4753.00","1367.27","9023.30","100","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","4880.00","1844.78","6550.62","1 through 10","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","5200.80","1516.15","9237.65","14","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8112.83","8112.83","8278.39","1 through 10","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC","897","MS-DRG","","","","","","","","inpatient","","","18223.44","13667.58","WELLSENSE [1003]","HB BWF MEDICARE","163.82","","Case rate ($163.82) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8090.63","7397.49","8146.34","1 through 10","163.82","9061.94","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","12263.70","9197.77","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","155.72","","Case rate ($148.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","2825.34","2825.34","4012.43","1 through 10","148.3","6332.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","12263.70","9197.77","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","148.30","","Case rate ($148.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","2810.52","1624.20","5880.96","1 through 10","148.3","6332.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","12263.70","9197.77","HUMANA [1012]","HB BWF MEDICARE","148.30","","Case rate ($148.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","1204.54","1204.54","1204.54","1 through 10","148.3","6332.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","12263.70","9197.77","MEDICARE [2001]","HB BWF MEDICARE","148.30","","Case rate ($148.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","1865.74","1395.07","6456.89","12","148.3","6332.48","other","Inpatient Psych"
"Alcohol, Drug Abuse Or Dependence, Left Ama","894","MS-DRG","","","","","","","","inpatient","","","12263.70","9197.77","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","148.30","","Case rate ($148.30) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","3094.03","3094.03","3094.03","1 through 10","148.3","6332.48","other","Inpatient Psych"
"Alcoholic Liver Disease,EXTREME","280","DRG","","","","","","","","inpatient","","","69862.13","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","25078.36","","Case rate ($27,728.44). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,158.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,259.36 and the sum of the standard inlier and any outlier amount.","31231.08","31231.08","31231.08","1 through 10","2296","54577.22","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","38926.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24157.08","","Standard inlier is a Case rate ($24,157.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,430, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,429.19) for the length of stay and the standard reimbursement.","23059.34","23059.34","23059.34","1 through 10","2296","54577.22","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","38926.94","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11172.34","","Case rate ($12,352.94). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,782.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12349.91","12349.91","12349.91","1 through 10","2296","54577.22","case rate",""
"Alcoholic Liver Disease,MAJOR","280","DRG","","","","","","","","inpatient","","","38926.94","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11172.34","","Case rate ($12,352.94). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,782.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12349.91","2614.56","12349.91","1 through 10","2296","54577.22","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","24683.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17040.73","","Standard inlier is a Case rate ($17,040.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,923, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,418.86) for the length of stay and the standard reimbursement.","16266.15","16266.15","17040.73","1 through 10","2296","54577.22","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","24683.96","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6285.30","","Case rate ($6,949.48). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,379.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6947.77","6947.77","6947.77","1 through 10","2296","54577.22","case rate",""
"Alcoholic Liver Disease,MODERATE","280","DRG","","","","","","","","inpatient","","","24683.96","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6285.30","","Case rate ($6,949.48). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,379.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6947.77","6947.77","16859.70","1 through 10","2296","54577.22","case rate",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","79.00","59.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.06","58.3","","43.66","43.66","43.66","1 through 10","9.52","57.67","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","both","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.87","53","","40.81","40.81","40.81","1 through 10","9.52","57.67","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","79.00","59.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.85","59.3","","45.12","44.04","45.12","1 through 10","10.01","61.98","percent of total billed charges",""
"Aldolase","PX-30000288","CDM","82085","CPT","0301","RC","","","","outpatient","","","79.00","59.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.98","78.45","","59.20","35.08","59.20","1 through 10","10.01","61.98","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","341.00","255.75","AETNA [1001]","HB CH AETNA HMO / PPO","198.80","58.3","","188.24","188.24","188.24","1 through 10","39.94","248.93","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.57","44.45","","255.24","255.24","255.24","1 through 10","39.94","248.93","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","341.00","255.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.21","59.3","","194.55","194.55","194.55","1 through 10","42.03","267.51","percent of total billed charges",""
"Aldosterone","PX-30000289","CDM","82088","CPT","0301","RC","","","","outpatient","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","255.24","255.24","255.24","1 through 10","42.03","267.51","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","both","","","90.00","67.50","WELLPOINT [1015]","HB CH WELLPOINT","70.12","77.91","","69.31","69.31","69.31","15","17.57","105.83","percent of total billed charges",""
"Allergen Spec Ige Recombinant/Purified Compnt Ea","PX-30003473","CDM","86008","CPT","0302","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","67.36","67.36","67.36","1 through 10","32.94","70.61","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","AETNA [1001]","HB CH AETNA HMO / PPO","36.15","58.3","","34.02","34.02","34.02","118","5.12","45.26","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.86","53","","31.80","31.80","127.20","1 through 10","5.12","45.26","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.56","44.45","","46.13","46.13","46.13","17","5.12","45.26","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.77","59.3","","35.16","35.16","35.16","90","5.39","48.64","percent of total billed charges",""
"Allergen Specific Ige Quan/Semiquan Ea Allergen","PX-30001851","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.64","78.45","","46.13","19.60","46.13","246","5.39","48.64","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","62.00","46.50","AETNA [1001]","HB CH AETNA HMO / PPO","36.15","58.3","","34.02","34.02","34.02","118","5.12","45.26","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","62.00","46.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.86","53","","31.80","31.80","127.20","1 through 10","5.12","45.26","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.56","44.45","","46.13","46.13","46.13","17","5.12","45.26","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","62.00","46.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.77","59.3","","35.16","35.16","35.16","90","5.39","48.64","percent of total billed charges",""
"Allergen Specific Ige; Quantitative or Semiquantitative, Crude Allergen Extract, Each","PX-30003777","CDM","86003","CPT","0300","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.64","78.45","","46.13","19.60","46.13","246","5.39","48.64","percent of total billed charges",""
"Allergic Reactions Without McC","916","MS-DRG","","","","","","","","inpatient","","","13821.76","10366.32","MEDICARE [2001]","HB BWF MEDICARE","6474.16","","Case rate ($6,474.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,484.17, add-ons for qualifying new technology services are included. If operating cost exceeds $52,007.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,031.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,663.89 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,144.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $471.05. The transfer capital threshold is the transfer adjustment factor * $471.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6854.63","6854.63","6854.63","1 through 10","6344.68","6668.38","other","Inpatient Replacement Plans DRG"
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","16097.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23547.86","","Standard inlier is a Case rate ($23,547.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,137, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,342.52) for the length of stay and the standard reimbursement.","10027.55","10027.55","10027.55","1 through 10","2536","30283.56","case rate",""
"Allergic Reactions,MAJOR","811","DRG","","","","","","","","inpatient","","","16097.61","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9286.29","","Case rate ($10,267.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,697.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,565.14 and the sum of the standard inlier and any outlier amount.","10680.99","10680.99","10680.99","1 through 10","2536","30283.56","case rate",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","954.00","715.50","AETNA [1001]","HB CH AETNA HMO / PPO","556.18","58.3","","66.84","33.42","66.84","3696","92.01","743.26","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.62","53","","16493.60","16493.60","16493.60","1 through 10","92.01","743.26","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","954.00","715.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","696.42","73","","10382.90","10382.90","10382.90","1 through 10","92.01","743.26","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","both","","","954.00","715.50","WELLPOINT [1015]","HB CH WELLPOINT","743.26","77.91","","31178.94","77.77","31197.77","2412","92.01","743.26","percent of total billed charges",""
"Alloderm 12 Sq Cm T1","PX-27000612","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","954.00","715.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","497.99","52.2","","67.43","30.35","93.27","9212","477","497.99","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6850.73","5138.05","AETNA [1001]","HB CH AETNA HMO / PPO","3993.98","58.3","","66.84","33.42","66.84","3696","92.01","5337.4","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6850.73","5138.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3630.89","53","","16493.60","16493.60","16493.60","1 through 10","92.01","5337.4","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6850.73","5138.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5001.03","73","","10382.90","10382.90","10382.90","1 through 10","92.01","5337.4","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6850.73","5138.05","WELLPOINT [1015]","HB CH WELLPOINT","5337.40","77.91","","31178.94","77.77","31197.77","2412","92.01","5337.4","percent of total billed charges",""
"Alloderm 128 Sq Cm T3","PX-27000613","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6850.73","5138.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","3576.08","52.2","","67.43","30.35","93.27","9212","3425.37","3576.08","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7240.00","5430.00","AETNA [1001]","HB CH AETNA HMO / PPO","4220.92","58.3","","66.84","33.42","66.84","3696","92.01","5640.68","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7240.00","5430.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3837.20","53","","16493.60","16493.60","16493.60","1 through 10","92.01","5640.68","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7240.00","5430.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5285.20","73","","10382.90","10382.90","10382.90","1 through 10","92.01","5640.68","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7240.00","5430.00","WELLPOINT [1015]","HB CH WELLPOINT","5640.68","77.91","","31178.94","77.77","31197.77","2412","92.01","5640.68","percent of total billed charges",""
"Alloderm 132 Sq Cm Tier3","PX-27001079","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7240.00","5430.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3779.28","52.2","","67.43","30.35","93.27","9212","3620","3779.28","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8582.00","6436.50","AETNA [1001]","HB CH AETNA HMO / PPO","5003.31","58.3","","66.84","33.42","66.84","3696","92.01","6686.24","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8582.00","6436.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4548.46","53","","16493.60","16493.60","16493.60","1 through 10","92.01","6686.24","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8582.00","6436.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6264.86","73","","10382.90","10382.90","10382.90","1 through 10","92.01","6686.24","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","both","","","8582.00","6436.50","WELLPOINT [1015]","HB CH WELLPOINT","6686.24","77.91","","31178.94","77.77","31197.77","2412","92.01","6686.24","percent of total billed charges",""
"Alloderm 144 Sq Cm T3","PX-27000614","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","8582.00","6436.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4479.80","52.2","","67.43","30.35","93.27","9212","4291","4479.8","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9772.00","7329.00","AETNA [1001]","HB CH AETNA HMO / PPO","5697.08","58.3","","66.84","33.42","66.84","3696","92.01","7613.37","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9772.00","7329.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5179.16","53","","16493.60","16493.60","16493.60","1 through 10","92.01","7613.37","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9772.00","7329.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7133.56","73","","10382.90","10382.90","10382.90","1 through 10","92.01","7613.37","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9772.00","7329.00","WELLPOINT [1015]","HB CH WELLPOINT","7613.37","77.91","","31178.94","77.77","31197.77","2412","92.01","7613.37","percent of total billed charges",""
"Alloderm 164 Sq Cm Tier3","PX-27001078","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9772.00","7329.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5100.98","52.2","","67.43","30.35","93.27","9212","4886","5100.98","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","414.00","310.50","AETNA [1001]","HB CH AETNA HMO / PPO","241.36","58.3","","66.84","33.42","66.84","3696","92.01","322.55","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","414.00","310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","219.42","53","","16493.60","16493.60","16493.60","1 through 10","92.01","322.55","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","414.00","310.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","302.22","73","","10382.90","10382.90","10382.90","1 through 10","92.01","322.55","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","both","","","414.00","310.50","WELLPOINT [1015]","HB CH WELLPOINT","322.55","77.91","","31178.94","77.77","31197.77","2412","92.01","322.55","percent of total billed charges",""
"Alloderm 2 Sq Cm T1","PX-27000615","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","414.00","310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","216.11","52.2","","67.43","30.35","93.27","9212","207","216.11","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1713.00","1284.75","AETNA [1001]","HB CH AETNA HMO / PPO","998.68","58.3","","66.84","33.42","66.84","3696","92.01","1334.6","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1713.00","1284.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","907.89","53","","16493.60","16493.60","16493.60","1 through 10","92.01","1334.6","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1713.00","1284.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1250.49","73","","10382.90","10382.90","10382.90","1 through 10","92.01","1334.6","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1713.00","1284.75","WELLPOINT [1015]","HB CH WELLPOINT","1334.60","77.91","","31178.94","77.77","31197.77","2412","92.01","1334.6","percent of total billed charges",""
"Alloderm 21 Sq Cm T1","PX-27000616","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1713.00","1284.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","894.19","52.2","","67.43","30.35","93.27","9212","856.5","894.19","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1268.65","951.49","AETNA [1001]","HB CH AETNA HMO / PPO","739.62","58.3","","66.84","33.42","66.84","3696","92.01","988.41","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1268.65","951.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","672.38","53","","16493.60","16493.60","16493.60","1 through 10","92.01","988.41","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1268.65","951.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","926.11","73","","10382.90","10382.90","10382.90","1 through 10","92.01","988.41","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1268.65","951.49","WELLPOINT [1015]","HB CH WELLPOINT","988.41","77.91","","31178.94","77.77","31197.77","2412","92.01","988.41","percent of total billed charges",""
"Alloderm 28 Sq Cm T1","PX-27000617","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1268.65","951.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.24","52.2","","67.43","30.35","93.27","9212","634.33","662.24","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","57.87","43.40","AETNA [1001]","HB CH AETNA HMO / PPO","33.74","58.3","","66.84","33.42","66.84","3696","30.67","100.55","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","57.87","43.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.67","53","","16493.60","16493.60","16493.60","1 through 10","30.67","100.55","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","57.87","43.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","42.25","73","","10382.90","10382.90","10382.90","1 through 10","30.67","100.55","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","both","","","57.87","43.40","WELLPOINT [1015]","HB CH WELLPOINT","45.09","77.91","","31178.94","77.77","31197.77","2412","30.67","100.55","percent of total billed charges",""
"Alloderm 320 Sq Cm T3","PX-27000618","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","57.87","43.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.21","52.2","","67.43","30.35","93.27","9212","28.94","30.21","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","693.00","519.75","AETNA [1001]","HB CH AETNA HMO / PPO","404.02","58.3","","66.84","33.42","66.84","3696","92.01","539.92","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","693.00","519.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","367.29","53","","16493.60","16493.60","16493.60","1 through 10","92.01","539.92","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","693.00","519.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","505.89","73","","10382.90","10382.90","10382.90","1 through 10","92.01","539.92","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","both","","","693.00","519.75","WELLPOINT [1015]","HB CH WELLPOINT","539.92","77.91","","31178.94","77.77","31197.77","2412","92.01","539.92","percent of total billed charges",""
"Alloderm 4 Sq Cm T1","PX-27000619","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","693.00","519.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","361.75","52.2","","67.43","30.35","93.27","9212","346.5","361.75","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2013.00","1509.75","AETNA [1001]","HB CH AETNA HMO / PPO","1173.58","58.3","","66.84","33.42","66.84","3696","92.01","1568.33","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2013.00","1509.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1066.89","53","","16493.60","16493.60","16493.60","1 through 10","92.01","1568.33","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2013.00","1509.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1469.49","73","","10382.90","10382.90","10382.90","1 through 10","92.01","1568.33","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2013.00","1509.75","WELLPOINT [1015]","HB CH WELLPOINT","1568.33","77.91","","31178.94","77.77","31197.77","2412","92.01","1568.33","percent of total billed charges",""
"Alloderm 48 Sq Cm T1","PX-27000620","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2013.00","1509.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1050.79","52.2","","67.43","30.35","93.27","9212","1006.5","1050.79","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","66.84","33.42","66.84","3696","92.01","946.61","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","643.95","53","","16493.60","16493.60","16493.60","1 through 10","92.01","946.61","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1215.00","911.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","886.95","73","","10382.90","10382.90","10382.90","1 through 10","92.01","946.61","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","31178.94","77.77","31197.77","2412","92.01","946.61","percent of total billed charges",""
"Alloderm 50 Sq Cm T1","PX-27000621","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","634.23","52.2","","67.43","30.35","93.27","9212","607.5","634.23","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3450.00","2587.50","AETNA [1001]","HB CH AETNA HMO / PPO","2011.35","58.3","","66.84","33.42","66.84","3696","92.01","2687.9","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3450.00","2587.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1828.50","53","","16493.60","16493.60","16493.60","1 through 10","92.01","2687.9","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3450.00","2587.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2518.50","73","","10382.90","10382.90","10382.90","1 through 10","92.01","2687.9","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3450.00","2587.50","WELLPOINT [1015]","HB CH WELLPOINT","2687.90","77.91","","31178.94","77.77","31197.77","2412","92.01","2687.9","percent of total billed charges",""
"Alloderm 50 Sq Cm T2","PX-27000622","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","3450.00","2587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1800.90","52.2","","67.43","30.35","93.27","9212","1725","1800.9","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4270.00","3202.50","AETNA [1001]","HB CH AETNA HMO / PPO","2489.41","58.3","","66.84","33.42","66.84","3696","92.01","3326.76","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4270.00","3202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2263.10","53","","16493.60","16493.60","16493.60","1 through 10","92.01","3326.76","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4270.00","3202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3117.10","73","","10382.90","10382.90","10382.90","1 through 10","92.01","3326.76","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4270.00","3202.50","WELLPOINT [1015]","HB CH WELLPOINT","3326.76","77.91","","31178.94","77.77","31197.77","2412","92.01","3326.76","percent of total billed charges",""
"Alloderm 64 Sq Cm T2","PX-27000623","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4270.00","3202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2228.94","52.2","","67.43","30.35","93.27","9212","2135","2228.94","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3828.00","2871.00","AETNA [1001]","HB CH AETNA HMO / PPO","2231.72","58.3","","66.84","33.42","66.84","3696","92.01","2982.39","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3828.00","2871.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2028.84","53","","16493.60","16493.60","16493.60","1 through 10","92.01","2982.39","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3828.00","2871.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2794.44","73","","10382.90","10382.90","10382.90","1 through 10","92.01","2982.39","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3828.00","2871.00","WELLPOINT [1015]","HB CH WELLPOINT","2982.39","77.91","","31178.94","77.77","31197.77","2412","92.01","2982.39","percent of total billed charges",""
"Alloderm 64 Sq Cm T3","PX-27000624","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","3828.00","2871.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1998.22","52.2","","67.43","30.35","93.27","9212","1914","1998.22","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4454.00","3340.50","AETNA [1001]","HB CH AETNA HMO / PPO","2596.68","58.3","","66.84","33.42","66.84","3696","92.01","3470.11","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4454.00","3340.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2360.62","53","","16493.60","16493.60","16493.60","1 through 10","92.01","3470.11","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4454.00","3340.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3251.42","73","","10382.90","10382.90","10382.90","1 through 10","92.01","3470.11","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","both","","","4454.00","3340.50","WELLPOINT [1015]","HB CH WELLPOINT","3470.11","77.91","","31178.94","77.77","31197.77","2412","92.01","3470.11","percent of total billed charges",""
"Alloderm 77 Sq Cm Tier3","PX-27001080","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","4454.00","3340.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2324.99","52.2","","67.43","30.35","93.27","9212","2227","2324.99","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","752.00","564.00","AETNA [1001]","HB CH AETNA HMO / PPO","438.42","58.3","","66.84","33.42","66.84","3696","92.01","585.88","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","752.00","564.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","398.56","53","","16493.60","16493.60","16493.60","1 through 10","92.01","585.88","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","752.00","564.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","548.96","73","","10382.90","10382.90","10382.90","1 through 10","92.01","585.88","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","both","","","752.00","564.00","WELLPOINT [1015]","HB CH WELLPOINT","585.88","77.91","","31178.94","77.77","31197.77","2412","92.01","585.88","percent of total billed charges",""
"Alloderm 8 Sq Cm T1","PX-27000625","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","752.00","564.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","392.54","52.2","","67.43","30.35","93.27","9212","376","392.54","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5600.00","4200.00","AETNA [1001]","HB CH AETNA HMO / PPO","3264.80","58.3","","66.84","33.42","66.84","3696","92.01","4362.96","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5600.00","4200.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2968.00","53","","16493.60","16493.60","16493.60","1 through 10","92.01","4362.96","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5600.00","4200.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4088.00","73","","10382.90","10382.90","10382.90","1 through 10","92.01","4362.96","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5600.00","4200.00","WELLPOINT [1015]","HB CH WELLPOINT","4362.96","77.91","","31178.94","77.77","31197.77","2412","92.01","4362.96","percent of total billed charges",""
"Alloderm 96 Sq Cm T3","PX-27000626","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5600.00","4200.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2923.20","52.2","","67.43","30.35","93.27","9212","2800","2923.2","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","AETNA [1001]","HB CH AETNA HMO / PPO","4453.37","58.3","","1830.28","315.58","1830.28","1 through 10","3395.41","7638.71","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5576.26","73","","4170.85","4170.85","4170.85","1 through 10","3395.41","7638.71","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3395.41","44.45","","649.55","649.55","649.55","1 through 10","3395.41","7638.71","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","both","","","7638.71","5729.03","WELLPOINT [1015]","HB CH WELLPOINT","5951.32","77.91","","8998.38","2542.37","8998.38","20","3395.41","7638.71","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7638.71","5729.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","4529.76","59.3","","1891.61","1609.14","3664.18","25","3819.36","5992.57","percent of total billed charges",""
"Allograft Cartilage T3","PX-27000665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7638.71","5729.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5992.57","78.45","","1470.68","1310.06","2481.69","19","3819.36","5992.57","percent of total billed charges",""
"ALLOGRAFT MATRIX 3X6CM PLACENTAL HUMAN DECELLULARIZED CENTAFLEX","SUP-ITM-10293117","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","AETNA [1001]","HB CH AETNA HMO / PPO","4314.20","58.3","","1830.28","315.58","1830.28","1 through 10","3289.3","7400","percent of total billed charges",""
"ALLOGRAFT MATRIX 3X6CM PLACENTAL HUMAN DECELLULARIZED CENTAFLEX","SUP-ITM-10293117","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5402.00","73","","4170.85","4170.85","4170.85","1 through 10","3289.3","7400","percent of total billed charges",""
"ALLOGRAFT MATRIX 3X6CM PLACENTAL HUMAN DECELLULARIZED CENTAFLEX","SUP-ITM-10293117","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3289.30","44.45","","649.55","649.55","649.55","1 through 10","3289.3","7400","percent of total billed charges",""
"ALLOGRAFT MATRIX 3X6CM PLACENTAL HUMAN DECELLULARIZED CENTAFLEX","SUP-ITM-10293117","CDM","C1889","HCPCS","0278","RC","","","","both","","","7400.00","5550.00","WELLPOINT [1015]","HB CH WELLPOINT","5765.34","77.91","","8998.38","2542.37","8998.38","20","3289.3","7400","percent of total billed charges",""
"ALLOGRAFT MATRIX 3X6CM PLACENTAL HUMAN DECELLULARIZED CENTAFLEX","SUP-ITM-10293117","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4388.20","59.3","","1891.61","1609.14","3664.18","25","3700","5805.3","percent of total billed charges",""
"ALLOGRAFT MATRIX 3X6CM PLACENTAL HUMAN DECELLULARIZED CENTAFLEX","SUP-ITM-10293117","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7400.00","5550.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5805.30","78.45","","1470.68","1310.06","2481.69","19","3700","5805.3","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","AETNA [1001]","HB CH AETNA HMO / PPO","886.58","58.3","","1830.28","315.58","1830.28","1 through 10","675.96","1520.72","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1110.13","73","","4170.85","4170.85","4170.85","1 through 10","675.96","1520.72","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.96","44.45","","649.55","649.55","649.55","1 through 10","675.96","1520.72","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","both","","","1520.72","1140.54","WELLPOINT [1015]","HB CH WELLPOINT","1184.79","77.91","","8998.38","2542.37","8998.38","20","675.96","1520.72","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1520.72","1140.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","901.79","59.3","","1891.61","1609.14","3664.18","25","760.36","1193","percent of total billed charges",""
"Allograft Tendon / Bone T1","PX-27000666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1520.72","1140.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1193.00","78.45","","1470.68","1310.06","2481.69","19","760.36","1193","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","AETNA [1001]","HB CH AETNA HMO / PPO","2046.09","58.3","","1830.28","315.58","1830.28","1 through 10","1560.01","3509.59","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2562.00","73","","4170.85","4170.85","4170.85","1 through 10","1560.01","3509.59","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.01","44.45","","649.55","649.55","649.55","1 through 10","1560.01","3509.59","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","both","","","3509.59","2632.19","WELLPOINT [1015]","HB CH WELLPOINT","2734.32","77.91","","8998.38","2542.37","8998.38","20","1560.01","3509.59","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3509.59","2632.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.19","59.3","","1891.61","1609.14","3664.18","25","1754.8","2753.27","percent of total billed charges",""
"Allograft Tendon / Bone T2","PX-27000667","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3509.59","2632.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.27","78.45","","1470.68","1310.06","2481.69","19","1754.8","2753.27","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","AETNA [1001]","HB CH AETNA HMO / PPO","2770.82","58.3","","1830.28","315.58","1830.28","1 through 10","2112.58","4752.7","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3469.47","73","","4170.85","4170.85","4170.85","1 through 10","2112.58","4752.7","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2112.58","44.45","","649.55","649.55","649.55","1 through 10","2112.58","4752.7","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","both","","","4752.70","3564.52","WELLPOINT [1015]","HB CH WELLPOINT","3702.83","77.91","","8998.38","2542.37","8998.38","20","2112.58","4752.7","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4752.70","3564.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","2818.35","59.3","","1891.61","1609.14","3664.18","25","2376.35","3728.49","percent of total billed charges",""
"Allograft Tendon / Bone T3","PX-27000668","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4752.70","3564.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3728.49","78.45","","1470.68","1310.06","2481.69","19","2376.35","3728.49","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","AETNA [1001]","HB CH AETNA HMO / PPO","5584.71","58.3","","1830.28","315.58","1830.28","1 through 10","4257.99","9579.27","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6992.87","73","","4170.85","4170.85","4170.85","1 through 10","4257.99","9579.27","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4257.99","44.45","","649.55","649.55","649.55","1 through 10","4257.99","9579.27","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","both","","","9579.27","7184.45","WELLPOINT [1015]","HB CH WELLPOINT","7463.21","77.91","","8998.38","2542.37","8998.38","20","4257.99","9579.27","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9579.27","7184.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","5680.51","59.3","","1891.61","1609.14","3664.18","25","4789.64","7514.94","percent of total billed charges",""
"Allograft Vein T3","PX-27000669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9579.27","7184.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7514.94","78.45","","1470.68","1310.06","2481.69","19","4789.64","7514.94","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","75.98","75.98","1 through 10","16.43","100.74","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","78.52","78.52","78.52","1 through 10","17.3","108.26","percent of total billed charges",""
"Alpha Fetoprotein Serum","PX-30000293","CDM","82105","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","17.3","108.26","percent of total billed charges",""
"Alpha-1 Antitrypsin Phenotype","PX-30000292","CDM","82104","CPT","0301","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","1 through 10","14.17","86.87","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","61.80","1 through 10","13.17","81.76","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","1 through 10","13.86","87.86","percent of total billed charges",""
"Alpha-1 Antitrypsin Total","PX-30000291","CDM","82103","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","83.80","83.80","1 through 10","13.86","87.86","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","1 through 10","5.19","34.73","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","19.59","19.59","19.59","1 through 10","5.19","34.73","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","19.59","19.59","19.59","1 through 10","5.19","34.73","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","16","5.46","34.52","percent of total billed charges",""
"Alt/Sgpt","PX-30000706","CDM","84460","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","19.59","33.06","1 through 10","5.46","34.52","percent of total billed charges",""
"Alteration In Consciousness,EXTREME","052","DRG","","","","","","","","inpatient","","","163184.92","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41246.49","","Standard inlier is a Case rate ($41,246.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $53,961, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,855.10) for the length of stay and the standard reimbursement.","39372.18","39372.18","39372.18","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","29407.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21090.25","","Standard inlier is a Case rate ($21,090.25). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,993.84) for the length of stay and the standard reimbursement.","21090.25","21090.25","21090.25","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","29407.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22655.14","","Standard inlier is a Case rate ($22,655.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,284, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,215.80) for the length of stay and the standard reimbursement.","22655.14","22655.14","22655.14","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","29407.62","","MASSHEALTH [3001]","HB BWF MEDICAID","8907.03","","Case rate ($9,848.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,278.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9845.83","9845.83","9845.83","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","29407.62","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8907.03","","Case rate ($9,848.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,278.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9732.10","9732.10","9845.83","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","29407.62","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","8907.03","","Case rate ($9,848.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,278.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9845.83","9845.83","9845.83","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MAJOR","052","DRG","","","","","","","","inpatient","","","29407.62","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8907.03","","Case rate ($9,848.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,278.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9845.83","9845.83","9845.83","1 through 10","5808.93","222741.55","case rate",""
"Alteration In Consciousness,MODERATE","052","DRG","","","","","","","","inpatient","","","14499.25","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5808.93","","Case rate ($6,422.77). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,852.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,094.17 and the sum of the standard inlier and any outlier amount.","695.29","695.29","1093.90","1 through 10","5808.93","222741.55","case rate",""
"Ammonia","PX-30000305","CDM","82140","CPT","0301","RC","","","","outpatient","","","124.00","93.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","70.91","70.91","1 through 10","15.03","97.28","percent of total billed charges",""
"Ampicillin","PX-30001480","CDM","80299","CPT","0300","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","121.91","121.91","121.91","1 through 10","18.27","122.64","percent of total billed charges",""
"Ampicillin","PX-30001480","CDM","80299","CPT","0300","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","165.29","165.29","165.29","1 through 10","14.12","131.8","percent of total billed charges",""
"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","240","MS-DRG","","","","","","","","inpatient","","","65559.64","49169.73","MEDICARE [2001]","HB BWF MEDICARE","29094.45","","Case rate ($29,094.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $26,627.89, add-ons for qualifying new technology services are included. If operating cost exceeds $72,151.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,575.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.3. The base transfer operating payment is the transfer adjustment factor * $26,740.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $26,288.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,015.19. The transfer capital threshold is the transfer adjustment factor * $2,015.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","29013.25","29013.25","29013.25","1 through 10","26053.42","29094.45","other","Inpatient DRG"
"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC","476","MS-DRG","","","","","","","","inpatient","","","73757.46","55318.09","MEDICARE [2001]","HB BWF MEDICARE","11205.88","","Case rate ($11,205.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,223.60, add-ons for qualifying new technology services are included. If operating cost exceeds $56,747.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,395.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $10,032.30 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,884.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $834.35. The transfer capital threshold is the transfer adjustment factor * $834.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11816.41","11816.41","11816.41","1 through 10","10981.76","11542.06","other","Inpatient Replacement Plans DRG"
"Amputation Of Lower Limb Except Toes,EXTREME","305","DRG","","","","","","","","inpatient","","","173204.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27002.8836","","Standard inlier is a Case rate ($101,238.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $108,333, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,370.37) for the length of stay and the standard reimbursement.","27002.8836","101238.42","101238.42","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","54069.59","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","35446.5725","","Fee schedule rate ($56,702.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35446.5725","67190.48","67190.48","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MAJOR","305","DRG","","","","","","","","inpatient","","","54069.59","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","43149.92","","Fee schedule rate ($43,149.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","50765.24","50765.24","50765.24","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MINOR","305","DRG","","","","","","","","inpatient","","","73757.46","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27002.8836","","Standard inlier is a Case rate ($27,002.88). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,437, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,832.95) for the length of stay and the standard reimbursement.","27002.8836","25775.47","25775.47","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MINOR","305","DRG","","","","","","","","inpatient","","","73757.46","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","45455.44","","Fee schedule rate ($45,455.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8819.84","8819.84","8819.84","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MODERATE","305","DRG","","","","","","","","inpatient","","","68231.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25137.681","","Standard inlier is a Case rate ($33,519.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,437, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,758.20) for the length of stay and the standard reimbursement.","25137.681","33519.35","33519.35","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MODERATE","305","DRG","","","","","","","","inpatient","","","68231.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27002.8836","","Standard inlier is a Case rate ($36,006.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $46,034, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,110.97) for the length of stay and the standard reimbursement.","27002.8836","34369.82","34369.82","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb Except Toes,MODERATE","305","DRG","","","","","","","","inpatient","","","68231.98","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","14157.34","","Case rate ($15,653.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,083.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15649.53","15649.53","15649.53","1 through 10","11767.51","215331.88","case rate",""
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","68231.98","51173.98","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","17559.97","","Case rate ($17,559.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,588.03, add-ons for qualifying new technology services are included. If operating cost exceeds $63,111.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,883.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,898.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,248.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.23. The transfer capital threshold is the transfer adjustment factor * $1,322.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15346.21","15346.21","15346.21","1 through 10","17208.77","19198.63","other","Inpatient Replacement Plans DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","68231.98","51173.98","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","17208.77","","Case rate ($17,559.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,588.03, add-ons for qualifying new technology services are included. If operating cost exceeds $63,111.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,883.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,898.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,248.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.23. The transfer capital threshold is the transfer adjustment factor * $1,322.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17421.86","17421.86","17421.86","1 through 10","17208.77","19198.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","68231.98","51173.98","MEDICARE [2001]","HB BWF MEDICARE","17559.97","","Case rate ($17,559.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,588.03, add-ons for qualifying new technology services are included. If operating cost exceeds $63,111.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,883.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,898.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,248.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.23. The transfer capital threshold is the transfer adjustment factor * $1,322.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19328.43","0.03","19457.96","11","17208.77","19198.63","other","Inpatient Replacement Plans DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","68231.98","51173.98","MOLINA [1014]","HB BWF MEDICARE","17559.97","","Case rate ($17,559.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,588.03, add-ons for qualifying new technology services are included. If operating cost exceeds $63,111.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,883.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,898.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,248.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.23. The transfer capital threshold is the transfer adjustment factor * $1,322.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35199.27","35199.27","35199.27","1 through 10","17208.77","19198.63","other","Inpatient Replacement Plans DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","617","MS-DRG","","","","","","","","inpatient","","","68231.98","51173.98","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","17208.77","","Case rate ($17,559.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,588.03, add-ons for qualifying new technology services are included. If operating cost exceeds $63,111.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,883.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $15,898.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,248.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,322.23. The transfer capital threshold is the transfer adjustment factor * $1,322.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17421.87","17421.87","17421.87","1 through 10","17208.77","19198.63","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","90657.05","67992.79","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","33422.84","","Case rate ($32,449.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,501.70, add-ons for qualifying new technology services are included. If operating cost exceeds $78,025.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $29,644.67 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,162.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,465.45. The transfer capital threshold is the transfer adjustment factor * $2,465.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","36344.24","36344.24","36344.24","1 through 10","31800.37","35798.16","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","90657.05","67992.79","MEDICARE [2001]","HB BWF MEDICARE","35519.37","","Case rate ($35,519.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,501.70, add-ons for qualifying new technology services are included. If operating cost exceeds $78,025.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $32,714.67 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,162.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,465.45. The transfer capital threshold is the transfer adjustment factor * $2,465.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","38682.65","38682.65","38682.65","1 through 10","31800.37","35798.16","other","Inpatient DRG"
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC","616","MS-DRG","","","","","","","","inpatient","","","90657.05","67992.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","31800.37","","Case rate ($32,449.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,501.70, add-ons for qualifying new technology services are included. If operating cost exceeds $78,025.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.8. The base transfer operating payment is the transfer adjustment factor * $29,644.67 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,162.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,465.45. The transfer capital threshold is the transfer adjustment factor * $2,465.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","27817.87","27817.87","27817.87","1 through 10","31800.37","35798.16","other","Inpatient DRG"
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","both","","","59.00","44.25","AETNA [1001]","HB CH AETNA HMO / PPO","34.40","58.3","","32.32","32.32","32.32","1 through 10","6.35","43.07","percent of total billed charges",""
"Amylase","PX-30000309","CDM","82150","CPT","0301","RC","","","","outpatient","","","59.00","44.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.99","59.3","","33.40","33.40","33.40","1 through 10","6.68","46.29","percent of total billed charges",""
"Anal And Stomal Procedures With McC","347","MS-DRG","","","","","","","","inpatient","","","35241.16","26430.87","MEDICARE [2001]","HB BWF MEDICARE","23496.74","","Case rate ($23,496.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,510.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,034.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,183.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,534.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,171.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,622.90. The transfer capital threshold is the transfer adjustment factor * $1,622.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23626.65","23626.65","23626.65","1 through 10","21046.37","23564.33","other","Inpatient DRG"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","both","","","775.00","581.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","737.03","other","OPPS APC"
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","775.00","581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","380.29","49.07","","2115.00","2115.00","2115.00","1 through 10","344.49","607.99","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","775.00","581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","388.28","50.1","","331.25","331.25","331.25","1 through 10","344.49","607.99","percent of total billed charges",""
"Anal Implt Peri Sq Field Stimul Gen","PX-76001747","CDM","64999","CPT","0761","RC","","","","outpatient","","","775.00","581.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","607.99","78.45","","282.15","282.15","282.15","1 through 10","344.49","607.99","percent of total billed charges",""
"Anal Sphincterotomy","PX-75000453","CDM","46080","CPT","0750","RC","","","","both","","","3708.00","2781.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1590.73","2706.84","per diem",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","257.00","192.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.40","59.3","","146.50","146.50","146.50","1 through 10","128.5","222.03","percent of total billed charges",""
"Analysis Gene F2 20210g>a Variant","PX-30000218","CDM","81240","CPT","0310","RC","","","","outpatient","","","257.00","192.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","201.62","78.45","","192.20","184.27","384.40","1 through 10","128.5","222.03","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","256.67","256.67","256.67","1 through 10","198.88","353.03","percent of total billed charges",""
"Analysis Gene Hfe Common Variants","PX-30000227","CDM","81256","CPT","0310","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","199.55","199.55","199.55","1 through 10","198.88","353.03","percent of total billed charges",""
"Analysis Gene Rearrang Trg","PX-30000269","CDM","81342","CPT","0301","RC","","","","both","","","1443.00","1082.25","AETNA [1001]","HB CH AETNA HMO / PPO","841.27","58.3","","795.50","795.50","795.50","1 through 10","197.47","1188.8","percent of total billed charges",""
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","927.00","695.25","MEDICARE [2001]","HB BWF MEDICARE","356.16","","APC Price ($356.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","356.16","326.00","356.16","1 through 10","338.35","1090.79","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","927.00","695.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","349.04","","APC Price ($356.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","349.04","349.04","349.04","1 through 10","338.35","1090.79","other","OPPS APC"
"Analysis Pump Pain W/Program","PX-76001484","CDM","62368","CPT","0761","RC","","","","both","","","927.00","695.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","349.04","","APC Price ($356.16). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.47","350.47","350.47","1 through 10","338.35","1090.79","other","OPPS APC"
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","AETNA [1001]","HB CH AETNA HMO / PPO","865.76","58.3","","554.95","91.85","1421.75","94","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1084.05","73","","2490.03","2490.03","2490.03","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","865.76","58.3","","750.00","750.00","750.00","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","787.05","53","","1192.50","120.84","4149.90","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1262.25","85","","750.00","75.00","750.00","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1485.00","100","","657.00","121.50","1971.00","14","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1485.00","100","","75.00","75.00","75.00","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1485.00","100","","366.00","144.00","1971.00","45","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1084.05","73","","667.50","667.50","667.50","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.08","44.45","","123.77","123.77","123.77","1 through 10","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","WELLPOINT [1015]","HB CH WELLPOINT","1156.96","77.91","","483.51","229.32","1316.08","96","660.08","1485","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","880.61","59.3","","439.50","225.34","1872.27","197","742.5","1164.98","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 MT SUT BL","SUP-ITM-10328390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1164.98","78.45","","385.32","55.36","1815.62","58","742.5","1164.98","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","554.95","91.85","1421.75","94","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","2490.03","2490.03","2490.03","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","750.00","750.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","1192.50","120.84","4149.90","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.25","85","","750.00","75.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.00","100","","657.00","121.50","1971.00","14","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.00","100","","75.00","75.00","75.00","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.00","100","","366.00","144.00","1971.00","45","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","667.50","667.50","667.50","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","123.77","123.77","123.77","1 through 10","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","483.51","229.32","1316.08","96","633.41","1425","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","439.50","225.34","1872.27","197","712.5","1117.91","percent of total billed charges",""
"ANCHOR ALL-SUTURE 1.8MM Q-FIX KNOTLESS W/1 UB SUT COBRAID BL","SUP-ITM-10328389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","385.32","55.36","1815.62","58","712.5","1117.91","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","554.95","91.85","1421.75","94","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2490.03","2490.03","2490.03","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","750.00","750.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","1192.50","120.84","4149.90","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","750.00","75.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","657.00","121.50","1971.00","14","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","75.00","75.00","75.00","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","366.00","144.00","1971.00","45","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","667.50","667.50","667.50","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","123.77","123.77","123.77","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","483.51","229.32","1316.08","96","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","439.50","225.34","1872.27","197","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3 WITH ARTHROSCOPIC DELIVERY SYSTEM","SUP-ITM-10216997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","385.32","55.36","1815.62","58","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","554.95","91.85","1421.75","94","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2490.03","2490.03","2490.03","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","750.00","750.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","1192.50","120.84","4149.90","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","750.00","75.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","657.00","121.50","1971.00","14","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","75.00","75.00","75.00","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","366.00","144.00","1971.00","45","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","667.50","667.50","667.50","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","123.77","123.77","123.77","1 through 10","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","483.51","229.32","1316.08","96","800.1","1800","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","439.50","225.34","1872.27","197","900","1412.1","percent of total billed charges",""
"ANCHOR BONE 3.4MM ARTHROSCOPIC DELIVERY SYSTEM ADVANCED","SUP-ITM-10217020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","385.32","55.36","1815.62","58","900","1412.1","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","554.95","91.85","1421.75","94","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","2490.03","2490.03","2490.03","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","750.00","750.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","1192.50","120.84","4149.90","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","382.50","85","","750.00","75.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.00","100","","657.00","121.50","1971.00","14","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","450.00","100","","75.00","75.00","75.00","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","366.00","144.00","1971.00","45","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","667.50","667.50","667.50","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","123.77","123.77","123.77","1 through 10","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","483.51","229.32","1316.08","96","200.03","450","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","439.50","225.34","1872.27","197","225","353.03","percent of total billed charges",""
"ANCHOR BONE PEEK NONABSORBABLE ROTATION","SUP-ITM-10216998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","385.32","55.36","1815.62","58","225","353.03","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","AETNA [1001]","HB CH AETNA HMO / PPO","290.05","58.3","","554.95","91.85","1421.75","94","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","363.19","73","","2490.03","2490.03","2490.03","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","290.05","58.3","","750.00","750.00","750.00","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","263.69","53","","1192.50","120.84","4149.90","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","422.89","85","","750.00","75.00","750.00","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","497.52","100","","657.00","121.50","1971.00","14","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","497.52","100","","75.00","75.00","75.00","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","497.52","100","","366.00","144.00","1971.00","45","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","363.19","73","","667.50","667.50","667.50","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","221.15","44.45","","123.77","123.77","123.77","1 through 10","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","both","","","497.52","373.14","WELLPOINT [1015]","HB CH WELLPOINT","387.62","77.91","","483.51","229.32","1316.08","96","221.15","497.52","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.52","373.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","295.03","59.3","","439.50","225.34","1872.27","197","248.76","390.3","percent of total billed charges",""
"ANCHOR KNEE 1.1X13MM CONTOUR MENISCUS ARROW COPOLYMER BIOABSORBABLE . OD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10028828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","497.52","373.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","390.30","78.45","","385.32","55.36","1815.62","58","248.76","390.3","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","AETNA [1001]","HB CH AETNA HMO / PPO","599.91","58.3","","554.95","91.85","1421.75","94","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","751.17","73","","2490.03","2490.03","2490.03","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","599.91","58.3","","750.00","750.00","750.00","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","545.37","53","","1192.50","120.84","4149.90","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","874.65","85","","750.00","75.00","750.00","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1029.00","100","","657.00","121.50","1971.00","14","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1029.00","100","","75.00","75.00","75.00","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1029.00","100","","366.00","144.00","1971.00","45","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","751.17","73","","667.50","667.50","667.50","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.39","44.45","","123.77","123.77","123.77","1 through 10","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB CH WELLPOINT","801.69","77.91","","483.51","229.32","1316.08","96","457.39","1029","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","610.20","59.3","","439.50","225.34","1872.27","197","514.5","807.25","percent of total billed charges",""
"ANCHOR MICROFIX 4 0 NEEDLE C 1 LENGTH 1.3MM QUICK BIT","SUP-ITM-10030995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","807.25","78.45","","385.32","55.36","1815.62","58","514.5","807.25","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","554.95","91.85","1421.75","94","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","2490.03","2490.03","2490.03","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","750.00","750.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","1192.50","120.84","4149.90","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","701.25","85","","750.00","75.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","825.00","100","","657.00","121.50","1971.00","14","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","825.00","100","","75.00","75.00","75.00","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","825.00","100","","366.00","144.00","1971.00","45","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","667.50","667.50","667.50","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","123.77","123.77","123.77","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","483.51","229.32","1316.08","96","366.71","825","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","439.50","225.34","1872.27","197","412.5","647.21","percent of total billed charges",""
"ANCHOR SURGICAL 1.8MM Q FIX SUTURE","SUP-ITM-10124147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","385.32","55.36","1815.62","58","412.5","647.21","percent of total billed charges",""
"ANCHOR SURGICAL CLICKX MRI SAFE","SUP-ITM-10174952","CDM","C1883","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","1892.10","1892.10","1892.10","1 through 10","596.25","1125","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","AETNA [1001]","HB CH AETNA HMO / PPO","918.23","58.3","","554.95","91.85","1421.75","94","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","2490.03","2490.03","2490.03","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","918.23","58.3","","750.00","750.00","750.00","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","834.75","53","","1192.50","120.84","4149.90","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1338.75","85","","750.00","75.00","750.00","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1575.00","100","","657.00","121.50","1971.00","14","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1575.00","100","","75.00","75.00","75.00","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1575.00","100","","366.00","144.00","1971.00","45","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","667.50","667.50","667.50","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","123.77","123.77","123.77","1 through 10","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB CH WELLPOINT","1227.08","77.91","","483.51","229.32","1316.08","96","700.09","1575","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","933.98","59.3","","439.50","225.34","1872.27","197","787.5","1235.59","percent of total billed charges",""
"ANCHOR SUTURE 0.9ST NEEDLE FIBERTAK DBL LOADED W/BLUE BX/5EA","SUP-ITM-10318998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","385.32","55.36","1815.62","58","787.5","1235.59","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","AETNA [1001]","HB CH AETNA HMO / PPO","769.56","58.3","","554.95","91.85","1421.75","94","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","963.60","73","","2490.03","2490.03","2490.03","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","769.56","58.3","","750.00","750.00","750.00","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","699.60","53","","1192.50","120.84","4149.90","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1122.00","85","","750.00","75.00","750.00","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1320.00","100","","657.00","121.50","1971.00","14","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1320.00","100","","75.00","75.00","75.00","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1320.00","100","","366.00","144.00","1971.00","45","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","963.60","73","","667.50","667.50","667.50","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","586.74","44.45","","123.77","123.77","123.77","1 through 10","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","both","","","1320.00","990.00","WELLPOINT [1015]","HB CH WELLPOINT","1028.41","77.91","","483.51","229.32","1316.08","96","586.74","1320","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","782.76","59.3","","439.50","225.34","1872.27","197","660","1035.54","percent of total billed charges",""
"ANCHOR SUTURE 1.8MM KNOTLESS NUMBER 2 FIBERTAK GEN2 SOFT BX/5EA","SUP-ITM-10318069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1320.00","990.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1035.54","78.45","","385.32","55.36","1815.62","58","660","1035.54","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","AETNA [1001]","HB CH AETNA HMO / PPO","822.03","58.3","","554.95","91.85","1421.75","94","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1029.30","73","","2490.03","2490.03","2490.03","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","822.03","58.3","","750.00","750.00","750.00","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","747.30","53","","1192.50","120.84","4149.90","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1198.50","85","","750.00","75.00","750.00","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1410.00","100","","657.00","121.50","1971.00","14","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1410.00","100","","75.00","75.00","75.00","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1410.00","100","","366.00","144.00","1971.00","45","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1029.30","73","","667.50","667.50","667.50","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","626.75","44.45","","123.77","123.77","123.77","1 through 10","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","both","","","1410.00","1057.50","WELLPOINT [1015]","HB CH WELLPOINT","1098.53","77.91","","483.51","229.32","1316.08","96","626.75","1410","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1410.00","1057.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","836.13","59.3","","439.50","225.34","1872.27","197","705","1106.15","percent of total billed charges",""
"ANCHOR SUTURE 19.1X4.75MM VENTED CLOSED EYELET FIBERTAPE LOOP SWIVELOCK BIOCOMPOSITE BX/5EA","SUP-ITM-10318096","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1410.00","1057.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1106.15","78.45","","385.32","55.36","1815.62","58","705","1106.15","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","554.95","91.85","1421.75","94","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2490.03","2490.03","2490.03","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","750.00","750.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","1192.50","120.84","4149.90","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","750.00","75.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","657.00","121.50","1971.00","14","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","75.00","75.00","75.00","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","366.00","144.00","1971.00","45","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","667.50","667.50","667.50","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","123.77","123.77","123.77","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","483.51","229.32","1316.08","96","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","439.50","225.34","1872.27","197","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 19.1X5.5MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","385.32","55.36","1815.62","58","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","463.49","58.3","","554.95","91.85","1421.75","94","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","2490.03","2490.03","2490.03","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","463.49","58.3","","750.00","750.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","421.35","53","","1192.50","120.84","4149.90","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","675.75","85","","750.00","75.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","795.00","100","","657.00","121.50","1971.00","14","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","795.00","100","","75.00","75.00","75.00","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","795.00","100","","366.00","144.00","1971.00","45","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","667.50","667.50","667.50","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","123.77","123.77","123.77","1 through 10","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","WELLPOINT [1015]","HB CH WELLPOINT","619.38","77.91","","483.51","229.32","1316.08","96","353.38","795","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","439.50","225.34","1872.27","197","397.5","623.68","percent of total billed charges",""
"ANCHOR SUTURE 19MM SUTUREFIX CURVED","SUP-ITM-10213098","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","385.32","55.36","1815.62","58","397.5","623.68","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","AETNA [1001]","HB CH AETNA HMO / PPO","391.78","58.3","","554.95","91.85","1421.75","94","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","2490.03","2490.03","2490.03","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","391.78","58.3","","750.00","750.00","750.00","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","356.16","53","","1192.50","120.84","4149.90","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","571.20","85","","750.00","75.00","750.00","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","672.00","100","","657.00","121.50","1971.00","14","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","672.00","100","","75.00","75.00","75.00","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","672.00","100","","366.00","144.00","1971.00","45","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","667.50","667.50","667.50","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","123.77","123.77","123.77","1 through 10","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB CH WELLPOINT","523.56","77.91","","483.51","229.32","1316.08","96","298.7","672","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","398.50","59.3","","439.50","225.34","1872.27","197","336","527.18","percent of total billed charges",""
"ANCHOR SUTURE 2.3MMX2 SZ 0 MINILOK QUICK PLUS PANACRYL BIO A - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10024825","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","385.32","55.36","1815.62","58","336","527.18","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","AETNA [1001]","HB CH AETNA HMO / PPO","662.87","58.3","","554.95","91.85","1421.75","94","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","830.01","73","","2490.03","2490.03","2490.03","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","662.87","58.3","","750.00","750.00","750.00","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","602.61","53","","1192.50","120.84","4149.90","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","966.45","85","","750.00","75.00","750.00","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1137.00","100","","657.00","121.50","1971.00","14","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1137.00","100","","75.00","75.00","75.00","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1137.00","100","","366.00","144.00","1971.00","45","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","830.01","73","","667.50","667.50","667.50","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","505.40","44.45","","123.77","123.77","123.77","1 through 10","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","both","","","1137.00","852.75","WELLPOINT [1015]","HB CH WELLPOINT","885.84","77.91","","483.51","229.32","1316.08","96","505.4","1137","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.00","852.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","674.24","59.3","","439.50","225.34","1872.27","197","568.5","891.98","percent of total billed charges",""
"ANCHOR SUTURE 2.4MM KNOTLESS","SUP-ITM-10191418","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1137.00","852.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","891.98","78.45","","385.32","55.36","1815.62","58","568.5","891.98","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","AETNA [1001]","HB CH AETNA HMO / PPO","900.74","58.3","","554.95","91.85","1421.75","94","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1127.85","73","","2490.03","2490.03","2490.03","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","900.74","58.3","","750.00","750.00","750.00","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","818.85","53","","1192.50","120.84","4149.90","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1313.25","85","","750.00","75.00","750.00","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1545.00","100","","657.00","121.50","1971.00","14","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1545.00","100","","75.00","75.00","75.00","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1545.00","100","","366.00","144.00","1971.00","45","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1127.85","73","","667.50","667.50","667.50","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","686.75","44.45","","123.77","123.77","123.77","1 through 10","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","both","","","1545.00","1158.75","WELLPOINT [1015]","HB CH WELLPOINT","1203.71","77.91","","483.51","229.32","1316.08","96","686.75","1545","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.00","1158.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","916.19","59.3","","439.50","225.34","1872.27","197","772.5","1212.05","percent of total billed charges",""
"ANCHOR SUTURE 2.9MM BIORAPTOR KNOTLESS HIP INSERTER","SUP-ITM-10079994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1545.00","1158.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1212.05","78.45","","385.32","55.36","1815.62","58","772.5","1212.05","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","554.95","91.85","1421.75","94","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","2490.03","2490.03","2490.03","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","734.58","58.3","","750.00","750.00","750.00","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","1192.50","120.84","4149.90","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1071.00","85","","750.00","75.00","750.00","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1260.00","100","","657.00","121.50","1971.00","14","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1260.00","100","","75.00","75.00","75.00","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1260.00","100","","366.00","144.00","1971.00","45","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","667.50","667.50","667.50","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","560.07","44.45","","123.77","123.77","123.77","1 through 10","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","483.51","229.32","1316.08","96","560.07","1260","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","439.50","225.34","1872.27","197","630","988.47","percent of total billed charges",""
"ANCHOR SUTURE 24.5X4.75MM ARTHROSCOPY SWIVELOCK BIOCOMPOSITE VENTED CLOSED EYELET BX/5EA","SUP-ITM-10078784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","385.32","55.36","1815.62","58","630","988.47","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","AETNA [1001]","HB CH AETNA HMO / PPO","545.69","58.3","","554.95","91.85","1421.75","94","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","683.28","73","","2490.03","2490.03","2490.03","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","545.69","58.3","","750.00","750.00","750.00","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","496.08","53","","1192.50","120.84","4149.90","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","795.60","85","","750.00","75.00","750.00","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","936.00","100","","657.00","121.50","1971.00","14","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","936.00","100","","75.00","75.00","75.00","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","936.00","100","","366.00","144.00","1971.00","45","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","683.28","73","","667.50","667.50","667.50","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.05","44.45","","123.77","123.77","123.77","1 through 10","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.00","702.00","WELLPOINT [1015]","HB CH WELLPOINT","729.24","77.91","","483.51","229.32","1316.08","96","416.05","936","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","555.05","59.3","","439.50","225.34","1872.27","197","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 3.0MM ARTHROSCOPY GRYPHON P BIOCRYL RAPIDE ORTHOCORD PEEK BIOCOMPOSITE PUSH THREAD BARBED DUAL 210813","SUP-ITM-10072968","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.00","702.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","734.29","78.45","","385.32","55.36","1815.62","58","468","734.29","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","554.95","91.85","1421.75","94","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2490.03","2490.03","2490.03","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","750.00","750.00","750.00","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","1192.50","120.84","4149.90","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","750.00","75.00","750.00","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","657.00","121.50","1971.00","14","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","75.00","75.00","75.00","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","366.00","144.00","1971.00","45","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","667.50","667.50","667.50","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","123.77","123.77","123.77","1 through 10","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","483.51","229.32","1316.08","96","400.05","900","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","439.50","225.34","1872.27","197","450","706.05","percent of total billed charges",""
"ANCHOR SUTURE 3.4MM SPEEDLOCK OPUS PEEK KNOTLESS INTERFERENCE RADIOLUCENT","SUP-ITM-10092010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","385.32","55.36","1815.62","58","450","706.05","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","AETNA [1001]","HB CH AETNA HMO / PPO","673.37","58.3","","554.95","91.85","1421.75","94","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","843.15","73","","2490.03","2490.03","2490.03","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","673.37","58.3","","750.00","750.00","750.00","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","612.15","53","","1192.50","120.84","4149.90","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","981.75","85","","750.00","75.00","750.00","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1155.00","100","","657.00","121.50","1971.00","14","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1155.00","100","","75.00","75.00","75.00","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1155.00","100","","366.00","144.00","1971.00","45","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","843.15","73","","667.50","667.50","667.50","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.40","44.45","","123.77","123.77","123.77","1 through 10","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","WELLPOINT [1015]","HB CH WELLPOINT","899.86","77.91","","483.51","229.32","1316.08","96","513.4","1155","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","684.92","59.3","","439.50","225.34","1872.27","197","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 3X12.7MM NUMBER 2 PEEK KNOTLESS TAK W/NUMBER FIBERWIRE CL BX/5EA","SUP-ITM-10148166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","906.10","78.45","","385.32","55.36","1815.62","58","577.5","906.1","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","AETNA [1001]","HB CH AETNA HMO / PPO","963.70","58.3","","554.95","91.85","1421.75","94","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1206.69","73","","2490.03","2490.03","2490.03","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","963.70","58.3","","750.00","750.00","750.00","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","876.09","53","","1192.50","120.84","4149.90","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1405.05","85","","750.00","75.00","750.00","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1653.00","100","","657.00","121.50","1971.00","14","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1653.00","100","","75.00","75.00","75.00","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1653.00","100","","366.00","144.00","1971.00","45","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1206.69","73","","667.50","667.50","667.50","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","734.76","44.45","","123.77","123.77","123.77","1 through 10","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","both","","","1653.00","1239.75","WELLPOINT [1015]","HB CH WELLPOINT","1287.85","77.91","","483.51","229.32","1316.08","96","734.76","1653","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1653.00","1239.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","980.23","59.3","","439.50","225.34","1872.27","197","826.5","1296.78","percent of total billed charges",""
"ANCHOR SUTURE 4.5MM FOOTPRINT ULTRA PK ACHILLES TENDON REPAIR SL","SUP-ITM-10217179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1653.00","1239.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1296.78","78.45","","385.32","55.36","1815.62","58","826.5","1296.78","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","554.95","91.85","1421.75","94","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2490.03","2490.03","2490.03","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","750.00","750.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","1192.50","120.84","4149.90","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","750.00","75.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","657.00","121.50","1971.00","14","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","75.00","75.00","75.00","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","366.00","144.00","1971.00","45","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","667.50","667.50","667.50","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","123.77","123.77","123.77","1 through 10","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","483.51","229.32","1316.08","96","1066.8","2400","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","439.50","225.34","1872.27","197","1200","1882.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75 LOOP N TAK SWIVELOCK TENODESIS IMPLANT SYSTEM","SUP-ITM-10289566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","385.32","55.36","1815.62","58","1200","1882.8","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","554.95","91.85","1421.75","94","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","2490.03","2490.03","2490.03","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","750.00","750.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","1192.50","120.84","4149.90","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","752.25","85","","750.00","75.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","885.00","100","","657.00","121.50","1971.00","14","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","885.00","100","","75.00","75.00","75.00","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","885.00","100","","366.00","144.00","1971.00","45","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","667.50","667.50","667.50","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","123.77","123.77","123.77","1 through 10","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","483.51","229.32","1316.08","96","393.38","885","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","439.50","225.34","1872.27","197","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM HEALICOIL REGENSORB WITH 2 #2 ULTRABRAID","SUP-ITM-10126696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","385.32","55.36","1815.62","58","442.5","694.28","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","554.95","91.85","1421.75","94","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","2490.03","2490.03","2490.03","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","750.00","750.00","750.00","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","1192.50","120.84","4149.90","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","803.25","85","","750.00","75.00","750.00","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","945.00","100","","657.00","121.50","1971.00","14","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","945.00","100","","75.00","75.00","75.00","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","945.00","100","","366.00","144.00","1971.00","45","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","667.50","667.50","667.50","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","123.77","123.77","123.77","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","483.51","229.32","1316.08","96","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","439.50","225.34","1872.27","197","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75MM PRELOADED HEALICOIL REGENESORB ULTRATAPE NUMBER 2 ULTRABRAID","SUP-ITM-10165188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","385.32","55.36","1815.62","58","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","AETNA [1001]","HB CH AETNA HMO / PPO","804.54","58.3","","554.95","91.85","1421.75","94","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1007.40","73","","2490.03","2490.03","2490.03","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","804.54","58.3","","750.00","750.00","750.00","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","731.40","53","","1192.50","120.84","4149.90","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1173.00","85","","750.00","75.00","750.00","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1380.00","100","","657.00","121.50","1971.00","14","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1380.00","100","","75.00","75.00","75.00","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1380.00","100","","366.00","144.00","1971.00","45","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1007.40","73","","667.50","667.50","667.50","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.41","44.45","","123.77","123.77","123.77","1 through 10","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.00","1035.00","WELLPOINT [1015]","HB CH WELLPOINT","1075.16","77.91","","483.51","229.32","1316.08","96","613.41","1380","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.00","1035.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","818.34","59.3","","439.50","225.34","1872.27","197","690","1082.61","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM KNOTLESS NUMBER 2 BLUE BX/5EA","SUP-ITM-10297912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.00","1035.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1082.61","78.45","","385.32","55.36","1815.62","58","690","1082.61","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","AETNA [1001]","HB CH AETNA HMO / PPO","2536.05","58.3","","554.95","91.85","1421.75","94","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3175.50","73","","2490.03","2490.03","2490.03","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2536.05","58.3","","750.00","750.00","750.00","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2305.50","53","","1192.50","120.84","4149.90","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3697.50","85","","750.00","75.00","750.00","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4350.00","100","","657.00","121.50","1971.00","14","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4350.00","100","","75.00","75.00","75.00","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4350.00","100","","366.00","144.00","1971.00","45","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3175.50","73","","667.50","667.50","667.50","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.58","44.45","","123.77","123.77","123.77","1 through 10","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","WELLPOINT [1015]","HB CH WELLPOINT","3389.09","77.91","","483.51","229.32","1316.08","96","1933.58","4350","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2579.55","59.3","","439.50","225.34","1872.27","197","2175","3412.58","percent of total billed charges",""
"ANCHOR SUTURE 4.75X19.1MM SWIVELOCK IMPLANT ARTHROSCOPY SPEEDBRIDGE BIOCOMPOSITE","SUP-ITM-10114047","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3412.58","78.45","","385.32","55.36","1815.62","58","2175","3412.58","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","554.95","91.85","1421.75","94","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","2490.03","2490.03","2490.03","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","750.00","750.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","1192.50","120.84","4149.90","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","701.25","85","","750.00","75.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","825.00","100","","657.00","121.50","1971.00","14","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","825.00","100","","75.00","75.00","75.00","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","825.00","100","","366.00","144.00","1971.00","45","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","667.50","667.50","667.50","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","123.77","123.77","123.77","1 through 10","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","483.51","229.32","1316.08","96","366.71","825","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","439.50","225.34","1872.27","197","412.5","647.21","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ARTHROSCOPY SOFT TISSUE FIXATION FOOTPRINT ULTRA PACK SHOULDER","SUP-ITM-10079977","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","385.32","55.36","1815.62","58","412.5","647.21","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","554.95","91.85","1421.75","94","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","2490.03","2490.03","2490.03","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","750.00","750.00","750.00","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","1192.50","120.84","4149.90","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","803.25","85","","750.00","75.00","750.00","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","945.00","100","","657.00","121.50","1971.00","14","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","945.00","100","","75.00","75.00","75.00","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","945.00","100","","366.00","144.00","1971.00","45","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","667.50","667.50","667.50","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","123.77","123.77","123.77","1 through 10","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","483.51","229.32","1316.08","96","420.05","945","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","439.50","225.34","1872.27","197","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM HEALICOIL REGENESORB","SUP-ITM-10158759","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","385.32","55.36","1815.62","58","472.5","741.35","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","AETNA [1001]","HB CH AETNA HMO / PPO","559.68","58.3","","554.95","91.85","1421.75","94","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","700.80","73","","2490.03","2490.03","2490.03","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","559.68","58.3","","750.00","750.00","750.00","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","508.80","53","","1192.50","120.84","4149.90","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","816.00","85","","750.00","75.00","750.00","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","960.00","100","","657.00","121.50","1971.00","14","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","960.00","100","","75.00","75.00","75.00","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","960.00","100","","366.00","144.00","1971.00","45","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","700.80","73","","667.50","667.50","667.50","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.72","44.45","","123.77","123.77","123.77","1 through 10","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.00","720.00","WELLPOINT [1015]","HB CH WELLPOINT","747.94","77.91","","483.51","229.32","1316.08","96","426.72","960","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.00","720.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","569.28","59.3","","439.50","225.34","1872.27","197","480","753.12","percent of total billed charges",""
"ANCHOR SUTURE 5.5MM ULTRA KNOTLESS MULTIFIX S DISPOSABLE","SUP-ITM-10216731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.00","720.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","753.12","78.45","","385.32","55.36","1815.62","58","480","753.12","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","AETNA [1001]","HB CH AETNA HMO / PPO","543.94","58.3","","554.95","91.85","1421.75","94","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","681.09","73","","2490.03","2490.03","2490.03","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","543.94","58.3","","750.00","750.00","750.00","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","494.49","53","","1192.50","120.84","4149.90","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","793.05","85","","750.00","75.00","750.00","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","933.00","100","","657.00","121.50","1971.00","14","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","933.00","100","","75.00","75.00","75.00","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","933.00","100","","366.00","144.00","1971.00","45","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","681.09","73","","667.50","667.50","667.50","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.72","44.45","","123.77","123.77","123.77","1 through 10","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","WELLPOINT [1015]","HB CH WELLPOINT","726.90","77.91","","483.51","229.32","1316.08","96","414.72","933","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","933.00","699.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","553.27","59.3","","439.50","225.34","1872.27","197","466.5","731.94","percent of total billed charges",""
"ANCHOR SUTURE BIOABSORBABLE LUPINE DUAL LOOP ORTHOCORD - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020268","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","933.00","699.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","731.94","78.45","","385.32","55.36","1815.62","58","466.5","731.94","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","AETNA [1001]","HB CH AETNA HMO / PPO","1040.66","58.3","","554.95","91.85","1421.75","94","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1303.05","73","","2490.03","2490.03","2490.03","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1040.66","58.3","","750.00","750.00","750.00","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","946.05","53","","1192.50","120.84","4149.90","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1517.25","85","","750.00","75.00","750.00","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1785.00","100","","657.00","121.50","1971.00","14","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1785.00","100","","75.00","75.00","75.00","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1785.00","100","","366.00","144.00","1971.00","45","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1303.05","73","","667.50","667.50","667.50","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.43","44.45","","123.77","123.77","123.77","1 through 10","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","WELLPOINT [1015]","HB CH WELLPOINT","1390.69","77.91","","483.51","229.32","1316.08","96","793.43","1785","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1058.51","59.3","","439.50","225.34","1872.27","197","892.5","1400.33","percent of total billed charges",""
"ANCHOR SUTURE DX #2 MTS W/NEEDLE KNOTLESS FIBERTAK BX/5EA","SUP-ITM-10318936","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1400.33","78.45","","385.32","55.36","1815.62","58","892.5","1400.33","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"ANCHOR SUTURE LENGTH 5.0MM ARTHROSCOPY FASTIN RC TITANIUM ORTHOCORD NEEDLELESS","SUP-ITM-10019874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","AETNA [1001]","HB CH AETNA HMO / PPO","594.66","58.3","","554.95","91.85","1421.75","94","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","744.60","73","","2490.03","2490.03","2490.03","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","594.66","58.3","","750.00","750.00","750.00","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","540.60","53","","1192.50","120.84","4149.90","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","867.00","85","","750.00","75.00","750.00","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1020.00","100","","657.00","121.50","1971.00","14","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1020.00","100","","75.00","75.00","75.00","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1020.00","100","","366.00","144.00","1971.00","45","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","744.60","73","","667.50","667.50","667.50","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.39","44.45","","123.77","123.77","123.77","1 through 10","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.00","765.00","WELLPOINT [1015]","HB CH WELLPOINT","794.68","77.91","","483.51","229.32","1316.08","96","453.39","1020","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.00","765.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","604.86","59.3","","439.50","225.34","1872.27","197","510","800.19","percent of total billed charges",""
"ANCHOR SUTURE MICRORAPTOR KNOTLESS PEEK","SUP-ITM-10239433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.00","765.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","800.19","78.45","","385.32","55.36","1815.62","58","510","800.19","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","AETNA [1001]","HB CH AETNA HMO / PPO","568.43","58.3","","554.95","91.85","1421.75","94","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","711.75","73","","2490.03","2490.03","2490.03","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","568.43","58.3","","750.00","750.00","750.00","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.75","53","","1192.50","120.84","4149.90","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","828.75","85","","750.00","75.00","750.00","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","975.00","100","","657.00","121.50","1971.00","14","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","975.00","100","","75.00","75.00","75.00","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","975.00","100","","366.00","144.00","1971.00","45","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","711.75","73","","667.50","667.50","667.50","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.39","44.45","","123.77","123.77","123.77","1 through 10","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","WELLPOINT [1015]","HB CH WELLPOINT","759.62","77.91","","483.51","229.32","1316.08","96","433.39","975","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","578.18","59.3","","439.50","225.34","1872.27","197","487.5","764.89","percent of total billed charges",""
"ANCHOR SUTURE SIZE 0 NEEDLE26.2MM ARTHROSCOPY TAK BIOCOMPOSITE FIBERWIRE 4 EA DIAMOND BX/5EA - DISCONTINUED PER SUPPLIER","SUP-ITM-10117596","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.89","78.45","","385.32","55.36","1815.62","58","487.5","764.89","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","AETNA [1001]","HB CH AETNA HMO / PPO","529.63","58.3","","554.95","91.85","1421.75","94","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","663.18","73","","2490.03","2490.03","2490.03","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.63","58.3","","750.00","750.00","750.00","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","481.48","53","","1192.50","120.84","4149.90","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","772.19","85","","750.00","75.00","750.00","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","908.46","100","","657.00","121.50","1971.00","14","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","908.46","100","","75.00","75.00","75.00","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","908.46","100","","366.00","144.00","1971.00","45","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","663.18","73","","667.50","667.50","667.50","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.81","44.45","","123.77","123.77","123.77","1 through 10","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","both","","","908.46","681.34","WELLPOINT [1015]","HB CH WELLPOINT","707.78","77.91","","483.51","229.32","1316.08","96","403.81","908.46","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","908.46","681.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.72","59.3","","439.50","225.34","1872.27","197","454.23","712.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 1.0MM ARTHROSCOPY JUGGERKNOT SOFT MAXBRAID POLYESTER SLEEVE DRILL MINI","SUP-ITM-10094373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","908.46","681.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","712.69","78.45","","385.32","55.36","1815.62","58","454.23","712.69","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","AETNA [1001]","HB CH AETNA HMO / PPO","556.18","58.3","","554.95","91.85","1421.75","94","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","696.42","73","","2490.03","2490.03","2490.03","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","556.18","58.3","","750.00","750.00","750.00","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.62","53","","1192.50","120.84","4149.90","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","810.90","85","","750.00","75.00","750.00","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","954.00","100","","657.00","121.50","1971.00","14","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","954.00","100","","75.00","75.00","75.00","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","954.00","100","","366.00","144.00","1971.00","45","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","696.42","73","","667.50","667.50","667.50","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.05","44.45","","123.77","123.77","123.77","1 through 10","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","WELLPOINT [1015]","HB CH WELLPOINT","743.26","77.91","","483.51","229.32","1316.08","96","424.05","954","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","565.72","59.3","","439.50","225.34","1872.27","197","477","748.41","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 ARTHROSCOPY VERSALOK ORTHOCORD NONABSORBABLE","SUP-ITM-10020961","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","748.41","78.45","","385.32","55.36","1815.62","58","477","748.41","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","554.95","91.85","1421.75","94","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","2490.03","2490.03","2490.03","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.47","58.3","","750.00","750.00","750.00","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","453.15","53","","1192.50","120.84","4149.90","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","726.75","85","","750.00","75.00","750.00","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","855.00","100","","657.00","121.50","1971.00","14","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","855.00","100","","75.00","75.00","75.00","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","855.00","100","","366.00","144.00","1971.00","45","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","667.50","667.50","667.50","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","123.77","123.77","123.77","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","483.51","229.32","1316.08","96","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","439.50","225.34","1872.27","197","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH10.0X3.5MM ARTHROSCOPY CORKSCREW BIOCOMPOSITE FULL THREAD BX/5EA","SUP-ITM-10154647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","385.32","55.36","1815.62","58","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","AETNA [1001]","HB CH AETNA HMO / PPO","458.24","58.3","","554.95","91.85","1421.75","94","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","573.78","73","","2490.03","2490.03","2490.03","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","458.24","58.3","","750.00","750.00","750.00","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","416.58","53","","1192.50","120.84","4149.90","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","668.10","85","","750.00","75.00","750.00","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","786.00","100","","657.00","121.50","1971.00","14","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","786.00","100","","75.00","75.00","75.00","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","786.00","100","","366.00","144.00","1971.00","45","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","573.78","73","","667.50","667.50","667.50","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.38","44.45","","123.77","123.77","123.77","1 through 10","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","WELLPOINT [1015]","HB CH WELLPOINT","612.37","77.91","","483.51","229.32","1316.08","96","349.38","786","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.00","589.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","466.10","59.3","","439.50","225.34","1872.27","197","393","616.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 LENGTH36IN ARTHROSCOPY LUPINE BIOABSORBABLE ORTHOCORD","SUP-ITM-10021990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.00","589.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","616.62","78.45","","385.32","55.36","1815.62","58","393","616.62","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","AETNA [1001]","HB CH AETNA HMO / PPO","346.30","58.3","","554.95","91.85","1421.75","94","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","433.62","73","","2490.03","2490.03","2490.03","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","346.30","58.3","","750.00","750.00","750.00","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","314.82","53","","1192.50","120.84","4149.90","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","504.90","85","","750.00","75.00","750.00","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","594.00","100","","657.00","121.50","1971.00","14","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","594.00","100","","75.00","75.00","75.00","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","594.00","100","","366.00","144.00","1971.00","45","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","433.62","73","","667.50","667.50","667.50","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.03","44.45","","123.77","123.77","123.77","1 through 10","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","WELLPOINT [1015]","HB CH WELLPOINT","462.79","77.91","","483.51","229.32","1316.08","96","264.03","594","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","352.24","59.3","","439.50","225.34","1872.27","197","297","465.99","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLECP2 LENGTH8.8X2.4MM ARTHROSCOPY GII QUICK SS ORTHOCORD","SUP-ITM-10017713","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","465.99","78.45","","385.32","55.36","1815.62","58","297","465.99","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB CH AETNA HMO / PPO","363.79","58.3","","554.95","91.85","1421.75","94","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","2490.03","2490.03","2490.03","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.79","58.3","","750.00","750.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.72","53","","1192.50","120.84","4149.90","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","530.40","85","","750.00","75.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","624.00","100","","657.00","121.50","1971.00","14","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","624.00","100","","75.00","75.00","75.00","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","624.00","100","","366.00","144.00","1971.00","45","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","667.50","667.50","667.50","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","123.77","123.77","123.77","1 through 10","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB CH WELLPOINT","486.16","77.91","","483.51","229.32","1316.08","96","277.37","624","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","370.03","59.3","","439.50","225.34","1872.27","197","312","489.53","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV 5 LENGTH18IN ARTHROSCOPY QUICK MINI PK/1EA","SUP-ITM-10082673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","385.32","55.36","1815.62","58","312","489.53","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","AETNA [1001]","HB CH AETNA HMO / PPO","591.16","58.3","","554.95","91.85","1421.75","94","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","740.22","73","","2490.03","2490.03","2490.03","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","591.16","58.3","","750.00","750.00","750.00","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.42","53","","1192.50","120.84","4149.90","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","861.90","85","","750.00","75.00","750.00","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1014.00","100","","657.00","121.50","1971.00","14","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1014.00","100","","75.00","75.00","75.00","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1014.00","100","","366.00","144.00","1971.00","45","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","740.22","73","","667.50","667.50","667.50","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.72","44.45","","123.77","123.77","123.77","1 through 10","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.00","760.50","WELLPOINT [1015]","HB CH WELLPOINT","790.01","77.91","","483.51","229.32","1316.08","96","450.72","1014","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.00","760.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","601.30","59.3","","439.50","225.34","1872.27","197","507","795.48","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2 0 NEEDLEV5 LENGTH2.0MM ARTHROSCOPY GII QUICK SS DRILL BIT ORTHOCORD BRAIDED MINI","SUP-ITM-10030988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.00","760.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","795.48","78.45","","385.32","55.36","1815.62","58","507","795.48","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","AETNA [1001]","HB CH AETNA HMO / PPO","629.64","58.3","","554.95","91.85","1421.75","94","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","788.40","73","","2490.03","2490.03","2490.03","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","629.64","58.3","","750.00","750.00","750.00","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","572.40","53","","1192.50","120.84","4149.90","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","918.00","85","","750.00","75.00","750.00","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1080.00","100","","657.00","121.50","1971.00","14","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1080.00","100","","75.00","75.00","75.00","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1080.00","100","","366.00","144.00","1971.00","45","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","788.40","73","","667.50","667.50","667.50","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.06","44.45","","123.77","123.77","123.77","1 through 10","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","WELLPOINT [1015]","HB CH WELLPOINT","841.43","77.91","","483.51","229.32","1316.08","96","480.06","1080","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","640.44","59.3","","439.50","225.34","1872.27","197","540","847.26","percent of total billed charges",""
"ANCHOR SUTURE SIZE 2.5MM LENGTH8MM ARTHROSCOPY PUSHLOCK PEEK MINI DIAMETER BX/5EA","SUP-ITM-10051969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","847.26","78.45","","385.32","55.36","1815.62","58","540","847.26","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","554.95","91.85","1421.75","94","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","2490.03","2490.03","2490.03","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","750.00","750.00","750.00","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","1192.50","120.84","4149.90","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","739.50","85","","750.00","75.00","750.00","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","870.00","100","","657.00","121.50","1971.00","14","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","870.00","100","","75.00","75.00","75.00","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","870.00","100","","366.00","144.00","1971.00","45","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","667.50","667.50","667.50","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","123.77","123.77","123.77","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","483.51","229.32","1316.08","96","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","439.50","225.34","1872.27","197","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM ARTHROSCOPY OSTEORAPTOR LF HA ULTRABRAID DISPOSABLE BLACK","SUP-ITM-10049682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","385.32","55.36","1815.62","58","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","554.95","91.85","1421.75","94","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2490.03","2490.03","2490.03","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","750.00","750.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","1192.50","120.84","4149.90","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","750.00","75.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","657.00","121.50","1971.00","14","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","75.00","75.00","75.00","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","366.00","144.00","1971.00","45","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","667.50","667.50","667.50","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","123.77","123.77","123.77","1 through 10","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","483.51","229.32","1316.08","96","533.4","1200","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","439.50","225.34","1872.27","197","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.3MM BIORAPTOR TITANIUM ULTRABRAID PRELOADED COBRAID SM JOINT BLACK WHITE","SUP-ITM-10026698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","385.32","55.36","1815.62","58","600","941.4","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","554.95","91.85","1421.75","94","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","2490.03","2490.03","2490.03","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","750.00","750.00","750.00","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","1192.50","120.84","4149.90","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","739.50","85","","750.00","75.00","750.00","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","870.00","100","","657.00","121.50","1971.00","14","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","870.00","100","","75.00","75.00","75.00","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","870.00","100","","366.00","144.00","1971.00","45","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","667.50","667.50","667.50","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","123.77","123.77","123.77","1 through 10","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","483.51","229.32","1316.08","96","386.72","870","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","439.50","225.34","1872.27","197","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ARTHROSCOPY OSTEORAPTOR LF HYDROXYAPATITE ULTRABRAID DISPOSABLE WHITE BLACK","SUP-ITM-10049684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","385.32","55.36","1815.62","58","435","682.52","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","554.95","91.85","1421.75","94","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","2490.03","2490.03","2490.03","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.47","58.3","","750.00","750.00","750.00","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","453.15","53","","1192.50","120.84","4149.90","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","726.75","85","","750.00","75.00","750.00","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","855.00","100","","657.00","121.50","1971.00","14","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","855.00","100","","75.00","75.00","75.00","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","855.00","100","","366.00","144.00","1971.00","45","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","667.50","667.50","667.50","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","123.77","123.77","123.77","1 through 10","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","483.51","229.32","1316.08","96","380.05","855","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","439.50","225.34","1872.27","197","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 2.9MM ENDOSCOPY OSTEORAPTOR 2 ULTRABRAID COBRAIDED WHITE BLUE","SUP-ITM-10049687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","385.32","55.36","1815.62","58","427.5","670.75","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","AETNA [1001]","HB CH AETNA HMO / PPO","542.19","58.3","","554.95","91.85","1421.75","94","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","678.90","73","","2490.03","2490.03","2490.03","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","542.19","58.3","","750.00","750.00","750.00","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","492.90","53","","1192.50","120.84","4149.90","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","790.50","85","","750.00","75.00","750.00","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","930.00","100","","657.00","121.50","1971.00","14","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","930.00","100","","75.00","75.00","75.00","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","930.00","100","","366.00","144.00","1971.00","45","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","678.90","73","","667.50","667.50","667.50","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.39","44.45","","123.77","123.77","123.77","1 through 10","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.00","697.50","WELLPOINT [1015]","HB CH WELLPOINT","724.56","77.91","","483.51","229.32","1316.08","96","413.39","930","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.00","697.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","551.49","59.3","","439.50","225.34","1872.27","197","465","729.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 5.5MM PACK HEALICOIL ULTRATAPE BLUE","SUP-ITM-10151412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.00","697.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","729.59","78.45","","385.32","55.36","1815.62","58","465","729.59","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","AETNA [1001]","HB CH AETNA HMO / PPO","381.28","58.3","","554.95","91.85","1421.75","94","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","477.42","73","","2490.03","2490.03","2490.03","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","381.28","58.3","","750.00","750.00","750.00","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","346.62","53","","1192.50","120.84","4149.90","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","555.90","85","","750.00","75.00","750.00","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","654.00","100","","657.00","121.50","1971.00","14","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","654.00","100","","75.00","75.00","75.00","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","654.00","100","","366.00","144.00","1971.00","45","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","477.42","73","","667.50","667.50","667.50","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","290.70","44.45","","123.77","123.77","123.77","1 through 10","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","both","","","654.00","490.50","WELLPOINT [1015]","HB CH WELLPOINT","509.53","77.91","","483.51","229.32","1316.08","96","290.7","654","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.00","490.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","387.82","59.3","","439.50","225.34","1872.27","197","327","513.06","percent of total billed charges",""
"ANCHOR SUTURE SZ 2 DOUBLE LOADED NEEDLE ORTHOCORD PERMANENT POLYETHYLENE SUPER QUICK","SUP-ITM-10018177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","654.00","490.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","513.06","78.45","","385.32","55.36","1815.62","58","327","513.06","percent of total billed charges",""
"Angina Pectoris","311","MS-DRG","","","","","","","","inpatient","","","22207.00","16655.25","MEDICARE [2001]","HB BWF MEDICARE","6801.97","","Case rate ($6,801.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,812.49, add-ons for qualifying new technology services are included. If operating cost exceeds $52,336.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,057.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,966.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,473.25 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $496.22. The transfer capital threshold is the transfer adjustment factor * $496.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7147.87","7147.87","7147.87","1 through 10","6665.93","7006.03","other","Inpatient Replacement Plans DRG"
"Angina Pectoris And Coronary Atherosclerosis,MINOR","198","DRG","","","","","","","","inpatient","","","22207.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11291.61","","Standard inlier is a Case rate ($11,291.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,602.89) for the length of stay and the standard reimbursement.","10778.50","10778.50","10778.50","1 through 10","3782.37","17208.62","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MINOR","198","DRG","","","","","","","","inpatient","","","22207.00","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7998.5406","","Fee schedule rate ($7,998.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7998.5406","7998.54","7998.54","1 through 10","3782.37","17208.62","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","19320.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13493.06","","Standard inlier is a Case rate ($13,493.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,231, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,915.39) for the length of stay and the standard reimbursement.","12879.91","12879.91","12879.91","1 through 10","3782.37","17208.62","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","19320.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14494.23","","Standard inlier is a Case rate ($14,494.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,491, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,057.40) for the length of stay and the standard reimbursement.","14494.23","14494.23","14494.23","1 through 10","3782.37","17208.62","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","19320.84","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15036.22","","Fee schedule rate ($15,036.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33948.22","33948.22","33948.22","1 through 10","3782.37","17208.62","case rate",""
"Angina Pectoris And Coronary Atherosclerosis,MODERATE","198","DRG","","","","","","","","inpatient","","","19320.84","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4514.63","","Case rate ($4,991.70). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,421.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,097.35 and the sum of the standard inlier and any outlier amount.","2096.84","1215.98","4990.47","1 through 10","3782.37","17208.62","case rate",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","both","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.23","44.45","","91.49","91.49","91.49","1 through 10","14.31","89.06","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","122.00","91.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.35","59.3","","69.73","69.73","69.73","1 through 10","15.06","95.71","percent of total billed charges",""
"Angiotensin I Enzyme (Ace)","PX-30000315","CDM","82164","CPT","0301","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.71","78.45","","91.49","91.49","91.49","1 through 10","15.06","95.71","percent of total billed charges",""
"Angiovac Thromb/Embol Cannula","PX-27001176","CDM","C1757","HCPCS","0272","RC","","","","both","","","23000.00","17250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","19550.00","85","","1621.37","1621.37","1621.37","1 through 10","10223.5","23000","percent of total billed charges",""
"Angiovac Thromb/Embol Cannula","PX-27001176","CDM","C1757","HCPCS","0272","RC","","","","both","","","23000.00","17250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","23000.00","100","","2116.03","232.05","2316.03","1 through 10","10223.5","23000","percent of total billed charges",""
"Angiovac Thromb/Embol Cannula","PX-27001176","CDM","C1757","HCPCS","0272","RC","","","","outpatient","","","23000.00","17250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18043.50","78.45","","178.40","178.40","269.84","1 through 10","11500","18043.5","percent of total billed charges",""
"Angiovac Thromb/Embol Cannula, Plus Circuit","PX-27001177","CDM","C1757","HCPCS","0272","RC","","","","both","","","26000.00","19500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","22100.00","85","","1621.37","1621.37","1621.37","1 through 10","11557","26000","percent of total billed charges",""
"Angiovac Thromb/Embol Cannula, Plus Circuit","PX-27001177","CDM","C1757","HCPCS","0272","RC","","","","both","","","26000.00","19500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","26000.00","100","","2116.03","232.05","2316.03","1 through 10","11557","26000","percent of total billed charges",""
"Angiovac Thromb/Embol Cannula, Plus Circuit","PX-27001177","CDM","C1757","HCPCS","0272","RC","","","","outpatient","","","26000.00","19500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","20397.00","78.45","","178.40","178.40","269.84","1 through 10","13000","20397","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1634.24","1004.95","1718.99","42","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","2123.89","1900.92","2123.89","1 through 10","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1089.63","58.3","","3729.00","1254.19","3729.00","1 through 10","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","939.37","939.37","5593.65","1 through 10","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1588.65","85","","2323.25","1864.50","2882.25","16","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1869.00","100","","2909.44","1772.40","10952.08","45","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1869.00","100","","2323.25","2323.25","2323.25","1 through 10","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1869.00","100","","2882.25","1772.40","10169.17","187","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","1659.41","1659.41","1659.41","1 through 10","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","2050.91","1468.48","2902.83","52","830.77","1869","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1548.60","1092.60","3613.79","82","934.5","1466.23","percent of total billed charges",""
"ANKLE BASE 16MM STEM PROPHECY INBONE UHMWPE PLASMA COATED","SUP-ITM-10056991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","2085.51","998.68","6202.11","56","934.5","1466.23","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","AETNA [1001]","HB CH AETNA HMO / PPO","2412.16","58.3","","1634.24","1004.95","1718.99","42","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3020.38","73","","2123.89","1900.92","2123.89","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2412.16","58.3","","3729.00","1254.19","3729.00","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2192.88","53","","939.37","939.37","5593.65","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3516.88","85","","2323.25","1864.50","2882.25","16","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4137.50","100","","2909.44","1772.40","10952.08","45","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4137.50","100","","2323.25","2323.25","2323.25","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4137.50","100","","2882.25","1772.40","10169.17","187","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3020.38","73","","1659.41","1659.41","1659.41","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","WELLPOINT [1015]","HB CH WELLPOINT","3223.53","77.91","","2050.91","1468.48","2902.83","52","1839.12","4137.5","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2453.54","59.3","","1548.60","1092.60","3613.79","82","2068.75","3245.87","percent of total billed charges",""
"ANKLE BEARING SZ 2 6MM INBONE II POLYETHYLENE","SUP-ITM-10120306","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3245.87","78.45","","2085.51","998.68","6202.11","56","2068.75","3245.87","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","AETNA [1001]","HB CH AETNA HMO / PPO","2328.48","58.3","","1634.24","1004.95","1718.99","42","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2915.59","73","","2123.89","1900.92","2123.89","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2328.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2116.80","53","","939.37","939.37","5593.65","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3394.87","85","","2323.25","1864.50","2882.25","16","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3993.96","100","","2909.44","1772.40","10952.08","45","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3993.96","100","","2323.25","2323.25","2323.25","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3993.96","100","","2882.25","1772.40","10169.17","187","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2915.59","73","","1659.41","1659.41","1659.41","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","WELLPOINT [1015]","HB CH WELLPOINT","3111.69","77.91","","2050.91","1468.48","2902.83","52","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3993.96","2995.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","2368.42","59.3","","1548.60","1092.60","3613.79","82","1996.98","3133.26","percent of total billed charges",""
"ANKLE COMPONENT 10MM UHMWPE POLY SLIDING CORE","SUP-ITM-10232772","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3993.96","2995.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3133.26","78.45","","2085.51","998.68","6202.11","56","1996.98","3133.26","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","AETNA [1001]","HB CH AETNA HMO / PPO","2328.48","58.3","","1634.24","1004.95","1718.99","42","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2915.59","73","","2123.89","1900.92","2123.89","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2328.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2116.80","53","","939.37","939.37","5593.65","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3394.87","85","","2323.25","1864.50","2882.25","16","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3993.96","100","","2909.44","1772.40","10952.08","45","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3993.96","100","","2323.25","2323.25","2323.25","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3993.96","100","","2882.25","1772.40","10169.17","187","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2915.59","73","","1659.41","1659.41","1659.41","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","WELLPOINT [1015]","HB CH WELLPOINT","3111.69","77.91","","2050.91","1468.48","2902.83","52","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3993.96","2995.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","2368.42","59.3","","1548.60","1092.60","3613.79","82","1996.98","3133.26","percent of total billed charges",""
"ANKLE COMPONENT 6MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3993.96","2995.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3133.26","78.45","","2085.51","998.68","6202.11","56","1996.98","3133.26","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","AETNA [1001]","HB CH AETNA HMO / PPO","2328.48","58.3","","1634.24","1004.95","1718.99","42","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2915.59","73","","2123.89","1900.92","2123.89","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2328.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2116.80","53","","939.37","939.37","5593.65","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3394.87","85","","2323.25","1864.50","2882.25","16","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3993.96","100","","2909.44","1772.40","10952.08","45","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3993.96","100","","2323.25","2323.25","2323.25","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3993.96","100","","2882.25","1772.40","10169.17","187","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2915.59","73","","1659.41","1659.41","1659.41","1 through 10","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","both","","","3993.96","2995.47","WELLPOINT [1015]","HB CH WELLPOINT","3111.69","77.91","","2050.91","1468.48","2902.83","52","1775.32","3993.96","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3993.96","2995.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","2368.42","59.3","","1548.60","1092.60","3613.79","82","1996.98","3133.26","percent of total billed charges",""
"ANKLE COMPONENT 7MM UHMPWE POLY SLIDING CORE","SUP-ITM-10232775","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3993.96","2995.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3133.26","78.45","","2085.51","998.68","6202.11","56","1996.98","3133.26","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","AETNA [1001]","HB CH AETNA HMO / PPO","5812.51","58.3","","1634.24","1004.95","1718.99","42","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7278.10","73","","2123.89","1900.92","2123.89","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5812.51","58.3","","3729.00","1254.19","3729.00","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5284.10","53","","939.37","939.37","5593.65","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8474.50","85","","2323.25","1864.50","2882.25","16","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9970.00","100","","2909.44","1772.40","10952.08","45","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9970.00","100","","2323.25","2323.25","2323.25","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9970.00","100","","2882.25","1772.40","10169.17","187","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7278.10","73","","1659.41","1659.41","1659.41","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","WELLPOINT [1015]","HB CH WELLPOINT","7767.63","77.91","","2050.91","1468.48","2902.83","52","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9970.00","7477.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5912.21","59.3","","1548.60","1092.60","3613.79","82","4985","7821.47","percent of total billed charges",""
"ANKLE COMPONENT SZ 1 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680031","SUP-ITM-10286131","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9970.00","7477.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7821.47","78.45","","2085.51","998.68","6202.11","56","4985","7821.47","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","AETNA [1001]","HB CH AETNA HMO / PPO","5812.51","58.3","","1634.24","1004.95","1718.99","42","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7278.10","73","","2123.89","1900.92","2123.89","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5812.51","58.3","","3729.00","1254.19","3729.00","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5284.10","53","","939.37","939.37","5593.65","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8474.50","85","","2323.25","1864.50","2882.25","16","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9970.00","100","","2909.44","1772.40","10952.08","45","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9970.00","100","","2323.25","2323.25","2323.25","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9970.00","100","","2882.25","1772.40","10169.17","187","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7278.10","73","","1659.41","1659.41","1659.41","1 through 10","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","both","","","9970.00","7477.50","WELLPOINT [1015]","HB CH WELLPOINT","7767.63","77.91","","2050.91","1468.48","2902.83","52","4431.67","9970","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9970.00","7477.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5912.21","59.3","","1548.60","1092.60","3613.79","82","4985","7821.47","percent of total billed charges",""
"ANKLE COMPONENT SZ 4 FLAT CUT TALAR DOME INFINITY ADAPTIS 33680034","SUP-ITM-10286134","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9970.00","7477.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7821.47","78.45","","2085.51","998.68","6202.11","56","4985","7821.47","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","AETNA [1001]","HB CH AETNA HMO / PPO","5479.03","58.3","","1634.24","1004.95","1718.99","42","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6860.54","73","","2123.89","1900.92","2123.89","1 through 10","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5479.03","58.3","","3729.00","1254.19","3729.00","1 through 10","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4980.94","53","","939.37","939.37","5593.65","1 through 10","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7988.30","85","","2323.25","1864.50","2882.25","16","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9398.00","100","","2909.44","1772.40","10952.08","45","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9398.00","100","","2323.25","2323.25","2323.25","1 through 10","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9398.00","100","","2882.25","1772.40","10169.17","187","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6860.54","73","","1659.41","1659.41","1659.41","1 through 10","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","both","","","9398.00","7048.50","WELLPOINT [1015]","HB CH WELLPOINT","7321.98","77.91","","2050.91","1468.48","2902.83","52","4177.41","9398","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9398.00","7048.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5573.01","59.3","","1548.60","1092.60","3613.79","82","4699","7372.73","percent of total billed charges",""
"ANKLE COMPONENT SZ 5 FLAT CUT TALAR DOME INFINITY ADAPTIS LONG","SUP-ITM-10286143","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9398.00","7048.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7372.73","78.45","","2085.51","998.68","6202.11","56","4699","7372.73","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","AETNA [1001]","HB CH AETNA HMO / PPO","4785.26","58.3","","1634.24","1004.95","1718.99","42","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5991.84","73","","2123.89","1900.92","2123.89","1 through 10","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4785.26","58.3","","3729.00","1254.19","3729.00","1 through 10","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4350.24","53","","939.37","939.37","5593.65","1 through 10","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6976.80","85","","2323.25","1864.50","2882.25","16","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8208.00","100","","2909.44","1772.40","10952.08","45","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8208.00","100","","2323.25","2323.25","2323.25","1 through 10","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8208.00","100","","2882.25","1772.40","10169.17","187","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5991.84","73","","1659.41","1659.41","1659.41","1 through 10","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","WELLPOINT [1015]","HB CH WELLPOINT","6394.85","77.91","","2050.91","1468.48","2902.83","52","3648.46","8208","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4867.34","59.3","","1548.60","1092.60","3613.79","82","4104","6439.18","percent of total billed charges",""
"ANKLE DOME 42X12MM SIZE 5 TALAR INBONE II SULCUS","SUP-ITM-10131994","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6439.18","78.45","","2085.51","998.68","6202.11","56","4104","6439.18","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","AETNA [1001]","HB CH AETNA HMO / PPO","7309.64","58.3","","1634.24","1004.95","1718.99","42","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9152.73","73","","2123.89","1900.92","2123.89","1 through 10","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7309.64","58.3","","3729.00","1254.19","3729.00","1 through 10","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6645.13","53","","939.37","939.37","5593.65","1 through 10","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10657.28","85","","2323.25","1864.50","2882.25","16","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12537.98","100","","2909.44","1772.40","10952.08","45","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12537.98","100","","2323.25","2323.25","2323.25","1 through 10","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12537.98","100","","2882.25","1772.40","10169.17","187","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9152.73","73","","1659.41","1659.41","1659.41","1 through 10","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","both","","","12537.98","9403.48","WELLPOINT [1015]","HB CH WELLPOINT","9768.34","77.91","","2050.91","1468.48","2902.83","52","5573.13","12537.98","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12537.98","9403.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","7435.02","59.3","","1548.60","1092.60","3613.79","82","6268.99","9836.05","percent of total billed charges",""
"ANKLE IMPLANT 30X31MM XS COMPONENT STAR COBALT TITANIUM RT TALAR","SUP-ITM-10079335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12537.98","9403.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9836.05","78.45","","2085.51","998.68","6202.11","56","6268.99","9836.05","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","AETNA [1001]","HB CH AETNA HMO / PPO","6598.32","58.3","","1634.24","1004.95","1718.99","42","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8262.05","73","","2123.89","1900.92","2123.89","1 through 10","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6598.32","58.3","","3729.00","1254.19","3729.00","1 through 10","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5998.48","53","","939.37","939.37","5593.65","1 through 10","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9620.20","85","","2323.25","1864.50","2882.25","16","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11317.88","100","","2909.44","1772.40","10952.08","45","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11317.88","100","","2323.25","2323.25","2323.25","1 through 10","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11317.88","100","","2882.25","1772.40","10169.17","187","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8262.05","73","","1659.41","1659.41","1659.41","1 through 10","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","WELLPOINT [1015]","HB CH WELLPOINT","8817.76","77.91","","2050.91","1468.48","2902.83","52","5030.8","11317.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11317.88","8488.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","6711.50","59.3","","1548.60","1092.60","3613.79","82","5658.94","8878.88","percent of total billed charges",""
"ANKLE IMPLANT 33.5X45MM XL COMPONENT STAR COBALT CEMENTED LESS TIBIAL","SUP-ITM-10079343","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11317.88","8488.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8878.88","78.45","","2085.51","998.68","6202.11","56","5658.94","8878.88","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","AETNA [1001]","HB CH AETNA HMO / PPO","2399.05","58.3","","1634.24","1004.95","1718.99","42","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","2123.89","1900.92","2123.89","1 through 10","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2399.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2180.95","53","","939.37","939.37","5593.65","1 through 10","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3497.75","85","","2323.25","1864.50","2882.25","16","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4115.00","100","","2909.44","1772.40","10952.08","45","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4115.00","100","","2323.25","2323.25","2323.25","1 through 10","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4115.00","100","","2882.25","1772.40","10169.17","187","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","1659.41","1659.41","1659.41","1 through 10","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","WELLPOINT [1015]","HB CH WELLPOINT","3206.00","77.91","","2050.91","1468.48","2902.83","52","1829.12","4115","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2440.20","59.3","","1548.60","1092.60","3613.79","82","2057.5","3228.22","percent of total billed charges",""
"ANKLE IMPLANT 8MM SZ 2 PLUS TOTAL INFINITY EVERLAST","SUP-ITM-10308088","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3228.22","78.45","","2085.51","998.68","6202.11","56","2057.5","3228.22","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","AETNA [1001]","HB CH AETNA HMO / PPO","5054.61","58.3","","1634.24","1004.95","1718.99","42","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6329.10","73","","2123.89","1900.92","2123.89","1 through 10","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5054.61","58.3","","3729.00","1254.19","3729.00","1 through 10","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4595.10","53","","939.37","939.37","5593.65","1 through 10","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7369.50","85","","2323.25","1864.50","2882.25","16","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8670.00","100","","2909.44","1772.40","10952.08","45","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8670.00","100","","2323.25","2323.25","2323.25","1 through 10","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8670.00","100","","2882.25","1772.40","10169.17","187","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6329.10","73","","1659.41","1659.41","1659.41","1 through 10","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","WELLPOINT [1015]","HB CH WELLPOINT","6754.80","77.91","","2050.91","1468.48","2902.83","52","3853.82","8670","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5141.31","59.3","","1548.60","1092.60","3613.79","82","4335","6801.62","percent of total billed charges",""
"ANKLE IMPLANT SIZE 1 PROSTHESIS TALAR INFINITY LT RIGHT","SUP-ITM-10132226","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6801.62","78.45","","2085.51","998.68","6202.11","56","4335","6801.62","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","AETNA [1001]","HB CH AETNA HMO / PPO","2253.88","58.3","","1634.24","1004.95","1718.99","42","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2822.18","73","","2123.89","1900.92","2123.89","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2253.88","58.3","","3729.00","1254.19","3729.00","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2048.98","53","","939.37","939.37","5593.65","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3286.10","85","","2323.25","1864.50","2882.25","16","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3866.00","100","","2909.44","1772.40","10952.08","45","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3866.00","100","","2323.25","2323.25","2323.25","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3866.00","100","","2882.25","1772.40","10169.17","187","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2822.18","73","","1659.41","1659.41","1659.41","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","WELLPOINT [1015]","HB CH WELLPOINT","3012.00","77.91","","2050.91","1468.48","2902.83","52","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3866.00","2899.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2292.54","59.3","","1548.60","1092.60","3613.79","82","1933","3032.88","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3866.00","2899.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3032.88","78.45","","2085.51","998.68","6202.11","56","1933","3032.88","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","AETNA [1001]","HB CH AETNA HMO / PPO","2412.16","58.3","","1634.24","1004.95","1718.99","42","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3020.38","73","","2123.89","1900.92","2123.89","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2412.16","58.3","","3729.00","1254.19","3729.00","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2192.88","53","","939.37","939.37","5593.65","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3516.88","85","","2323.25","1864.50","2882.25","16","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4137.50","100","","2909.44","1772.40","10952.08","45","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4137.50","100","","2323.25","2323.25","2323.25","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4137.50","100","","2882.25","1772.40","10169.17","187","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3020.38","73","","1659.41","1659.41","1659.41","1 through 10","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","both","","","4137.50","3103.12","WELLPOINT [1015]","HB CH WELLPOINT","3223.53","77.91","","2050.91","1468.48","2902.83","52","1839.12","4137.5","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2453.54","59.3","","1548.60","1092.60","3613.79","82","2068.75","3245.87","percent of total billed charges",""
"ANKLE INSERT 10MM SIZE 4 INBONE II POLYETHYLENE SULCUS PLUS","SUP-ITM-10132109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4137.50","3103.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3245.87","78.45","","2085.51","998.68","6202.11","56","2068.75","3245.87","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","AETNA [1001]","HB CH AETNA HMO / PPO","2253.88","58.3","","1634.24","1004.95","1718.99","42","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2822.18","73","","2123.89","1900.92","2123.89","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2253.88","58.3","","3729.00","1254.19","3729.00","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2048.98","53","","939.37","939.37","5593.65","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3286.10","85","","2323.25","1864.50","2882.25","16","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3866.00","100","","2909.44","1772.40","10952.08","45","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3866.00","100","","2323.25","2323.25","2323.25","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3866.00","100","","2882.25","1772.40","10169.17","187","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2822.18","73","","1659.41","1659.41","1659.41","1 through 10","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3866.00","2899.50","WELLPOINT [1015]","HB CH WELLPOINT","3012.00","77.91","","2050.91","1468.48","2902.83","52","1718.44","3866","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3866.00","2899.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2292.54","59.3","","1548.60","1092.60","3613.79","82","1933","3032.88","percent of total billed charges",""
"ANKLE INSERT 13MM SIZE 3 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3866.00","2899.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3032.88","78.45","","2085.51","998.68","6202.11","56","1933","3032.88","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1634.24","1004.95","1718.99","42","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","2123.89","1900.92","2123.89","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2085.68","58.3","","3729.00","1254.19","3729.00","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","939.37","939.37","5593.65","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3040.88","85","","2323.25","1864.50","2882.25","16","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3577.50","100","","2909.44","1772.40","10952.08","45","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3577.50","100","","2323.25","2323.25","2323.25","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3577.50","100","","2882.25","1772.40","10169.17","187","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","1659.41","1659.41","1659.41","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","2050.91","1468.48","2902.83","52","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1548.60","1092.60","3613.79","82","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 6.0MM SIZE 2 INFINITY POLYETHYLENE PLUS 33653206","SUP-ITM-10132239","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","2085.51","998.68","6202.11","56","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1634.24","1004.95","1718.99","42","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","2123.89","1900.92","2123.89","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2085.68","58.3","","3729.00","1254.19","3729.00","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","939.37","939.37","5593.65","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3040.88","85","","2323.25","1864.50","2882.25","16","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3577.50","100","","2909.44","1772.40","10952.08","45","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3577.50","100","","2323.25","2323.25","2323.25","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3577.50","100","","2882.25","1772.40","10169.17","187","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","1659.41","1659.41","1659.41","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","2050.91","1468.48","2902.83","52","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1548.60","1092.60","3613.79","82","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 6MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132231","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","2085.51","998.68","6202.11","56","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1634.24","1004.95","1718.99","42","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","2123.89","1900.92","2123.89","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2085.68","58.3","","3729.00","1254.19","3729.00","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","939.37","939.37","5593.65","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3040.88","85","","2323.25","1864.50","2882.25","16","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3577.50","100","","2909.44","1772.40","10952.08","45","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3577.50","100","","2323.25","2323.25","2323.25","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3577.50","100","","2882.25","1772.40","10169.17","187","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","1659.41","1659.41","1659.41","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","2050.91","1468.48","2902.83","52","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1548.60","1092.60","3613.79","82","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 8.0MM SIZE 1 INFINITY POLYETHYLENE PLUS","SUP-ITM-10132232","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","2085.51","998.68","6202.11","56","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1634.24","1004.95","1718.99","42","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","2123.89","1900.92","2123.89","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2085.68","58.3","","3729.00","1254.19","3729.00","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","939.37","939.37","5593.65","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3040.88","85","","2323.25","1864.50","2882.25","16","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3577.50","100","","2909.44","1772.40","10952.08","45","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3577.50","100","","2323.25","2323.25","2323.25","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3577.50","100","","2882.25","1772.40","10169.17","187","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","1659.41","1659.41","1659.41","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","2050.91","1468.48","2902.83","52","1590.2","3577.5","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1548.60","1092.60","3613.79","82","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT 8MM SIZE 2 INFINITY POLYETHYLENE PLUS 33652208","SUP-ITM-10132236","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","2085.51","998.68","6202.11","56","1788.75","2806.55","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","AETNA [1001]","HB CH AETNA HMO / PPO","2827.55","58.3","","1634.24","1004.95","1718.99","42","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3540.50","73","","2123.89","1900.92","2123.89","1 through 10","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2827.55","58.3","","3729.00","1254.19","3729.00","1 through 10","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2570.50","53","","939.37","939.37","5593.65","1 through 10","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4122.50","85","","2323.25","1864.50","2882.25","16","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4850.00","100","","2909.44","1772.40","10952.08","45","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4850.00","100","","2323.25","2323.25","2323.25","1 through 10","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4850.00","100","","2882.25","1772.40","10169.17","187","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3540.50","73","","1659.41","1659.41","1659.41","1 through 10","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","both","","","4850.00","3637.50","WELLPOINT [1015]","HB CH WELLPOINT","3778.64","77.91","","2050.91","1468.48","2902.83","52","2155.83","4850","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","3637.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2876.05","59.3","","1548.60","1092.60","3613.79","82","2425","3804.83","percent of total billed charges",""
"ANKLE INSERT SZ 2 PLUS 14MM INBONE II EVERLAST POLYMER 22023214","SUP-ITM-10286098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4850.00","3637.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3804.83","78.45","","2085.51","998.68","6202.11","56","2425","3804.83","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","AETNA [1001]","HB CH AETNA HMO / PPO","2616.21","58.3","","1634.24","1004.95","1718.99","42","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3275.88","73","","2123.89","1900.92","2123.89","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2616.21","58.3","","3729.00","1254.19","3729.00","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2378.38","53","","939.37","939.37","5593.65","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3814.38","85","","2323.25","1864.50","2882.25","16","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4487.50","100","","2909.44","1772.40","10952.08","45","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4487.50","100","","2323.25","2323.25","2323.25","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4487.50","100","","2882.25","1772.40","10169.17","187","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3275.88","73","","1659.41","1659.41","1659.41","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","WELLPOINT [1015]","HB CH WELLPOINT","3496.21","77.91","","2050.91","1468.48","2902.83","52","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4487.50","3365.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2661.09","59.3","","1548.60","1092.60","3613.79","82","2243.75","3520.44","percent of total billed charges",""
"ANKLE INSERT SZ 3 PLUS 12MM INBONE II EVERLAST POLYMER 22024312","SUP-ITM-10286108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4487.50","3365.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3520.44","78.45","","2085.51","998.68","6202.11","56","2243.75","3520.44","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","AETNA [1001]","HB CH AETNA HMO / PPO","2616.21","58.3","","1634.24","1004.95","1718.99","42","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3275.88","73","","2123.89","1900.92","2123.89","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2616.21","58.3","","3729.00","1254.19","3729.00","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2378.38","53","","939.37","939.37","5593.65","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3814.38","85","","2323.25","1864.50","2882.25","16","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4487.50","100","","2909.44","1772.40","10952.08","45","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4487.50","100","","2323.25","2323.25","2323.25","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4487.50","100","","2882.25","1772.40","10169.17","187","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3275.88","73","","1659.41","1659.41","1659.41","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","WELLPOINT [1015]","HB CH WELLPOINT","3496.21","77.91","","2050.91","1468.48","2902.83","52","1994.69","4487.5","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4487.50","3365.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2661.09","59.3","","1548.60","1092.60","3613.79","82","2243.75","3520.44","percent of total billed charges",""
"ANKLE INSERT SZ 4 PLUS 12MM INBONE II EVERLAST POLYMER","SUP-ITM-10286120","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4487.50","3365.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3520.44","78.45","","2085.51","998.68","6202.11","56","2243.75","3520.44","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","463.49","58.3","","554.95","91.85","1421.75","94","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","2490.03","2490.03","2490.03","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","463.49","58.3","","750.00","750.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","421.35","53","","1192.50","120.84","4149.90","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","675.75","85","","750.00","75.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","795.00","100","","657.00","121.50","1971.00","14","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","795.00","100","","75.00","75.00","75.00","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","795.00","100","","366.00","144.00","1971.00","45","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","667.50","667.50","667.50","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","123.77","123.77","123.77","1 through 10","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","WELLPOINT [1015]","HB CH WELLPOINT","619.38","77.91","","483.51","229.32","1316.08","96","353.38","795","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","439.50","225.34","1872.27","197","397.5","623.68","percent of total billed charges",""
"ANKLE PLATE 106.0MM 8 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","385.32","55.36","1815.62","58","397.5","623.68","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","554.95","91.85","1421.75","94","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2490.03","2490.03","2490.03","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","750.00","750.00","750.00","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","1192.50","120.84","4149.90","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","750.00","75.00","750.00","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","657.00","121.50","1971.00","14","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","75.00","75.00","75.00","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","366.00","144.00","1971.00","45","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","667.50","667.50","667.50","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","123.77","123.77","123.77","1 through 10","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","483.51","229.32","1316.08","96","733.43","1650","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","439.50","225.34","1872.27","197","825","1294.43","percent of total billed charges",""
"ANKLE PLATE 106MM 8 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076938","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","385.32","55.36","1815.62","58","825","1294.43","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","AETNA [1001]","HB CH AETNA HMO / PPO","1040.66","58.3","","554.95","91.85","1421.75","94","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1303.05","73","","2490.03","2490.03","2490.03","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1040.66","58.3","","750.00","750.00","750.00","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","946.05","53","","1192.50","120.84","4149.90","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1517.25","85","","750.00","75.00","750.00","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1785.00","100","","657.00","121.50","1971.00","14","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1785.00","100","","75.00","75.00","75.00","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1785.00","100","","366.00","144.00","1971.00","45","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1303.05","73","","667.50","667.50","667.50","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.43","44.45","","123.77","123.77","123.77","1 through 10","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","WELLPOINT [1015]","HB CH WELLPOINT","1390.69","77.91","","483.51","229.32","1316.08","96","793.43","1785","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1058.51","59.3","","439.50","225.34","1872.27","197","892.5","1400.33","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1785.00","1338.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1400.33","78.45","","385.32","55.36","1815.62","58","892.5","1400.33","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","554.95","91.85","1421.75","94","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","2490.03","2490.03","2490.03","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.72","58.3","","750.00","750.00","750.00","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","1192.50","120.84","4149.90","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","714.00","85","","750.00","75.00","750.00","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","840.00","100","","657.00","121.50","1971.00","14","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","840.00","100","","75.00","75.00","75.00","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","840.00","100","","366.00","144.00","1971.00","45","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","667.50","667.50","667.50","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","123.77","123.77","123.77","1 through 10","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","483.51","229.32","1316.08","96","373.38","840","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","439.50","225.34","1872.27","197","420","658.98","percent of total billed charges",""
"ANKLE PLATE 131MM 10 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","385.32","55.36","1815.62","58","420","658.98","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","554.95","91.85","1421.75","94","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2490.03","2490.03","2490.03","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","750.00","750.00","750.00","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","1192.50","120.84","4149.90","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","750.00","75.00","750.00","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","657.00","121.50","1971.00","14","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","75.00","75.00","75.00","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","366.00","144.00","1971.00","45","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","667.50","667.50","667.50","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","123.77","123.77","123.77","1 through 10","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","483.51","229.32","1316.08","96","400.05","900","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","439.50","225.34","1872.27","197","450","706.05","percent of total billed charges",""
"ANKLE PLATE 156.0MM 12 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","385.32","55.36","1815.62","58","450","706.05","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","AETNA [1001]","HB CH AETNA HMO / PPO","3323.10","58.3","","554.95","91.85","1421.75","94","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4161.00","73","","2490.03","2490.03","2490.03","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3323.10","58.3","","750.00","750.00","750.00","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3021.00","53","","1192.50","120.84","4149.90","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4845.00","85","","750.00","75.00","750.00","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5700.00","100","","657.00","121.50","1971.00","14","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5700.00","100","","75.00","75.00","75.00","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5700.00","100","","366.00","144.00","1971.00","45","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4161.00","73","","667.50","667.50","667.50","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2533.65","44.45","","123.77","123.77","123.77","1 through 10","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","WELLPOINT [1015]","HB CH WELLPOINT","4440.87","77.91","","483.51","229.32","1316.08","96","2533.65","5700","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3380.10","59.3","","439.50","225.34","1872.27","197","2850","4471.65","percent of total billed charges",""
"ANKLE PLATE 4-HOLE FUSION ANTERIOR TT LEFT","SUP-ITM-10270051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4471.65","78.45","","385.32","55.36","1815.62","58","2850","4471.65","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","AETNA [1001]","HB CH AETNA HMO / PPO","2419.45","58.3","","554.95","91.85","1421.75","94","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3029.50","73","","2490.03","2490.03","2490.03","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2419.45","58.3","","750.00","750.00","750.00","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2199.50","53","","1192.50","120.84","4149.90","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3527.50","85","","750.00","75.00","750.00","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4150.00","100","","657.00","121.50","1971.00","14","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4150.00","100","","75.00","75.00","75.00","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4150.00","100","","366.00","144.00","1971.00","45","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3029.50","73","","667.50","667.50","667.50","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1844.68","44.45","","123.77","123.77","123.77","1 through 10","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","WELLPOINT [1015]","HB CH WELLPOINT","3233.27","77.91","","483.51","229.32","1316.08","96","1844.68","4150","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4150.00","3112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2460.95","59.3","","439.50","225.34","1872.27","197","2075","3255.68","percent of total billed charges",""
"ANKLE PLATE 5 HOLE BONE FUSION ANTERIOR TITANIUM LEFT","SUP-ITM-10148131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4150.00","3112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3255.68","78.45","","385.32","55.36","1815.62","58","2075","3255.68","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","AETNA [1001]","HB CH AETNA HMO / PPO","2740.10","58.3","","554.95","91.85","1421.75","94","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","2490.03","2490.03","2490.03","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2740.10","58.3","","750.00","750.00","750.00","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2491.00","53","","1192.50","120.84","4149.90","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3995.00","85","","750.00","75.00","750.00","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4700.00","100","","657.00","121.50","1971.00","14","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4700.00","100","","75.00","75.00","75.00","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4700.00","100","","366.00","144.00","1971.00","45","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","667.50","667.50","667.50","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2089.15","44.45","","123.77","123.77","123.77","1 through 10","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","WELLPOINT [1015]","HB CH WELLPOINT","3661.77","77.91","","483.51","229.32","1316.08","96","2089.15","4700","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2787.10","59.3","","439.50","225.34","1872.27","197","2350","3687.15","percent of total billed charges",""
"ANKLE PLATE 5-HOLE FUSION LATERAL TTC","SUP-ITM-10270063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3687.15","78.45","","385.32","55.36","1815.62","58","2350","3687.15","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","554.95","91.85","1421.75","94","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","2490.03","2490.03","2490.03","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","750.00","750.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","1192.50","120.84","4149.90","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","573.75","85","","750.00","75.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","675.00","100","","657.00","121.50","1971.00","14","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","675.00","100","","75.00","75.00","75.00","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","675.00","100","","366.00","144.00","1971.00","45","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","667.50","667.50","667.50","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","123.77","123.77","123.77","1 through 10","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","483.51","229.32","1316.08","96","300.04","675","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","439.50","225.34","1872.27","197","337.5","529.54","percent of total billed charges",""
"ANKLE PLATE 55.0MM 4 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076929","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","385.32","55.36","1815.62","58","337.5","529.54","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","AETNA [1001]","HB CH AETNA HMO / PPO","787.05","58.3","","554.95","91.85","1421.75","94","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","985.50","73","","2490.03","2490.03","2490.03","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","787.05","58.3","","750.00","750.00","750.00","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","715.50","53","","1192.50","120.84","4149.90","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1147.50","85","","750.00","75.00","750.00","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1350.00","100","","657.00","121.50","1971.00","14","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1350.00","100","","75.00","75.00","75.00","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1350.00","100","","366.00","144.00","1971.00","45","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","985.50","73","","667.50","667.50","667.50","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.08","44.45","","123.77","123.77","123.77","1 through 10","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","WELLPOINT [1015]","HB CH WELLPOINT","1051.79","77.91","","483.51","229.32","1316.08","96","600.08","1350","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","800.55","59.3","","439.50","225.34","1872.27","197","675","1059.08","percent of total billed charges",""
"ANKLE PLATE 55MM 4 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1059.08","78.45","","385.32","55.36","1815.62","58","675","1059.08","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","AETNA [1001]","HB CH AETNA HMO / PPO","1442.93","58.3","","554.95","91.85","1421.75","94","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1806.75","73","","2490.03","2490.03","2490.03","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1442.93","58.3","","750.00","750.00","750.00","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1311.75","53","","1192.50","120.84","4149.90","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2103.75","85","","750.00","75.00","750.00","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2475.00","100","","657.00","121.50","1971.00","14","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2475.00","100","","75.00","75.00","75.00","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2475.00","100","","366.00","144.00","1971.00","45","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1806.75","73","","667.50","667.50","667.50","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1100.14","44.45","","123.77","123.77","123.77","1 through 10","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","both","","","2475.00","1856.25","WELLPOINT [1015]","HB CH WELLPOINT","1928.27","77.91","","483.51","229.32","1316.08","96","1100.14","2475","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1467.68","59.3","","439.50","225.34","1872.27","197","1237.5","1941.64","percent of total billed charges",""
"ANKLE PLATE 61MM 3 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2475.00","1856.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1941.64","78.45","","385.32","55.36","1815.62","58","1237.5","1941.64","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","AETNA [1001]","HB CH AETNA HMO / PPO","411.02","58.3","","554.95","91.85","1421.75","94","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","2490.03","2490.03","2490.03","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","411.02","58.3","","750.00","750.00","750.00","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.65","53","","1192.50","120.84","4149.90","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","599.25","85","","750.00","75.00","750.00","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","705.00","100","","657.00","121.50","1971.00","14","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","705.00","100","","75.00","75.00","75.00","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","705.00","100","","366.00","144.00","1971.00","45","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","667.50","667.50","667.50","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.37","44.45","","123.77","123.77","123.77","1 through 10","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","WELLPOINT [1015]","HB CH WELLPOINT","549.27","77.91","","483.51","229.32","1316.08","96","313.37","705","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","418.07","59.3","","439.50","225.34","1872.27","197","352.5","553.07","percent of total billed charges",""
"ANKLE PLATE 63.5MM 5 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10154264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","553.07","78.45","","385.32","55.36","1815.62","58","352.5","553.07","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","554.95","91.85","1421.75","94","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","2490.03","2490.03","2490.03","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.30","58.3","","750.00","750.00","750.00","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.00","53","","1192.50","120.84","4149.90","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1785.00","85","","750.00","75.00","750.00","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2100.00","100","","657.00","121.50","1971.00","14","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2100.00","100","","75.00","75.00","75.00","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2100.00","100","","366.00","144.00","1971.00","45","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","667.50","667.50","667.50","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","123.77","123.77","123.77","1 through 10","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","483.51","229.32","1316.08","96","933.45","2100","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","439.50","225.34","1872.27","197","1050","1647.45","percent of total billed charges",""
"ANKLE PLATE 72MM 3 HOLE BONE LATERAL HOOK SS LOCKING","SUP-ITM-10076941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","385.32","55.36","1815.62","58","1050","1647.45","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"ANKLE PLATE 80.0MM 6 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076930","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","554.95","91.85","1421.75","94","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","2490.03","2490.03","2490.03","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","750.00","750.00","750.00","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","1192.50","120.84","4149.90","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","650.25","85","","750.00","75.00","750.00","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","765.00","100","","657.00","121.50","1971.00","14","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","765.00","100","","75.00","75.00","75.00","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","765.00","100","","366.00","144.00","1971.00","45","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","667.50","667.50","667.50","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","123.77","123.77","123.77","1 through 10","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","483.51","229.32","1316.08","96","340.04","765","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","439.50","225.34","1872.27","197","382.5","600.14","percent of total billed charges",""
"ANKLE PLATE 93.0MM 7 HOLE BONE THIRD TUBULAR SS LOCKING STRAIGHT","SUP-ITM-10076931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","385.32","55.36","1815.62","58","382.5","600.14","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","AETNA [1001]","HB CH AETNA HMO / PPO","918.23","58.3","","554.95","91.85","1421.75","94","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","2490.03","2490.03","2490.03","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","918.23","58.3","","750.00","750.00","750.00","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","834.75","53","","1192.50","120.84","4149.90","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1338.75","85","","750.00","75.00","750.00","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1575.00","100","","657.00","121.50","1971.00","14","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1575.00","100","","75.00","75.00","75.00","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1575.00","100","","366.00","144.00","1971.00","45","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","667.50","667.50","667.50","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","123.77","123.77","123.77","1 through 10","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB CH WELLPOINT","1227.08","77.91","","483.51","229.32","1316.08","96","700.09","1575","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","933.98","59.3","","439.50","225.34","1872.27","197","787.5","1235.59","percent of total billed charges",""
"ANKLE PLATE 93MM 7 HOLE BONE SS LOCKING STRAIGHT","SUP-ITM-10076937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","385.32","55.36","1815.62","58","787.5","1235.59","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","554.95","91.85","1421.75","94","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2490.03","2490.03","2490.03","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","750.00","750.00","750.00","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","1192.50","120.84","4149.90","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","750.00","75.00","750.00","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","657.00","121.50","1971.00","14","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","75.00","75.00","75.00","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","366.00","144.00","1971.00","45","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","667.50","667.50","667.50","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.15","44.45","","123.77","123.77","123.77","1 through 10","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","483.51","229.32","1316.08","96","1200.15","2700","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","439.50","225.34","1872.27","197","1350","2118.15","percent of total billed charges",""
"ANKLE PLATE 97MM 7 HOLE BONE MEDIAL SS LOCKING","SUP-ITM-10076946","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","385.32","55.36","1815.62","58","1350","2118.15","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","AETNA [1001]","HB CH AETNA HMO / PPO","2616.21","58.3","","554.95","91.85","1421.75","94","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3275.88","73","","2490.03","2490.03","2490.03","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2616.21","58.3","","750.00","750.00","750.00","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2378.38","53","","1192.50","120.84","4149.90","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3814.38","85","","750.00","75.00","750.00","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4487.50","100","","657.00","121.50","1971.00","14","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4487.50","100","","75.00","75.00","75.00","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4487.50","100","","366.00","144.00","1971.00","45","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3275.88","73","","667.50","667.50","667.50","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1994.69","44.45","","123.77","123.77","123.77","1 through 10","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","both","","","4487.50","3365.62","WELLPOINT [1015]","HB CH WELLPOINT","3496.21","77.91","","483.51","229.32","1316.08","96","1994.69","4487.5","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.50","3365.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2661.09","59.3","","439.50","225.34","1872.27","197","2243.75","3520.44","percent of total billed charges",""
"ANKLE PLATE MINIMALLY INVASIVE ANTERIOR TT","SUP-ITM-10270057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4487.50","3365.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3520.44","78.45","","385.32","55.36","1815.62","58","2243.75","3520.44","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","AETNA [1001]","HB CH AETNA HMO / PPO","2053.33","58.3","","1634.24","1004.95","1718.99","42","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2571.06","73","","2123.89","1900.92","2123.89","1 through 10","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2053.33","58.3","","3729.00","1254.19","3729.00","1 through 10","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1866.66","53","","939.37","939.37","5593.65","1 through 10","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2993.70","85","","2323.25","1864.50","2882.25","16","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3522.00","100","","2909.44","1772.40","10952.08","45","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3522.00","100","","2323.25","2323.25","2323.25","1 through 10","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3522.00","100","","2882.25","1772.40","10169.17","187","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2571.06","73","","1659.41","1659.41","1659.41","1 through 10","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","both","","","3522.00","2641.50","WELLPOINT [1015]","HB CH WELLPOINT","2743.99","77.91","","2050.91","1468.48","2902.83","52","1565.53","3522","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3522.00","2641.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2088.55","59.3","","1548.60","1092.60","3613.79","82","1761","2763.01","percent of total billed charges",""
"ANKLE STEM 10MM LG SIZE 1 TALAR IMPLANT 01B","SUP-ITM-10057024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3522.00","2641.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2763.01","78.45","","2085.51","998.68","6202.11","56","1761","2763.01","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","AETNA [1001]","HB CH AETNA HMO / PPO","1068.64","58.3","","1634.24","1004.95","1718.99","42","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1338.09","73","","2123.89","1900.92","2123.89","1 through 10","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1068.64","58.3","","3729.00","1254.19","3729.00","1 through 10","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","971.49","53","","939.37","939.37","5593.65","1 through 10","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1558.05","85","","2323.25","1864.50","2882.25","16","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1833.00","100","","2909.44","1772.40","10952.08","45","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1833.00","100","","2323.25","2323.25","2323.25","1 through 10","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1833.00","100","","2882.25","1772.40","10169.17","187","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1338.09","73","","1659.41","1659.41","1659.41","1 through 10","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1833.00","1374.75","WELLPOINT [1015]","HB CH WELLPOINT","1428.09","77.91","","2050.91","1468.48","2902.83","52","814.77","1833","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1833.00","1374.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1086.97","59.3","","1548.60","1092.60","3613.79","82","916.5","1437.99","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED MID","SUP-ITM-10056993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1833.00","1374.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1437.99","78.45","","2085.51","998.68","6202.11","56","916.5","1437.99","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","AETNA [1001]","HB CH AETNA HMO / PPO","1000.43","58.3","","1634.24","1004.95","1718.99","42","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1252.68","73","","2123.89","1900.92","2123.89","1 through 10","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1000.43","58.3","","3729.00","1254.19","3729.00","1 through 10","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","909.48","53","","939.37","939.37","5593.65","1 through 10","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1458.60","85","","2323.25","1864.50","2882.25","16","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1716.00","100","","2909.44","1772.40","10952.08","45","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1716.00","100","","2323.25","2323.25","2323.25","1 through 10","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1716.00","100","","2882.25","1772.40","10169.17","187","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1252.68","73","","1659.41","1659.41","1659.41","1 through 10","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","both","","","1716.00","1287.00","WELLPOINT [1015]","HB CH WELLPOINT","1336.94","77.91","","2050.91","1468.48","2902.83","52","762.76","1716","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.00","1287.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1017.59","59.3","","1548.60","1092.60","3613.79","82","858","1346.2","percent of total billed charges",""
"ANKLE STEM 14MM PROPHECY INBONE UHMWPE PLASMA COATED TOP","SUP-ITM-10056997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1716.00","1287.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1346.20","78.45","","2085.51","998.68","6202.11","56","858","1346.2","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","AETNA [1001]","HB CH AETNA HMO / PPO","6529.60","58.3","","1634.24","1004.95","1718.99","42","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8176.00","73","","2123.89","1900.92","2123.89","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6529.60","58.3","","3729.00","1254.19","3729.00","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5936.00","53","","939.37","939.37","5593.65","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9520.00","85","","2323.25","1864.50","2882.25","16","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11200.00","100","","2909.44","1772.40","10952.08","45","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11200.00","100","","2323.25","2323.25","2323.25","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11200.00","100","","2882.25","1772.40","10169.17","187","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8176.00","73","","1659.41","1659.41","1659.41","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","WELLPOINT [1015]","HB CH WELLPOINT","8725.92","77.91","","2050.91","1468.48","2902.83","52","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11200.00","8400.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6641.60","59.3","","1548.60","1092.60","3613.79","82","5600","8786.4","percent of total billed charges",""
"ANKLE TALAR SZ 2 STD DOME INVISION","SUP-ITM-10239298","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11200.00","8400.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8786.40","78.45","","2085.51","998.68","6202.11","56","5600","8786.4","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","AETNA [1001]","HB CH AETNA HMO / PPO","6529.60","58.3","","1634.24","1004.95","1718.99","42","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8176.00","73","","2123.89","1900.92","2123.89","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6529.60","58.3","","3729.00","1254.19","3729.00","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5936.00","53","","939.37","939.37","5593.65","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9520.00","85","","2323.25","1864.50","2882.25","16","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11200.00","100","","2909.44","1772.40","10952.08","45","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11200.00","100","","2323.25","2323.25","2323.25","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11200.00","100","","2882.25","1772.40","10169.17","187","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8176.00","73","","1659.41","1659.41","1659.41","1 through 10","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","both","","","11200.00","8400.00","WELLPOINT [1015]","HB CH WELLPOINT","8725.92","77.91","","2050.91","1468.48","2902.83","52","4978.4","11200","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11200.00","8400.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6641.60","59.3","","1548.60","1092.60","3613.79","82","5600","8786.4","percent of total billed charges",""
"ANKLE TALAR SZ 3 STD DOME INVISION","SUP-ITM-10239297","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11200.00","8400.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8786.40","78.45","","2085.51","998.68","6202.11","56","5600","8786.4","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1634.24","1004.95","1718.99","42","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","2123.89","1900.92","2123.89","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","939.37","939.37","5593.65","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3427.63","85","","2323.25","1864.50","2882.25","16","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4032.50","100","","2909.44","1772.40","10952.08","45","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4032.50","100","","2323.25","2323.25","2323.25","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4032.50","100","","2882.25","1772.40","10169.17","187","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","1659.41","1659.41","1659.41","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","2050.91","1468.48","2902.83","52","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1548.60","1092.60","3613.79","82","2016.25","3163.5","percent of total billed charges",""
"ANKLE TRAY 10MM SIZE 5 TIBIAL INBONE II TOTAL STANDARD RIGHT","SUP-ITM-10057017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","2085.51","998.68","6202.11","56","2016.25","3163.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1634.24","1004.95","1718.99","42","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","2123.89","1900.92","2123.89","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","939.37","939.37","5593.65","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3427.63","85","","2323.25","1864.50","2882.25","16","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4032.50","100","","2909.44","1772.40","10952.08","45","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4032.50","100","","2323.25","2323.25","2323.25","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4032.50","100","","2882.25","1772.40","10169.17","187","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","1659.41","1659.41","1659.41","1 through 10","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","2050.91","1468.48","2902.83","52","1792.45","4032.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1548.60","1092.60","3613.79","82","2016.25","3163.5","percent of total billed charges",""
"ANKLE TRAY SIZE 4 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10057021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","2085.51","998.68","6202.11","56","2016.25","3163.5","percent of total billed charges",""
"Anoscopy W/Biopsy","PX-75000225","CDM","46606","CPT","0750","RC","","","","outpatient","","","2620.00","1965.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1285.63","49.07","","792.16","792.16","792.16","1 through 10","1048","2055.39","percent of total billed charges",""
"Antepartum With O.R. Procedure,MAJOR","547","DRG","","","","","","","","inpatient","","","51961.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32769.20","","Standard inlier is a Case rate ($32,769.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $45,266, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,651.72) for the length of stay and the standard reimbursement.","31280.11","31280.11","31280.11","1 through 10","14874.75","35200.66","case rate",""
"Antepartum With O.R. Procedure,MAJOR","547","DRG","","","","","","","","inpatient","","","51961.04","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","14874.75","","Case rate ($16,446.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,876.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","16442.55","1 through 10","14874.75","35200.66","case rate",""
"Antepartum Without O.R. Procedure,MAJOR","566","DRG","","","","","","","","inpatient","","","23783.84","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7341.99","","Case rate ($8,117.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,547.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8115.84","8115.84","8115.84","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24050.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8906.16","","Standard inlier is a Case rate ($8,906.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $20,153, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,264.19) for the length of stay and the standard reimbursement.","8906.15","8906.15","8906.15","1 through 10","2937.47","24244.26","case rate",""
"Antepartum Without O.R. Procedure,MODERATE","566","DRG","","","","","","","","inpatient","","","24050.21","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5398.82","","Case rate ($5,969.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,399.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5967.86","917.63","5967.86","1 through 10","2937.47","24244.26","case rate",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","AETNA [1001]","HB CH AETNA HMO / PPO","2164.75","58.3","","554.95","91.85","1421.75","94","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2710.58","73","","2490.03","2490.03","2490.03","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2164.75","58.3","","750.00","750.00","750.00","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1967.96","53","","1192.50","120.84","4149.90","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3156.16","85","","750.00","75.00","750.00","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3713.13","100","","657.00","121.50","1971.00","14","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3713.13","100","","75.00","75.00","75.00","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3713.13","100","","366.00","144.00","1971.00","45","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2710.58","73","","667.50","667.50","667.50","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1650.49","44.45","","123.77","123.77","123.77","1 through 10","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","both","","","3713.13","2784.85","WELLPOINT [1015]","HB CH WELLPOINT","2892.90","77.91","","483.51","229.32","1316.08","96","1650.49","3713.13","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.13","2784.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","2201.89","59.3","","439.50","225.34","1872.27","197","1856.57","2912.95","percent of total billed charges",""
"ANTERIOR DISTAL TIBIA PLATE 13-HOLE","SUP-ITM-10303721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3713.13","2784.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2912.95","78.45","","385.32","55.36","1815.62","58","1856.57","2912.95","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","AETNA [1001]","HB CH AETNA HMO / PPO","2086.56","58.3","","554.95","91.85","1421.75","94","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2612.67","73","","2490.03","2490.03","2490.03","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2086.56","58.3","","750.00","750.00","750.00","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.87","53","","1192.50","120.84","4149.90","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3042.15","85","","750.00","75.00","750.00","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3579.00","100","","657.00","121.50","1971.00","14","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3579.00","100","","75.00","75.00","75.00","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3579.00","100","","366.00","144.00","1971.00","45","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2612.67","73","","667.50","667.50","667.50","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.87","44.45","","123.77","123.77","123.77","1 through 10","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","WELLPOINT [1015]","HB CH WELLPOINT","2788.40","77.91","","483.51","229.32","1316.08","96","1590.87","3579","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2122.35","59.3","","439.50","225.34","1872.27","197","1789.5","2807.73","percent of total billed charges",""
"ANTERIOR PLATE 95X11MM 8 HOLE TITANIUM LOCKING","SUP-ITM-10073381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2807.73","78.45","","385.32","55.36","1815.62","58","1789.5","2807.73","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","AETNA [1001]","HB CH AETNA HMO / PPO","85.70","58.3","","85.62","85.62","171.24","103","16.92","107.31","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","77.91","53","","80.03","80.03","80.03","1 through 10","16.92","107.31","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","both","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.34","44.45","","67.80","67.80","67.80","1 through 10","16.92","107.31","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","inpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","103.78","70.6","","232.18","232.18","232.18","1 through 10","82.32","103.78","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","147.00","110.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.17","59.3","","88.49","88.49","353.95","74","13.35","115.32","percent of total billed charges",""
"Anti Mullerian Hormone Quant","PX-30002790","CDM","83520","CPT","0301","RC","","","","outpatient","","","147.00","110.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","115.32","78.45","","116.09","66.39","116.09","106","13.35","115.32","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Anti-Adalimumab Antibody","PX-30003523","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Anti-Ustekinumab Antibody","PX-30003525","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","AETNA [1001]","HB CH AETNA HMO / PPO","59.47","58.3","","56.13","56.13","56.13","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","65.64","65.64","65.64","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.34","44.45","","76.11","76.11","76.11","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","both","","","102.00","76.50","WELLPOINT [1015]","HB CH WELLPOINT","79.47","77.91","","77.97","77.97","77.97","1 through 10","11.81","97","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.49","59.3","","174.03","58.01","174.03","1 through 10","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","58.85","57.7","","59.70","59.70","59.70","1 through 10","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","61.71","60.5","","65.64","62.67","65.64","1 through 10","29.85","80.02","percent of total billed charges",""
"Antineutrophil Cytoplasmic Antb Screen Ea Antb","PX-30003762","CDM","86036","CPT","0302","RC","","","","outpatient","","","102.00","76.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.02","78.45","","76.11","76.11","76.11","1 through 10","29.85","80.02","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","55.57","22","11.85","73.73","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","53.53","53","","51.94","51.94","51.94","1 through 10","11.85","73.73","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","both","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.89","44.45","","44.00","44.00","44.00","1 through 10","11.85","73.73","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","172.29","19","12.46","79.23","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","101.00","75.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","100.85","100.85","100.85","1 through 10","12.46","79.23","percent of total billed charges",""
"Antinuclear Antibodies (Ana) Screen","PX-30000783","CDM","86038","CPT","0302","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","75.34","44.65","75.34","27","12.46","79.23","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","113.00","84.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.01","59.3","","64.46","64.46","64.46","1 through 10","12.22","88.65","percent of total billed charges",""
"Antithrombin III Activity","PX-30001071","CDM","85300","CPT","0305","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.65","78.45","","84.57","81.14","84.57","1 through 10","12.22","88.65","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","1 through 10","20.67","111.99","percent of total billed charges",""
"Apolipoprotein","PX-30000316","CDM","82172","CPT","0301","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","73.25","73.25","73.25","1 through 10","15.99","101.2","percent of total billed charges",""
"Appendectomy With Complex Principal Diagnosis,MINOR","233","DRG","","","","","","","","inpatient","","","43484.28","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24527.26","","Standard inlier is a Case rate ($24,527.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,810, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,481.74) for the length of stay and the standard reimbursement.","23412.70","23412.70","23412.70","1 through 10","8821.35","47470.31","case rate",""
"Appendectomy With Complex Principal Diagnosis,MODERATE","233","DRG","","","","","","","","inpatient","","","81521.52","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11149.49","","Case rate ($12,327.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,757.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12997.97","12997.97","12997.97","1 through 10","8821.35","47470.31","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MINOR","234","DRG","","","","","","","","inpatient","","","28680.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21367.41","","Standard inlier is a Case rate ($21,367.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,055, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,033.01) for the length of stay and the standard reimbursement.","21367.40","21367.40","21367.40","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","35396.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27598.03","","Standard inlier is a Case rate ($27,598.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,004, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,917.42) for the length of stay and the standard reimbursement.","26343.57","26343.57","26343.57","1 through 10","6046.54","27598.03","case rate",""
"Appendectomy Without Complex Principal Diagnosis,MODERATE","234","DRG","","","","","","","","inpatient","","","35396.71","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7947.44","","Case rate ($8,787.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,217.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8785.10","8785.10","8785.10","1 through 10","6046.54","27598.03","case rate",""
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","40521.76","30391.32","MEDICARE [2001]","HB BWF MEDICARE","14275.65","","Case rate ($14,275.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,298.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,822.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,630.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,866.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,959.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,070.05. The transfer capital threshold is the transfer adjustment factor * $1,070.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6297.49","1407.84","6297.49","1 through 10","13990.14","14964.0348","other","Inpatient Replacement Plans DRG"
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","40521.76","30391.32","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","14275.65","","Case rate ($14,275.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,298.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,822.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,630.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,866.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,959.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,070.05. The transfer capital threshold is the transfer adjustment factor * $1,070.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13706.46","13706.46","13706.46","1 through 10","13990.14","14964.0348","other","Inpatient Replacement Plans DRG"
"Appendix Procedures With Cc","398","MS-DRG","","","","","","","","inpatient","","","40521.76","30391.32","MOLINA [1014]","HB BWF MEDICARE","14275.65","","Case rate ($14,275.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,298.37, add-ons for qualifying new technology services are included. If operating cost exceeds $59,822.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,630.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,866.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,959.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,070.05. The transfer capital threshold is the transfer adjustment factor * $1,070.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","27792.94","27792.94","27792.94","1 through 10","13990.14","14964.0348","other","Inpatient Replacement Plans DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","30259.29","22694.47","MEDICARE [2001]","HB BWF MEDICARE","10879.02","","Case rate ($10,879.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,896.21, add-ons for qualifying new technology services are included. If operating cost exceeds $56,419.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,370.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,730.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,556.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.26. The transfer capital threshold is the transfer adjustment factor * $809.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6929.65","6929.65","6929.65","1 through 10","10661.44","11750.35","other","Inpatient Replacement Plans DRG"
"Appendix Procedures Without Cc/McC","399","MS-DRG","","","","","","","","inpatient","","","30259.29","22694.47","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","10661.44","","Case rate ($10,879.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,896.21, add-ons for qualifying new technology services are included. If operating cost exceeds $56,419.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,370.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,730.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,556.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $809.26. The transfer capital threshold is the transfer adjustment factor * $809.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10272.46","10272.46","10272.46","1 through 10","10661.44","11750.35","other","Inpatient DRG"
"Appl Cast Hand/Lower Forearm","PX-76000696","CDM","29085","CPT","0761","RC","","","","both","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","183.64","","APC Price ($187.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","187.39","187.39","1 through 10","134.62","396.35","other","OPPS APC"
"Appl Cast Leg Short","PX-76000713","CDM","29405","CPT","0510","RC","","","","both","","","466.00","349.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","324.85","","APC Price ($315.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","512.98","512.98","512.98","1 through 10","207.14","699.12","other","OPPS APC"
"Appl Cast Leg Short","PX-76000713","CDM","29405","CPT","0510","RC","","","","both","","","466.00","349.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","388.07","388.07","388.07","1 through 10","207.14","699.12","other","Multiple Surgery"
"Appl Cast Leg Short","PX-76000713","CDM","29405","CPT","0510","RC","","","","both","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","309.08","","APC Price ($315.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","315.39","310.35","315.39","1 through 10","207.14","699.12","other","OPPS APC"
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","184.00","138.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","92.18","50.1","","285.72","285.72","285.72","1 through 10","90.29","567.68","percent of total billed charges",""
"Appl of Capsaicin Patch 1 or More","PX-76002971","CDM","17999","CPT","0761","RC","","","","outpatient","","","184.00","138.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","106.17","57.7","","8477.00","8477.00","8477.00","1 through 10","90.29","567.68","percent of total billed charges",""
"Appl Splint Forarm/Arm Shrt Static","PX-76000699","CDM","29125","CPT","0510","RC","","","","both","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","153.08","153.08","153.08","1 through 10","145.42","414.21","other","OPPS APC"
"Appl Splint Leg Short","PX-76000720","CDM","29515","CPT","0510","RC","","","","outpatient","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","264.38","78.45","","252.17","252.17","252.17","1 through 10","134.62","484.95","percent of total billed charges",""
"Application Finger Splint Static","PX-76001959","CDM","29130","CPT","0761","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","1 through 10","98.58","217.45","percent of total billed charges",""
"Apply Cast Arm Long","PX-76000694","CDM","29065","CPT","0761","RC","","","","both","","","466.00","349.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","235.58","","Case rate ($235.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","379.49","332.86","379.49","1 through 10","207.14","699.12","other","Multiple Surgery"
"Apply Cast Arm Short","PX-76000695","CDM","29075","CPT","0510","RC","","","","both","","","466.00","349.50","AETNA [1001]","HB CH AETNA HMO / PPO","271.68","58.3","","256.85","256.85","256.85","1 through 10","235.58","699.12","percent of total billed charges",""
"Apply Cast Arm Short","PX-76000695","CDM","29075","CPT","0510","RC","","","","both","","","466.00","349.50","MEDICARE [2001]","HB BWF MEDICARE","315.39","","APC Price ($315.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","315.39","315.39","315.39","1 through 10","235.58","699.12","other","OPPS APC"
"Apply Cast Arm Short","PX-76000695","CDM","29075","CPT","0510","RC","","","","both","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","309.08","","APC Price ($315.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","315.39","315.39","315.39","11","235.58","699.12","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","337.00","252.75","AETNA [1001]","HB CH AETNA HMO / PPO","196.47","58.3","","185.98","185.98","185.98","1 through 10","134.62","396.35","percent of total billed charges",""
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","337.00","252.75","MEDICARE [2001]","HB BWF MEDICARE","187.39","","APC Price ($187.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","171.97","343.94","16","134.62","396.35","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","337.00","252.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","187.39","","APC Price ($187.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","168.53","168.53","168.53","1 through 10","134.62","396.35","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","both","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","183.64","","APC Price ($187.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","171.97","187.39","1 through 10","134.62","396.35","other","OPPS APC"
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","outpatient","","","337.00","252.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","199.84","59.3","","192.21","192.21","192.21","1 through 10","134.62","484.95","percent of total billed charges",""
"Apply Cast Finger","PX-76000697","CDM","29086","CPT","0761","RC","","","","outpatient","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","264.38","78.45","","252.17","252.17","252.17","1 through 10","134.62","484.95","percent of total billed charges",""
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","both","","","337.00","252.75","MEDICARE [2001]","HB BWF MEDICARE","187.39","","APC Price ($187.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","187.39","171.97","187.39","1 through 10","134.62","396.35","other","OPPS APC"
"Apply Splint Arm Long","PX-76000698","CDM","29105","CPT","0510","RC","","","","both","","","337.00","252.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","183.64","","APC Price ($187.39). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.39","187.39","187.39","1 through 10","134.62","396.35","other","OPPS APC"
"Apply Splint Finger Static","PX-76000701","CDM","29130","CPT","0510","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","1 through 10","98.58","217.45","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","1 through 10","18.59","111.93","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","both","","","118.00","88.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","62.54","53","","60.95","60.95","60.95","1 through 10","18.59","111.93","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","67.39","1 through 10","19.57","119.57","percent of total billed charges",""
"Arsenic","PX-30000317","CDM","82175","CPT","0301","RC","","","","outpatient","","","118.00","88.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","115.26","115.26","115.26","1 through 10","19.57","119.57","percent of total billed charges",""
"Arthrd Ant Interbody Decompress Cervical Belw C2","PX-76000370","CDM","22551","CPT","0761","RC","","","","outpatient","","","9886.00","7414.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7755.57","78.45","","32816.90","32816.90","32816.90","1 through 10","7755.57","7755.57","percent of total billed charges",""
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","350.56","1 through 10","247.48","731.58","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US","PX-76002077","CDM","20610","CPT","0761","RC","","","","both","","","606.00","454.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","323.26","475.20","15","247.48","731.58","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","606.00","454.50","MEDICARE [2001]","HB BWF MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","525.83","525.83","969.78","25","333.03","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","606.00","454.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","1 through 10","333.03","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","both","","","606.00","454.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","515.32","515.32","515.32","1 through 10","333.03","1444.05","other","OPPS APC"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US|BILATERAL PROCEDURE","PX-76002077","CDM","20610","CPT","0761","RC","","","50","outpatient","","","606.00","454.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","613.86","601.12","613.86","1 through 10","259.97","1055.88","other","ASC "
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-76002078","CDM","20611","CPT","0761","RC","","","","outpatient","","","305.00","228.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","581.58","1 through 10","152.5","567.68","other","Multiple Surgery"
"Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US","PX-98300796","CDM","20611","CPT","0983","RC","","","","outpatient","","","","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","581.58","1 through 10","151.17","567.68","other","Multiple Surgery"
"Arthrod Pst Cmbn Tq Sgl Interspace","PX-76000372","CDM","22633","CPT","0761","RC","","","","outpatient","","","8930.00","6697.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4381.95","49.07","","4597.84","4597.84","4597.84","1 through 10","3572","7005.59","percent of total billed charges",""
"Arthrosc Aid Rpr Cruciate Lig Ant","PX-76001853","CDM","29888","CPT","0761","RC","","","","outpatient","","","23058.00","17293.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","5129.63","","Case rate ($5,129.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","12054.63","12054.63","12054.63","1 through 10","5129.63","18089","other","Multiple Surgery"
"Arthrotomy IP Hand Rem FB","PX-76000482","CDM","26080","CPT","0761","RC","","","","both","","","4431.00","3323.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1994.61","","APC Price ($2,035.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1870.47","1870.47","1870.47","1 through 10","1182.01","3452.19","other","OPPS APC"
"Arthrp Intercarpal/Carp/Mtcrpl Jt Suspension","PX-98302528","CDM","25448","CPT","0983","RC","","","","both","","","4047.00","3035.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","4043.80","","APC Price ($4,126.33). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3784.01","3783.81","3784.01","1 through 10","1736.16","10275.68","other","OPPS APC"
"Aspergillus Agent Enzyme Infect Ant","PX-30001231","CDM","87305","CPT","0306","RC","","","","outpatient","","","115.00","86.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.22","78.45","","86.11","86.11","86.11","1 through 10","11.81","90.22","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","474.47","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","466.88","466.88","1 through 10","236.03","926.73","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","MEDICARE [2001]","HB BWF MEDICARE","474.47","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","326.40","474.47","1 through 10","236.03","926.73","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","both","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.99","464.99","464.99","1 through 10","236.03","926.73","other","OPPS APC"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","507.87","507.87","507.87","1 through 10","265.5","567.68","other","ASC "
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","508.58","254.29","519.36","1 through 10","265.5","567.68","other","ASC "
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","314.88","59.3","","302.38","302.38","302.38","1 through 10","265.5","567.68","percent of total billed charges",""
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1495.02","1495.02","1495.02","1 through 10","265.5","567.68","other","Multiple Surgery"
"Aspiration Abscess/Hema/Bulla/Cyst","PX-76000011","CDM","10160","CPT","0761","RC","","","","outpatient","","","531.00","398.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","416.57","78.45","","813.47","396.70","813.47","1 through 10","265.5","567.68","percent of total billed charges",""
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","4773.00","3579.75","MEDICARE [2001]","HB BWF MEDICARE","2432.73","","APC Price ($2,432.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","1565.78","3718.64","other","OPPS APC"
"Aspiration Bladder/Insert Suprapub","PX-76001844","CDM","51102","CPT","0761","RC","","","","both","","","4773.00","3579.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1565.78","3718.64","per diem",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","AETNA [1001]","HB CH AETNA HMO / PPO","765.48","58.3","","724.06","724.06","724.06","1 through 10","579.34","1707.36","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","FALLON HEALTH [1008]","HB BWF MEDICARE","835.56","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","1707.36","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","MEDICARE [2001]","HB BWF MEDICARE","835.56","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","1707.36","other","OPPS APC"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","both","","","1313.00","984.75","WELLPOINT [1015]","HB CH WELLPOINT","1022.96","77.91","","1005.77","1005.77","1005.77","1 through 10","579.34","1707.36","percent of total billed charges",""
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","938.11","938.11","938.11","1 through 10","579.34","1030.05","other","ASC "
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1361.45","680.73","1361.45","1 through 10","579.34","1030.05","other","Multiple Surgery"
"Aspiration Cyst Breast","PX-76000242","CDM","19000","CPT","0761","RC","","","","outpatient","","","1313.00","984.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1430.97","1430.97","1430.97","1 through 10","579.34","1030.05","other","Multiple Surgery"
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1197.00","897.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","587.37","49.07","","587.59","587.59","587.59","1 through 10","478.8","939.05","percent of total billed charges",""
"Assay Neurofilament Light Chain","PX-30003841","CDM","83884","CPT","0302","RC","","","","outpatient","","","1197.00","897.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","599.70","50.1","","599.93","599.93","737.98","1 through 10","478.8","939.05","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","AETNA [1001]","HB CH AETNA HMO / PPO","192.97","58.3","","182.57","182.57","182.57","1 through 10","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","209.85","63.4","","213.49","205.44","213.49","1 through 10","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","both","","","331.00","248.25","WELLPOINT [1015]","HB CH WELLPOINT","257.88","77.91","","253.61","253.61","253.61","1 through 10","37.85","314.78","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","162.42","49.07","","190.98","162.55","190.98","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","165.83","50.1","","165.96","165.96","204.15","20","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","196.28","59.3","","188.69","188.69","188.69","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","190.99","57.7","","194.17","194.17","582.51","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","200.26","60.5","","213.49","203.83","213.49","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Anti-Mullerian Hormone","PX-30003819","CDM","82166","CPT","0301","RC","","","","outpatient","","","331.00","248.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","259.67","78.45","","247.55","247.55","247.55","1 through 10","147.13","259.67","percent of total billed charges",""
"Assay of Direct Measurement Free Estradiol","PX-30003730","CDM","82681","CPT","0301","RC","","","","both","","","233.00","174.75","AETNA [1001]","HB CH AETNA HMO / PPO","135.84","58.3","","128.71","128.71","128.71","1 through 10","27.38","221.58","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","145.00","108.75","AETNA [1001]","HB CH AETNA HMO / PPO","84.54","58.3","","79.95","79.95","159.90","17","16.92","137.9","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","145.00","108.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","91.93","63.4","","93.48","93.48","93.48","1 through 10","16.92","137.9","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.45","44.45","","63.31","63.31","63.31","1 through 10","16.92","137.9","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","both","","","145.00","108.75","WELLPOINT [1015]","HB CH WELLPOINT","112.97","77.91","","393.05","111.05","393.05","1 through 10","16.92","137.9","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.99","59.3","","82.63","82.63","247.89","1 through 10","43.11","113.75","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","83.67","57.7","","85.02","81.78","163.56","14","43.11","113.75","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","87.73","60.5","","93.48","89.25","178.50","1 through 10","43.11","113.75","percent of total billed charges",""
"Assay of Interleukin-6 (Il-6)","PX-30003760","CDM","83529","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.75","78.45","","108.40","64.24","108.40","12","43.11","113.75","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","1 through 10","14.03","110.23","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","both","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","80.03","53","","77.91","77.91","77.91","1 through 10","14.03","110.23","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","12","13.35","118.46","percent of total billed charges",""
"Assay of Lipoprotein A","PX-30000553","CDM","83695","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","66.97","66.97","66.97","1 through 10","13.35","118.46","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","both","","","326.00","244.50","AETNA [1001]","HB CH AETNA HMO / PPO","190.06","58.3","","179.74","179.74","179.74","12","27.38","237.98","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","326.00","244.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.32","59.3","","185.76","185.76","185.76","1 through 10","28.81","255.75","percent of total billed charges",""
"Assay of Total Estradiol","PX-30000422","CDM","82670","CPT","0301","RC","","","","outpatient","","","326.00","244.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","255.75","78.45","","243.71","144.43","243.71","1 through 10","28.81","255.75","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","AETNA [1001]","HB CH AETNA HMO / PPO","2506.90","58.3","","1634.24","1004.95","1718.99","42","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3139.00","73","","2123.89","1900.92","2123.89","1 through 10","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2506.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2279.00","53","","939.37","939.37","5593.65","1 through 10","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3655.00","85","","2323.25","1864.50","2882.25","16","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4300.00","100","","2909.44","1772.40","10952.08","45","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4300.00","100","","2323.25","2323.25","2323.25","1 through 10","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4300.00","100","","2882.25","1772.40","10169.17","187","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3139.00","73","","1659.41","1659.41","1659.41","1 through 10","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","WELLPOINT [1015]","HB CH WELLPOINT","3350.13","77.91","","2050.91","1468.48","2902.83","52","1911.35","4300","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2549.90","59.3","","1548.60","1092.60","3613.79","82","2150","3373.35","percent of total billed charges",""
"ASSEMBLY ADAPTER 39MM HUMERAL HEAD CA REVERS UNIVERSAL","SUP-ITM-10240001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3373.35","78.45","","2085.51","998.68","6202.11","56","2150","3373.35","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","1634.24","1004.95","1718.99","42","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","2123.89","1900.92","2123.89","1 through 10","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.92","58.3","","3729.00","1254.19","3729.00","1 through 10","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","939.37","939.37","5593.65","1 through 10","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","204.00","85","","2323.25","1864.50","2882.25","16","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","240.00","100","","2909.44","1772.40","10952.08","45","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","240.00","100","","2323.25","2323.25","2323.25","1 through 10","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","240.00","100","","2882.25","1772.40","10169.17","187","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","1659.41","1659.41","1659.41","1 through 10","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","2050.91","1468.48","2902.83","52","106.68","240","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","1548.60","1092.60","3613.79","82","120","188.28","percent of total billed charges",""
"ASSEMBLY BALL 135DEG TAPER WARSAW SHOULDER GLOBAL AP FIXED NECK","SUP-ITM-10041809","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","2085.51","998.68","6202.11","56","120","188.28","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","AETNA [1001]","HB CH AETNA HMO / PPO","4848.23","58.3","","1634.24","1004.95","1718.99","42","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6070.68","73","","2123.89","1900.92","2123.89","1 through 10","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4848.23","58.3","","3729.00","1254.19","3729.00","1 through 10","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4407.48","53","","939.37","939.37","5593.65","1 through 10","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7068.60","85","","2323.25","1864.50","2882.25","16","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8316.00","100","","2909.44","1772.40","10952.08","45","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8316.00","100","","2323.25","2323.25","2323.25","1 through 10","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8316.00","100","","2882.25","1772.40","10169.17","187","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6070.68","73","","1659.41","1659.41","1659.41","1 through 10","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","both","","","8316.00","6237.00","WELLPOINT [1015]","HB CH WELLPOINT","6479.00","77.91","","2050.91","1468.48","2902.83","52","3696.46","8316","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4931.39","59.3","","1548.60","1092.60","3613.79","82","4158","6523.9","percent of total billed charges",""
"ASSEMBLY CEMENTED 54.5XM/L / 62MM SZ 3 COMPONENT FEMORAL KNEE LEGION HK RIGHT","SUP-ITM-10113669","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8316.00","6237.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6523.90","78.45","","2085.51","998.68","6202.11","56","4158","6523.9","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","24.38","1 through 10","5.08","33.93","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","both","","","44.00","33.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.56","44.45","","19.59","19.59","19.59","1 through 10","5.08","33.93","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","25.20","11","5.34","34.52","percent of total billed charges",""
"Ast/Sgot","PX-30000705","CDM","84450","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","21.60","33.06","1 through 10","5.34","34.52","percent of total billed charges",""
"Asthma,EXTREME","141","DRG","","","","","","","","inpatient","","","40584.40","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","13070.53","","Fee schedule rate ($13,070.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15376.98","15376.98","15376.98","1 through 10","4097.67","43370.42","case rate",""
"Asthma,EXTREME","141","DRG","","","","","","","","inpatient","","","40584.40","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","27858.65","","Fee schedule rate ($27,858.65). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32775.29","32775.29","32775.29","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","17430.35","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9070.55","","Standard inlier is a Case rate ($16,410.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $28,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,329.51) for the length of stay and the standard reimbursement.","9070.55","15664.62","16410.34","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","17430.35","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6503.49","","Case rate ($7,190.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,620.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7188.96","7188.96","7188.96","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MAJOR","141","DRG","","","","","","","","inpatient","","","17430.35","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6503.49","","Case rate ($7,190.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,620.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7188.96","7188.96","7188.96","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","17409.60","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4097.67","","Case rate ($4,530.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,960.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4529.56","2728.23","6584.71","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MINOR","141","DRG","","","","","","","","inpatient","","","17409.60","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4097.67","","Case rate ($4,530.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,960.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4529.56","4529.56","4529.56","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","25223.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9070.55","","Standard inlier is a Case rate ($13,645.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $20,953, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,936.97) for the length of stay and the standard reimbursement.","9070.55","13024.99","13645.04","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","25223.21","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5266.31","","Case rate ($5,822.81). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,252.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5821.38","2893.24","5821.38","1 through 10","4097.67","43370.42","case rate",""
"Asthma,MODERATE","141","DRG","","","","","","","","inpatient","","","25223.21","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5266.31","","Case rate ($5,822.81). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,252.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5821.38","5821.38","5821.38","1 through 10","4097.67","43370.42","case rate",""
"Atherosclerosis With McC","302","MS-DRG","","","","","","","","inpatient","","","37698.73","28274.05","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","11697.60","","Case rate ($11,356.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,374.84, add-ons for qualifying new technology services are included. If operating cost exceeds $56,898.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,406.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,171.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,035.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $845.95. The transfer capital threshold is the transfer adjustment factor * $845.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","11150.38","11150.38","11150.38","1 through 10","11129.75","12283.1","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","19554.87","14666.15","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6406.96","","Case rate ($6,537.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,547.81, add-ons for qualifying new technology services are included. If operating cost exceeds $52,071.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,036.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,722.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,208.57 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.93. The transfer capital threshold is the transfer adjustment factor * $475.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6242.00","6242.00","6242.00","1 through 10","6406.96","7130.34","other","Inpatient DRG"
"Atherosclerosis Without McC","303","MS-DRG","","","","","","","","inpatient","","","19554.87","14666.15","MEDICARE [2001]","HB BWF MEDICARE","7130.34","","Case rate ($7,130.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,547.81, add-ons for qualifying new technology services are included. If operating cost exceeds $52,071.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,036.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $6,315.17 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,208.57 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $475.93. The transfer capital threshold is the transfer adjustment factor * $475.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6937.16","6892.05","6937.16","1 through 10","6406.96","7130.34","other","Inpatient DRG"
"Autonomic Function Test Cardiovagal","PX-92000069","CDM","95921","CPT","0922","RC","","","","both","","","431.00","323.25","MEDICARE [2001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","528.85","other","OPPS APC"
"Autonomic Function Test Cardiovagal","PX-92000069","CDM","95921","CPT","0922","RC","","","","both","","","431.00","323.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","182.09","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.10","183.10","1 through 10","176.52","528.85","other","OPPS APC"
"Autonomic Function Test Cardiovagal","PX-92000069","CDM","95921","CPT","0922","RC","","","","outpatient","","","431.00","323.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","255.58","59.3","","245.53","245.53","245.53","1 through 10","191.58","344.05","percent of total billed charges",""
"Autonomic Function Test Cardiovagal","PX-92000069","CDM","95921","CPT","0922","RC","","","","outpatient","","","431.00","323.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","338.12","78.45","","322.13","322.13","322.13","1 through 10","191.58","344.05","percent of total billed charges",""
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","both","","","696.00","522.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","171.01","132.59","171.01","1 through 10","145.42","542.25","other","OPPS APC"
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","both","","","696.00","522.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","168.27","168.27","168.27","1 through 10","145.42","542.25","other","OPPS APC"
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","both","","","696.00","522.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","508.08","73","","494.21","479.61","494.21","1 through 10","145.42","542.25","percent of total billed charges",""
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","both","","","696.00","522.00","MEDICARE [2001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","306.16","306.16","306.16","1 through 10","145.42","542.25","other","OPPS APC"
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","both","","","696.00","522.00","WELLPOINT [1015]","HB CH WELLPOINT","542.25","77.91","","677.00","533.21","1210.21","1 through 10","145.42","542.25","percent of total billed charges",""
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","outpatient","","","696.00","522.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","412.73","59.3","","396.72","396.72","396.72","15","175.84","546.01","percent of total billed charges",""
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","outpatient","","","696.00","522.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","309.37","44.45","","308.44","308.44","308.44","1 through 10","175.84","546.01","percent of total billed charges",""
"Autonomic Function Test Sudomotor","PX-92000071","CDM","95923","CPT","0922","RC","","","","outpatient","","","696.00","522.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","546.01","78.45","","520.48","308.44","520.48","22","175.84","546.01","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","AETNA [1001]","HB CH AETNA HMO / PPO","1428.93","58.3","","1634.24","1004.95","1718.99","42","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1789.23","73","","2123.89","1900.92","2123.89","1 through 10","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1428.93","58.3","","3729.00","1254.19","3729.00","1 through 10","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1299.03","53","","939.37","939.37","5593.65","1 through 10","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2083.35","85","","2323.25","1864.50","2882.25","16","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2451.00","100","","2909.44","1772.40","10952.08","45","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2451.00","100","","2323.25","2323.25","2323.25","1 through 10","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2451.00","100","","2882.25","1772.40","10169.17","187","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1789.23","73","","1659.41","1659.41","1659.41","1 through 10","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","WELLPOINT [1015]","HB CH WELLPOINT","1909.57","77.91","","2050.91","1468.48","2902.83","52","1089.47","2451","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1453.44","59.3","","1548.60","1092.60","3613.79","82","1225.5","1922.81","percent of total billed charges",""
"AXLE FEMORAL 65MM IMPLANT HIP KINEMAX ROTATING HINGE STANDARD ONC 16A","SUP-ITM-10005312","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1922.81","78.45","","2085.51","998.68","6202.11","56","1225.5","1922.81","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","207.04","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","103.13","103.13","103.13","1 through 10","34.39","207.04","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","131.85","13","26.86","181.22","percent of total billed charges",""
"Babesia Microtiter Dna Pcr","PX-30002282","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","24","26.86","181.22","percent of total billed charges",""
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","39685.61","29764.21","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","19318.68","","Case rate ($18,756). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,786.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,309.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,974.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,002.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,446.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,414.06. The transfer capital threshold is the transfer adjustment factor * $1,414.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","18094.79","18094.79","18094.79","1 through 10","18380.88","20532.05","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion With Cc","519","MS-DRG","","","","","","","","inpatient","","","39685.61","29764.21","MEDICARE [2001]","HB BWF MEDICARE","18756.00","","Case rate ($18,756). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,786.02, add-ons for qualifying new technology services are included. If operating cost exceeds $64,309.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,974.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,002.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,446.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,414.06. The transfer capital threshold is the transfer adjustment factor * $1,414.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19246.92","0.03","19858.69","1 through 10","18380.88","20532.05","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator","518","MS-DRG","","","","","","","","inpatient","","","60862.57","45646.93","MEDICARE [2001]","HB BWF MEDICARE","38040.30","","Case rate ($38,040.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $34,806.39, add-ons for qualifying new technology services are included. If operating cost exceeds $80,330.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,202.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $35,058.94 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $34,467.15 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,642.12. The transfer capital threshold is the transfer adjustment factor * $2,642.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","34569.96","34569.96","34569.96","1 through 10","34055.29","38040.3","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","35464.71","26598.53","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","14094.26","","Case rate ($14,094.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,116.69, add-ons for qualifying new technology services are included. If operating cost exceeds $59,640.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,616.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,698.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,777.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,056.13. The transfer capital threshold is the transfer adjustment factor * $1,056.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13063.29","13063.29","13063.29","1 through 10","13812.37","15334.88","other","Inpatient Replacement Plans DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","35464.71","26598.53","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13812.37","","Case rate ($14,094.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,116.69, add-ons for qualifying new technology services are included. If operating cost exceeds $59,640.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,616.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,698.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,777.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,056.13. The transfer capital threshold is the transfer adjustment factor * $1,056.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13059.68","13059.68","13059.68","1 through 10","13812.37","15334.88","other","Inpatient DRG"
"Back And Neck Procedures Except Spinal Fusion Without Cc/McC","520","MS-DRG","","","","","","","","inpatient","","","35464.71","26598.53","MEDICARE [2001]","HB BWF MEDICARE","14094.26","","Case rate ($14,094.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,116.69, add-ons for qualifying new technology services are included. If operating cost exceeds $59,640.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,616.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $12,698.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,777.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,056.13. The transfer capital threshold is the transfer adjustment factor * $1,056.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14406.04","14208.76","14502.14","1 through 10","13812.37","15334.88","other","Inpatient Replacement Plans DRG"
"Bacterial And Tuberculous Infections Of Nervous System With Cc","095","MS-DRG","","","","","","","","inpatient","","","47440.29","35580.22","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","23605.39","","Case rate ($24,087.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,125.84, add-ons for qualifying new technology services are included. If operating cost exceeds $69,649.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,384.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $21,924.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,786.60 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,823.39. The transfer capital threshold is the transfer adjustment factor * $1,823.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","21626.26","21626.26","21626.26","1 through 10","23605.39","24809.74","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC","096","MS-DRG","","","","","","","","inpatient","","","38439.44","28829.58","MEDICARE [2001]","HB BWF MEDICARE","26357.64","","Case rate ($26,357.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,125.84, add-ons for qualifying new technology services are included. If operating cost exceeds $69,649.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,384.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.6. The base transfer operating payment is the transfer adjustment factor * $24,195.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,786.60 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,823.39. The transfer capital threshold is the transfer adjustment factor * $1,823.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23926.89","23926.89","23926.89","1 through 10","23605.39","26357.64","other","Inpatient DRG"
"Bacterial And Tuberculous Infections Of Nervous System,MAJOR","049","DRG","","","","","","","","inpatient","","","62133.36","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","19963.99","","Case rate ($22,073.62). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,503.62, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,254.71 and the sum of the standard inlier and any outlier amount.","12521.10","12521.10","12521.10","1 through 10","2537","76328","case rate",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","1634.24","1004.95","1718.99","42","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","2123.89","1900.92","2123.89","1 through 10","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.92","58.3","","3729.00","1254.19","3729.00","1 through 10","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","939.37","939.37","5593.65","1 through 10","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","204.00","85","","2323.25","1864.50","2882.25","16","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","240.00","100","","2909.44","1772.40","10952.08","45","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","240.00","100","","2323.25","2323.25","2323.25","1 through 10","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","240.00","100","","2882.25","1772.40","10169.17","187","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","1659.41","1659.41","1659.41","1 through 10","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","2050.91","1468.48","2902.83","52","106.68","240","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","1548.60","1092.60","3613.79","82","120","188.28","percent of total billed charges",""
"BALL ASSEMBLY TAPER DISTRACT SHOULDER GLOBAL ADJUSTABLE PROSTHESIS","SUP-ITM-10048258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","2085.51","998.68","6202.11","56","120","188.28","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","1634.24","1004.95","1718.99","42","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","2123.89","1900.92","2123.89","1 through 10","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","3729.00","1254.19","3729.00","1 through 10","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","939.37","939.37","5593.65","1 through 10","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","224.40","85","","2323.25","1864.50","2882.25","16","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","264.00","100","","2909.44","1772.40","10952.08","45","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","264.00","100","","2323.25","2323.25","2323.25","1 through 10","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","264.00","100","","2882.25","1772.40","10169.17","187","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","1659.41","1659.41","1659.41","1 through 10","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","2050.91","1468.48","2902.83","52","117.35","264","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","1548.60","1092.60","3613.79","82","132","207.11","percent of total billed charges",""
"BALL WRIST SZ 10 20 9.5MM UHMWP JOINT","SUP-ITM-10194562","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","2085.51","998.68","6202.11","56","132","207.11","percent of total billed charges",""
"BALLOON DRUG COATED 30FRX3CM URETHRAL AND INFLATION OPTILUME","SUP-ITM-10328001","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","6850.00","5137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5373.83","78.45","","2644.76","2644.76","2644.76","1 through 10","3425","5373.83","percent of total billed charges",""
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","both","","","2681.00","2010.75","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","2549.63","other","OPPS APC"
"Balloon Enteroscopy","PX-75000441","CDM","44799","CPT","0750","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1343.18","50.1","","6121.00","6121.00","6121.00","1 through 10","1315.57","7178","percent of total billed charges",""
"BALLOON SINUS 6X17MM DILATION NUVENT EM SEEKER","SUP-ITM-10209199","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","876.96","657.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","687.98","78.45","","2644.76","2644.76","2644.76","1 through 10","438.48","687.98","percent of total billed charges",""
"BARRIER ADHESION 3.0X4.0IN INTERCEED ABSORBABLE GYNECARE IMPLANTABLE BX/10EA","SUP-ITM-10074846","CDM","C1765","HCPCS","0278","RC","","","","both","","","871.40","653.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.84","53","","839.71","839.71","1567.77","1 through 10","387.34","871.4","percent of total billed charges",""
"BARRIER ADHESION 3.0X4.0IN INTERCEED ABSORBABLE GYNECARE IMPLANTABLE BX/10EA","SUP-ITM-10074846","CDM","C1765","HCPCS","0278","RC","","","","both","","","871.40","653.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","740.69","85","","2614.20","2614.20","2614.20","1 through 10","387.34","871.4","percent of total billed charges",""
"BARRIER ADHESION 3.0X4.0IN INTERCEED ABSORBABLE GYNECARE IMPLANTABLE BX/10EA","SUP-ITM-10074846","CDM","C1765","HCPCS","0278","RC","","","","outpatient","","","871.40","653.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","683.61","78.45","","397.01","397.01","397.01","1 through 10","435.7","683.61","percent of total billed charges",""
"BARRIER ADHESION 6X5IN SZ 1 SEPRAFILM ABDOMINOPELVIC CAVITY BIORESORBABLE BX/10EA","SUP-ITM-10002948","CDM","C1765","HCPCS","0278","RC","","","","both","","","986.02","739.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","522.59","53","","839.71","839.71","1567.77","1 through 10","438.29","986.02","percent of total billed charges",""
"BARRIER ADHESION 6X5IN SZ 1 SEPRAFILM ABDOMINOPELVIC CAVITY BIORESORBABLE BX/10EA","SUP-ITM-10002948","CDM","C1765","HCPCS","0278","RC","","","","both","","","986.02","739.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","838.12","85","","2614.20","2614.20","2614.20","1 through 10","438.29","986.02","percent of total billed charges",""
"BARRIER ADHESION 6X5IN SZ 1 SEPRAFILM ABDOMINOPELVIC CAVITY BIORESORBABLE BX/10EA","SUP-ITM-10002948","CDM","C1765","HCPCS","0278","RC","","","","outpatient","","","986.02","739.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","773.53","78.45","","397.01","397.01","397.01","1 through 10","493.01","773.53","percent of total billed charges",""
"Bartonella Antibody","PX-30000885","CDM","86611","CPT","0302","RC","","","","both","","","82.00","61.50","AETNA [1001]","HB CH AETNA HMO / PPO","47.81","58.3","","45.36","45.36","45.36","1 through 10","9.98","60.06","percent of total billed charges",""
"Bartonella Pcr,B","PX-30003035","CDM","87801","CPT","0306","RC","","","","outpatient","","","468.00","351.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","277.52","59.3","","266.63","266.63","266.63","1 through 10","53.71","367.15","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 25MM AEQUALIS STANDARD REVERSED PERFORM","SUP-ITM-10211839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID 29MM AEQUALIS STANDARD","SUP-ITM-10215287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","AETNA [1001]","HB CH AETNA HMO / PPO","2012.81","58.3","","1634.24","1004.95","1718.99","42","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2520.33","73","","2123.89","1900.92","2123.89","1 through 10","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2012.81","58.3","","3729.00","1254.19","3729.00","1 through 10","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1829.83","53","","939.37","939.37","5593.65","1 through 10","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2934.63","85","","2323.25","1864.50","2882.25","16","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3452.50","100","","2909.44","1772.40","10952.08","45","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3452.50","100","","2323.25","2323.25","2323.25","1 through 10","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3452.50","100","","2882.25","1772.40","10169.17","187","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2520.33","73","","1659.41","1659.41","1659.41","1 through 10","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","WELLPOINT [1015]","HB CH WELLPOINT","2689.84","77.91","","2050.91","1468.48","2902.83","52","1534.64","3452.5","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2047.33","59.3","","1548.60","1092.60","3613.79","82","1726.25","2708.49","percent of total billed charges",""
"BASEPLATE GLENOID REVERSE SHOULDER SM","SUP-ITM-10280223","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2708.49","78.45","","2085.51","998.68","6202.11","56","1726.25","2708.49","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","554.95","91.85","1421.75","94","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2490.03","2490.03","2490.03","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","750.00","750.00","750.00","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","1192.50","120.84","4149.90","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","750.00","75.00","750.00","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","657.00","121.50","1971.00","14","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","75.00","75.00","75.00","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","366.00","144.00","1971.00","45","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","667.50","667.50","667.50","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","123.77","123.77","123.77","1 through 10","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","483.51","229.32","1316.08","96","1466.85","3300","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","439.50","225.34","1872.27","197","1650","2588.85","percent of total billed charges",""
"BASEPLATE PLATFORM 24MM SMALL INHANCE SHOULDER SYSTEM CEMENTLESS","SUP-ITM-10336680","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","385.32","55.36","1815.62","58","1650","2588.85","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"BASEPLATE TIBIAL EMPOWR PRESS FIT 6 LEFT","SUP-ITM-10309403","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","AETNA [1001]","HB CH AETNA HMO / PPO","4271.58","58.3","","1634.24","1004.95","1718.99","42","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5348.64","73","","2123.89","1900.92","2123.89","1 through 10","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4271.58","58.3","","3729.00","1254.19","3729.00","1 through 10","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3883.26","53","","939.37","939.37","5593.65","1 through 10","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6227.87","85","","2323.25","1864.50","2882.25","16","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7326.90","100","","2909.44","1772.40","10952.08","45","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7326.90","100","","2323.25","2323.25","2323.25","1 through 10","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7326.90","100","","2882.25","1772.40","10169.17","187","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5348.64","73","","1659.41","1659.41","1659.41","1 through 10","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","both","","","7326.90","5495.17","WELLPOINT [1015]","HB CH WELLPOINT","5708.39","77.91","","2050.91","1468.48","2902.83","52","3256.81","7326.9","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7326.90","5495.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","4344.85","59.3","","1548.60","1092.60","3613.79","82","3663.45","5747.95","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 3 TOTAL ANKLE","SUP-ITM-10235654","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7326.90","5495.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5747.95","78.45","","2085.51","998.68","6202.11","56","3663.45","5747.95","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"BASEPLATE TIBIAL SIZE 8 RESTORIS MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236291","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0300","RC","","","","inpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.88","56","","54.34","54.34","54.34","1 through 10","54.88","69.19","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0300","RC","","","","inpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.19","70.6","","73.04","73.04","73.04","1 through 10","54.88","69.19","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","246","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","71.54","73","","69.35","67.16","69.35","1 through 10","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.86","53.86","53.86","1 through 10","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.94","53","","50.35","48.76","50.35","1 through 10","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","71.54","73","","69.35","53.87","69.35","1 through 10","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.56","44.45","","43.28","43.28","73.04","1 through 10","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.56","44.45","","43.28","43.28","43.28","1 through 10","8.29","71.54","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","167.01","256","8.73","76.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.66","55.67","1 through 10","8.73","76.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","73.04","73.04","1 through 10","8.73","76.88","percent of total billed charges",""
"Basic Metabolic Panel","PX-30000171","CDM","80048","CPT","0301","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","43.28","73.05","197","8.73","76.88","percent of total billed charges",""
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","both","","","2657.00","1992.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14973.01","","APC Price ($15,278.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","14974.52","14974.52","14974.52","1 through 10","1139.85","39882.95","other","OPPS APC"
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","both","","","2657.00","1992.75","MEDICARE [2001]","HB BWF MEDICARE","15278.58","","APC Price ($15,278.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15280.12","15280.12","15280.12","1 through 10","1139.85","39882.95","other","OPPS APC"
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","outpatient","","","2657.00","1992.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13524.18","","Case rate ($13,524.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","19555.96","19555.96","19555.96","1 through 10","1328.5","13524.18","other","ASC "
"Basivertebral Nerve Destruction Lumbar Two Bodies","PX-76002685","CDM","64628","CPT","0761","RC","","","","outpatient","","","2657.00","1992.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9642.49","","Case rate ($9,642.49). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","22659.85","22659.85","22659.85","1 through 10","1328.5","13524.18","other","Multiple Surgery"
"Bcw, 1284 Vwf Exon 28 Sequence Von Willebrand Factor Vwf28","PX-31001322","CDM","81403","CPT","0310","RC","","","","outpatient","","","1294.00","970.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1015.14","78.45","","562.39","562.39","562.39","1 through 10","456.38","1015.14","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","AETNA [1001]","HB CH AETNA HMO / PPO","2008.44","58.3","","554.95","91.85","1421.75","94","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2514.85","73","","2490.03","2490.03","2490.03","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2008.44","58.3","","750.00","750.00","750.00","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1825.85","53","","1192.50","120.84","4149.90","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2928.25","85","","750.00","75.00","750.00","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3445.00","100","","657.00","121.50","1971.00","14","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3445.00","100","","75.00","75.00","75.00","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3445.00","100","","366.00","144.00","1971.00","45","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2514.85","73","","667.50","667.50","667.50","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.30","44.45","","123.77","123.77","123.77","1 through 10","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","WELLPOINT [1015]","HB CH WELLPOINT","2684.00","77.91","","483.51","229.32","1316.08","96","1531.3","3445","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3445.00","2583.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2042.89","59.3","","439.50","225.34","1872.27","197","1722.5","2702.6","percent of total billed charges",""
"BEAM FUSION 7X115MM SALVATION FULL THREAD","SUP-ITM-10192891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2702.60","78.45","","385.32","55.36","1815.62","58","1722.5","2702.6","percent of total billed charges",""
"Behavral Qualit Analys Voice","PX-44000061","CDM","92524","CPT","0444","RC","","","","both","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","115.31","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($117.66). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($91.91). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","115.41","115.41","115.41","1 through 10","115.31","469.71","fee schedule",""
"Benign Prostatic Hypertrophy Without McC","726","MS-DRG","","","","","","","","inpatient","","","17877.71","13408.28","HUMANA [1012]","HB BWF MEDICARE","6987.03","","Case rate ($6,987.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,997.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,521.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,071.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,137.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,658.63 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.43. The transfer capital threshold is the transfer adjustment factor * $510.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6884.05","6884.05","6884.05","1 through 10","6847.29","7411.33","other","Inpatient Replacement Plans DRG"
"Benign Prostatic Hypertrophy Without McC","726","MS-DRG","","","","","","","","inpatient","","","17877.71","13408.28","MEDICARE [2001]","HB BWF MEDICARE","6987.03","","Case rate ($6,987.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,997.87, add-ons for qualifying new technology services are included. If operating cost exceeds $52,521.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,071.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,137.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,658.63 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $510.43. The transfer capital threshold is the transfer adjustment factor * $510.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7653.10","7653.10","7653.10","1 through 10","6847.29","7411.33","other","Inpatient Replacement Plans DRG"
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","130.00","97.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.09","59.3","","221.51","73.84","221.51","11","14.19","101.99","percent of total billed charges",""
"Beta 2 Glycoprotein I Antibody Ea","PX-30000789","CDM","86146","CPT","0302","RC","","","","outpatient","","","130.00","97.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.99","78.45","","185.02","96.87","193.74","1 through 10","14.19","101.99","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","both","","","22.05","16.54","AETNA [1001]","HB CH AETNA HMO / PPO","12.86","58.3","","16.30","16.20","16.30","1 through 10","11.69","19.22","percent of total billed charges",""
"Betameth Na Phos/Acet Inj 3mg/3mg","PX-63600079","CDM","J0702","HCPCS","0636","RC","","","","outpatient","","","22.05","16.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","11.51","52.2","","14.65","14.57","14.65","1 through 10","11.03","14.81","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","both","","","1671.00","1253.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1589.12","other","OPPS APC"
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1671.00","1253.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","819.96","49.07","","2115.00","2115.00","2115.00","1 through 10","567.68","1310.9","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1671.00","1253.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","837.17","50.1","","331.25","331.25","331.25","1 through 10","567.68","1310.9","percent of total billed charges",""
"Bier Block","PX-76001871","CDM","64999","CPT","0761","RC","","","","outpatient","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","282.15","282.15","282.15","1 through 10","567.68","1310.9","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","both","","","1043.00","782.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","991.89","other","OPPS APC"
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1043.00","782.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","511.80","49.07","","2115.00","2115.00","2115.00","1 through 10","463.61","818.23","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1043.00","782.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","522.54","50.1","","331.25","331.25","331.25","1 through 10","463.61","818.23","percent of total billed charges",""
"Bier Block","PX-98300612","CDM","64999","CPT","0983","RC","","","","outpatient","","","1043.00","782.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","818.23","78.45","","282.15","282.15","282.15","1 through 10","463.61","818.23","percent of total billed charges",""
"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without McC","462","MS-DRG","","","","","","","","inpatient","","","78568.96","58926.72","MEDICARE [2001]","HB BWF MEDICARE","27172.74","","Case rate ($27,172.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,871.02, add-ons for qualifying new technology services are included. If operating cost exceeds $70,394.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,441.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $24,952.98 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $24,531.78 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,880.51. The transfer capital threshold is the transfer adjustment factor * $1,880.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","28535.23","28535.23","28535.23","1 through 10","24334.49","27304.9","other","Inpatient DRG"
"Bile Acids","PX-30000322","CDM","82239","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.75","78.45","","108.40","108.40","108.40","1 through 10","17.66","113.75","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","23.81","23.81","23.81","1 through 10","4.92","31.39","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.50","59.3","","24.61","24.61","24.61","1 through 10","5.18","33.73","percent of total billed charges",""
"Bilirubin Direct","PX-30000325","CDM","82248","CPT","0301","RC","","","","outpatient","","","43.00","32.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.73","78.45","","32.29","19.14","32.29","1 through 10","5.18","33.73","percent of total billed charges",""
"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","478","MS-DRG","","","","","","","","inpatient","","","72261.41","54196.06","MEDICARE [2001]","HB BWF MEDICARE","25147.10","","Case rate ($25,147.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,019.15, add-ons for qualifying new technology services are included. If operating cost exceeds $68,542.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,299.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 5.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,069.31 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,679.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,738.56. The transfer capital threshold is the transfer adjustment factor * $1,738.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23348.14","23348.14","23348.14","1 through 10","22522.59","25147.1","other","Inpatient DRG"
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3855.09","3855.09","3855.09","1 through 10","1873.9","3745.99","other","ASC "
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3860.43","3860.43","3860.43","1 through 10","1873.9","3745.99","other","ASC "
"Biopsy Anorectal Wall Rectal Appr","PX-75000172","CDM","45100","CPT","0750","RC","","","","outpatient","","","4775.00","3581.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3745.99","78.45","","4061.57","4061.57","4061.57","1 through 10","1873.9","3745.99","percent of total billed charges",""
"Biopsy Bone Open Superficial","PX-76000278","CDM","20240","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2925.84","50.1","","3932.70","3932.70","3932.70","1 through 10","2336","4581.48","percent of total billed charges",""
"Biopsy Bone Trocar/Needle Superfic","PX-76000276","CDM","20220","CPT","0761","RC","","","","both","","","2156.00","1617.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.65","1887.65","1887.65","1 through 10","924.92","1981.66","other","OPPS APC"
"Biopsy Breast Incisional","PX-76000247","CDM","19101","CPT","0761","RC","","","","both","","","6638.00","4978.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","2847.7","5171.67","per diem",""
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","137.00","137.00","137.00","1 through 10","165.93","567.68","other","ASC "
"Biopsy Endometrial Sampling W/O Dil","PX-76001377","CDM","58100","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","268.69","268.69","268.69","1 through 10","165.93","567.68","other","ASC "
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","both","","","2359.00","1769.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","860.62","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.49","860.49","860.49","1 through 10","579.34","1837.9","other","OPPS APC"
"Biopsy Gland Salivary Needle","PX-75000057","CDM","42400","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4084.35","4084.35","4084.35","1 through 10","579.34","1873.9","other","Multiple Surgery"
"Biopsy Intranasal","PX-76000743","CDM","30100","CPT","0761","RC","","","","outpatient","","","1930.00","1447.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1514.09","78.45","","4825.00","4825.00","4825.00","1 through 10","965","1873.9","percent of total billed charges",""
"Biopsy Lesion Vulva/Perineum One","PX-76001335","CDM","56605","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","638.15","","Case rate ($638.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","922.76","922.76","922.76","1 through 10","558.04","972.78","other","ASC "
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1981.86","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1988.83","1988.83","1988.83","1 through 10","929.01","1981.86","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1924.13","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","929.01","1981.86","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","MEDICARE [2001]","HB BWF MEDICARE","1924.13","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","3398.86","1 through 10","929.01","1981.86","other","OPPS APC"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","both","","","2090.00","1567.50","WELLPOINT [1015]","HB CH WELLPOINT","1628.32","77.91","","1600.40","1600.40","1600.40","1 through 10","929.01","1981.86","percent of total billed charges",""
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2227.31","2227.31","2274.50","1 through 10","1045","1873.9","other","ASC "
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2909.18","2909.18","2909.18","1 through 10","1045","1873.9","other","Multiple Surgery"
"Biopsy Liver Needle Perc","PX-75000240","CDM","47000","CPT","0361","RC","","","","outpatient","","","2090.00","1567.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3639.57","3639.57","3639.57","1 through 10","1045","1873.9","other","Multiple Surgery"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1981.86","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1988.83","1988.83","1988.83","1 through 10","918.78","1981.86","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1924.13","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","918.78","1981.86","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","MEDICARE [2001]","HB BWF MEDICARE","1924.13","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","918.78","1981.86","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1885.65","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1887.65","1887.65","1887.65","1 through 10","918.78","1981.86","other","OPPS APC"
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","both","","","2067.00","1550.25","WELLPOINT [1015]","HB CH WELLPOINT","1610.40","77.91","","3593.08","3593.08","3593.08","1 through 10","918.78","1981.86","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2271.35","2271.35","2271.35","1 through 10","1033.5","1873.9","other","ASC "
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1033.5","1873.9","other","ASC "
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1225.73","59.3","","1177.86","1177.86","1177.86","1 through 10","1033.5","1873.9","percent of total billed charges",""
"Biopsy Mass Abdominal Perc","PX-75000280","CDM","49180","CPT","0361","RC","","","","outpatient","","","2067.00","1550.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8727.54","2909.18","8727.54","1 through 10","1033.5","1873.9","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","both","","","2089.00","1566.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1885.65","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1891.95","1891.95","1891.95","1 through 10","1107.17","1981.86","other","OPPS APC"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2089.00","1566.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1112.09","1112.09","1112.09","1 through 10","928.56","1873.9","other","ASC "
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2089.00","1566.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8727.54","2909.18","8727.54","1 through 10","928.56","1873.9","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2089.00","1566.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3057.74","3057.74","3057.74","1 through 10","928.56","1873.9","other","Multiple Surgery"
"Biopsy Muscle Needle Perc","PX-76000275","CDM","20206","CPT","0761","RC","","","","outpatient","","","2089.00","1566.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1638.82","78.45","","925.32","925.32","925.32","1 through 10","928.56","1873.9","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2505.46","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2510.28","2503.28","2510.28","1 through 10","1565.78","2781.39","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","1 through 10","1565.78","2781.39","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","4431.16","4431.16","4431.16","1 through 10","1565.78","2781.39","other","Multiple Surgery"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","MARTIN'S POINT [160007]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.98","2393.98","2393.98","1 through 10","1565.78","2781.39","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","MEDICARE [2001]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2185.86","2432.73","42","1565.78","2781.39","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","1565.78","2781.39","per diem",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","2068.00","2068.00","2068.00","1 through 10","1565.78","2781.39","per diem",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1565.78","2781.39","per diem",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.88","2391.88","2391.88","1 through 10","1565.78","2781.39","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2383.83","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.58","2388.95","2391.58","1 through 10","1565.78","2781.39","other","OPPS APC"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","both","","","3570.00","2677.50","WELLPOINT [1015]","HB CH WELLPOINT","2781.39","77.91","","4701.97","4701.97","4701.97","1 through 10","1565.78","2781.39","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3570.00","2677.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2813.15","2813.15","2872.84","11","1531.53","2800.67","other","ASC "
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3570.00","2677.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2817.13","2817.13","2817.13","1 through 10","1531.53","2800.67","other","ASC "
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3570.00","2677.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2817.13","2817.13","2876.82","12","1531.53","2800.67","other","ASC "
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3570.00","2677.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2117.01","59.3","","4845.05","3498.42","6191.68","1 through 10","1531.53","2800.67","percent of total billed charges",""
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3570.00","2677.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","7077.32","3538.66","7077.32","1 through 10","1531.53","2800.67","other","Multiple Surgery"
"Biopsy Prostate Needle/Punch","PX-76001323","CDM","55700","CPT","0761","RC","","","","outpatient","","","3570.00","2677.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2800.67","78.45","","4589.74","4589.74","4589.74","1 through 10","1531.53","2800.67","percent of total billed charges",""
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","both","","","2090.00","1567.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1885.65","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.35","1886.65","1893.55","1 through 10","1107.7","1981.86","other","OPPS APC"
"Biopsy/Exc Node Lymph Ndle Super","PX-76001206","CDM","38505","CPT","0761","RC","","","","outpatient","","","2090.00","1567.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2948.55","2948.55","2948.55","1 through 10","929.01","1873.9","other","Multiple Surgery"
"Bipolar Disorders,EXTREME","753","DRG","","","","","","","","inpatient","","","122901.31","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","93894.90","","Standard inlier is a Case rate ($93,894.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $107,973, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,328.75) for the length of stay and the standard reimbursement.","16152.00","16152.00","16152.00","1 through 10","954.59","100861.85","case rate",""
"Bipolar Disorders,EXTREME","753","DRG","","","","","","","","inpatient","","","122901.31","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","100861.85","","Standard inlier is a Case rate ($100,861.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $107,973, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,316.91) for the length of stay and the standard reimbursement.","31008.00","31008.00","31008.00","1 through 10","954.59","100861.85","case rate",""
"Bipolar Disorders,EXTREME","753","DRG","","","","","","","","inpatient","","","122901.31","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","31663.90","","Fee schedule rate ($31,663.90). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","115724.00","115724.00","115724.00","1 through 10","954.59","100861.85","case rate",""
"Bipolar Disorders,EXTREME","753","DRG","","","","","","","","inpatient","","","122901.31","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","41159.45","","Case rate ($45,508.84). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $87,938.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2710.99","2710.99","2710.99","1 through 10","954.59","100861.85","case rate",""
"Bipolar Disorders,EXTREME","753","DRG","","","","","","","","inpatient","","","122901.31","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","41159.45","","Case rate ($45,508.84). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $87,938.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","52069.99","52069.99","52069.99","1 through 10","954.59","100861.85","case rate",""
"Bipolar Disorders,MINOR","753","DRG","","","","","","","","inpatient","","","27860.92","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","17117.26","","Fee schedule rate ($17,117.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12201.00","12201.00","12201.00","1 through 10","954.59","100861.85","case rate",""
"Bipolar Disorders,MODERATE","753","DRG","","","","","","","","inpatient","","","36669.75","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5158.62","","Fee schedule rate ($5,158.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","2260.00","2260.00","2260.00","1 through 10","954.59","100861.85","case rate",""
"Bis Extracellular Fluid Alys Lymphedema Assmnt","PX-48000425","CDM","93702","CPT","0920","RC","","","","both","","","2432.00","1824.00","MEDICARE [2001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","182.09","2310.4","other","OPPS APC"
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","AETNA [1001]","HB CH AETNA HMO / PPO","830.11","58.3","","554.95","91.85","1421.75","94","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1039.42","73","","2490.03","2490.03","2490.03","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.11","58.3","","750.00","750.00","750.00","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","754.65","53","","1192.50","120.84","4149.90","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1210.28","85","","750.00","75.00","750.00","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1423.86","100","","657.00","121.50","1971.00","14","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1423.86","100","","75.00","75.00","75.00","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1423.86","100","","366.00","144.00","1971.00","45","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1039.42","73","","667.50","667.50","667.50","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","632.91","44.45","","123.77","123.77","123.77","1 through 10","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","both","","","1423.86","1067.89","WELLPOINT [1015]","HB CH WELLPOINT","1109.33","77.91","","483.51","229.32","1316.08","96","632.91","1423.86","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.86","1067.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","844.35","59.3","","439.50","225.34","1872.27","197","711.93","1117.02","percent of total billed charges",""
"BIT DRILL 4.5MM BONE TAP CORTICAL CANNULATED","SUP-ITM-10028082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1423.86","1067.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.02","78.45","","385.32","55.36","1815.62","58","711.93","1117.02","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus Pcr Quant","PX-30001492","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus Quant Pcr","PX-30003320","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","207.04","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","103.13","103.13","103.13","1 through 10","34.39","207.04","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","131.85","13","26.86","181.22","percent of total billed charges",""
"Bk Virus, Molecular Detection, Pcr, Plasma","PX-31001117","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","24","26.86","181.22","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","AETNA [1001]","HB CH AETNA HMO / PPO","889.16","58.3","","554.95","91.85","1421.75","94","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1113.35","73","","2490.03","2490.03","2490.03","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","889.16","58.3","","750.00","750.00","750.00","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","808.32","53","","1192.50","120.84","4149.90","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1296.37","85","","750.00","75.00","750.00","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1525.14","100","","657.00","121.50","1971.00","14","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1525.14","100","","75.00","75.00","75.00","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1525.14","100","","366.00","144.00","1971.00","45","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1113.35","73","","667.50","667.50","667.50","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","677.92","44.45","","123.77","123.77","123.77","1 through 10","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","both","","","1525.14","1143.85","WELLPOINT [1015]","HB CH WELLPOINT","1188.24","77.91","","483.51","229.32","1316.08","96","677.92","1525.14","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1525.14","1143.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","904.41","59.3","","439.50","225.34","1872.27","197","762.57","1196.47","percent of total billed charges",""
"BLADE BONE 10.5X80MM HELICAL TFN ADVANCED","SUP-ITM-10236235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1525.14","1143.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1196.47","78.45","","385.32","55.36","1815.62","58","762.57","1196.47","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","AETNA [1001]","HB CH AETNA HMO / PPO","839.36","58.3","","554.95","91.85","1421.75","94","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1051.00","73","","2490.03","2490.03","2490.03","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","839.36","58.3","","750.00","750.00","750.00","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","763.06","53","","1192.50","120.84","4149.90","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1223.77","85","","750.00","75.00","750.00","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1439.73","100","","657.00","121.50","1971.00","14","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1439.73","100","","75.00","75.00","75.00","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1439.73","100","","366.00","144.00","1971.00","45","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1051.00","73","","667.50","667.50","667.50","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","639.96","44.45","","123.77","123.77","123.77","1 through 10","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","both","","","1439.73","1079.80","WELLPOINT [1015]","HB CH WELLPOINT","1121.69","77.91","","483.51","229.32","1316.08","96","639.96","1439.73","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1439.73","1079.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","853.76","59.3","","439.50","225.34","1872.27","197","719.87","1129.47","percent of total billed charges",""
"BLADE BONE 100X11MM TROCHANTERIC FIXATION TITANIUM HELICAL","SUP-ITM-10009639","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1439.73","1079.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1129.47","78.45","","385.32","55.36","1815.62","58","719.87","1129.47","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","AETNA [1001]","HB CH AETNA HMO / PPO","656.19","58.3","","554.95","91.85","1421.75","94","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","2490.03","2490.03","2490.03","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","656.19","58.3","","750.00","750.00","750.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.54","53","","1192.50","120.84","4149.90","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","956.71","85","","750.00","75.00","750.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1125.54","100","","657.00","121.50","1971.00","14","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1125.54","100","","75.00","75.00","75.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1125.54","100","","366.00","144.00","1971.00","45","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","667.50","667.50","667.50","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.30","44.45","","123.77","123.77","123.77","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","WELLPOINT [1015]","HB CH WELLPOINT","876.91","77.91","","483.51","229.32","1316.08","96","500.3","1125.54","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.45","59.3","","439.50","225.34","1872.27","197","562.77","882.99","percent of total billed charges",""
"BLADE BONE 46MM SPIRAL SOLID HUMERAL NAIL TI","SUP-ITM-10017532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.99","78.45","","385.32","55.36","1815.62","58","562.77","882.99","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","AETNA [1001]","HB CH AETNA HMO / PPO","808.27","58.3","","554.95","91.85","1421.75","94","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1012.06","73","","2490.03","2490.03","2490.03","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","808.27","58.3","","750.00","750.00","750.00","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","734.79","53","","1192.50","120.84","4149.90","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1178.43","85","","750.00","75.00","750.00","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1386.39","100","","657.00","121.50","1971.00","14","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1386.39","100","","75.00","75.00","75.00","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1386.39","100","","366.00","144.00","1971.00","45","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1012.06","73","","667.50","667.50","667.50","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","123.77","123.77","123.77","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","WELLPOINT [1015]","HB CH WELLPOINT","1080.14","77.91","","483.51","229.32","1316.08","96","616.25","1386.39","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","822.13","59.3","","439.50","225.34","1872.27","197","693.2","1087.62","percent of total billed charges",""
"BLADE BONE 90MM HELICAL ADVANCED TFNA","SUP-ITM-10164407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","385.32","55.36","1815.62","58","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","AETNA [1001]","HB CH AETNA HMO / PPO","808.27","58.3","","554.95","91.85","1421.75","94","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1012.06","73","","2490.03","2490.03","2490.03","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","808.27","58.3","","750.00","750.00","750.00","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","734.79","53","","1192.50","120.84","4149.90","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1178.43","85","","750.00","75.00","750.00","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1386.39","100","","657.00","121.50","1971.00","14","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1386.39","100","","75.00","75.00","75.00","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1386.39","100","","366.00","144.00","1971.00","45","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1012.06","73","","667.50","667.50","667.50","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","616.25","44.45","","123.77","123.77","123.77","1 through 10","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1386.39","1039.79","WELLPOINT [1015]","HB CH WELLPOINT","1080.14","77.91","","483.51","229.32","1316.08","96","616.25","1386.39","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","822.13","59.3","","439.50","225.34","1872.27","197","693.2","1087.62","percent of total billed charges",""
"BLADE HELICAL 10.5X85MM FENESTRATED TFN-ADVANCED TITANIUM","SUP-ITM-10244707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1386.39","1039.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1087.62","78.45","","385.32","55.36","1815.62","58","693.2","1087.62","percent of total billed charges",""
"BLADE HYSTEROSCOPY 2.9MM TRUCLEAR MORCELLATOR INCISOR PLUS","SUP-ITM-10113777","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1710.00","1282.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1014.03","59.3","","1002.06","1002.06","1002.06","1 through 10","760.1","1341.5","percent of total billed charges",""
"BLADE HYSTEROSCOPY 4MM TRUCLEAR MORCELLATOR ROTARY","SUP-ITM-10023173","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1002.06","1002.06","1002.06","1 through 10","593.41","1047.31","percent of total billed charges",""
"BLADE RECIPROCATING 4MM MORCELLATOR TRUCLEAR ULTRA HYSTEROSCOPIC","SUP-ITM-10113776","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1002.06","1002.06","1002.06","1 through 10","1000.13","1765.13","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","AETNA [1001]","HB CH AETNA HMO / PPO","656.19","58.3","","554.95","91.85","1421.75","94","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","2490.03","2490.03","2490.03","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","656.19","58.3","","750.00","750.00","750.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.54","53","","1192.50","120.84","4149.90","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","956.71","85","","750.00","75.00","750.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1125.54","100","","657.00","121.50","1971.00","14","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1125.54","100","","75.00","75.00","75.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1125.54","100","","366.00","144.00","1971.00","45","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","667.50","667.50","667.50","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.30","44.45","","123.77","123.77","123.77","1 through 10","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","WELLPOINT [1015]","HB CH WELLPOINT","876.91","77.91","","483.51","229.32","1316.08","96","500.3","1125.54","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.45","59.3","","439.50","225.34","1872.27","197","562.77","882.99","percent of total billed charges",""
"BLADE SURGICAL 38MM SPIRAL IMPLANT SOLID HUMERAL NAIL TITANIUM","SUP-ITM-10013649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.99","78.45","","385.32","55.36","1815.62","58","562.77","882.99","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","AETNA [1001]","HB CH AETNA HMO / PPO","2295.56","58.3","","1634.24","1004.95","1718.99","42","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2874.38","73","","2123.89","1900.92","2123.89","1 through 10","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2295.56","58.3","","3729.00","1254.19","3729.00","1 through 10","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2086.88","53","","939.37","939.37","5593.65","1 through 10","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3346.88","85","","2323.25","1864.50","2882.25","16","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3937.50","100","","2909.44","1772.40","10952.08","45","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3937.50","100","","2323.25","2323.25","2323.25","1 through 10","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3937.50","100","","2882.25","1772.40","10169.17","187","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2874.38","73","","1659.41","1659.41","1659.41","1 through 10","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB CH WELLPOINT","3067.71","77.91","","2050.91","1468.48","2902.83","52","1750.22","3937.5","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1548.60","1092.60","3613.79","82","1968.75","3088.97","percent of total billed charges",""
"BLOCK AUGMENT 5MM KNEE FEMORAL NEXGEN TRABECULAR METAL DISTAL SZ C 19","SUP-ITM-10016405","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3088.97","78.45","","2085.51","998.68","6202.11","56","1968.75","3088.97","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1634.24","1004.95","1718.99","42","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","2123.89","1900.92","2123.89","1 through 10","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1089.63","58.3","","3729.00","1254.19","3729.00","1 through 10","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","939.37","939.37","5593.65","1 through 10","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1588.65","85","","2323.25","1864.50","2882.25","16","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1869.00","100","","2909.44","1772.40","10952.08","45","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1869.00","100","","2323.25","2323.25","2323.25","1 through 10","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1869.00","100","","2882.25","1772.40","10169.17","187","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","1659.41","1659.41","1659.41","1 through 10","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","2050.91","1468.48","2902.83","52","830.77","1869","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1548.60","1092.60","3613.79","82","934.5","1466.23","percent of total billed charges",""
"BLOCK FEMORAL 10MM SM KNEE MODULAR ROTATING HINGE DISTAL","SUP-ITM-10011611","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","2085.51","998.68","6202.11","56","934.5","1466.23","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0300","RC","","","","inpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.08","56","","51.48","51.48","51.48","1 through 10","52.08","65.66","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0300","RC","","","","inpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.66","70.6","","69.19","69.19","69.19","1 through 10","52.08","65.66","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","AETNA [1001]","HB CH AETNA HMO / PPO","54.22","58.3","","51.03","51.03","51.03","211","7.61","67.89","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","67.89","73","","65.70","65.70","65.70","1 through 10","7.61","67.89","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","49.29","53","","47.70","47.70","47.70","1 through 10","7.61","67.89","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","67.89","73","","65.70","51.03","65.70","1 through 10","7.61","67.89","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","both","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.34","44.45","","69.19","69.19","69.19","1 through 10","7.61","67.89","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.74","52.74","126.72","182","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.73","52.73","52.73","1 through 10","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","72.96","78.45","","69.19","69.19","69.19","1 through 10","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/Auto Diff","PX-30001037","CDM","85025","CPT","0305","RC","","","","outpatient","","","93.00","69.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.96","78.45","","69.19","41.00","69.19","205","8.01","72.96","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0300","RC","","","","inpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","52.95","70.6","","56.12","56.12","56.12","1 through 10","42","52.95","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","287","6.34","54.75","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","53.29","51.83","53.29","1 through 10","6.34","54.75","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","36.50","41.39","1 through 10","6.34","54.75","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","38.69","37.63","38.69","1 through 10","6.34","54.75","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","53.29","53.29","53.29","1 through 10","6.34","54.75","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","56.12","33.26","56.12","1 through 10","6.34","54.75","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","128.34","286","6.67","58.84","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","42.78","1 through 10","6.67","58.84","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","56.12","56.12","1 through 10","6.67","58.84","percent of total billed charges",""
"Blood Count Cbc Auto W/O Diff","PX-30001038","CDM","85027","CPT","0305","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","33.26","56.12","229","6.67","58.84","percent of total billed charges",""
"Blood Count Hematocrit (Hct)","PX-30001035","CDM","85014","CPT","0305","RC","","","","outpatient","","","26.00","19.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","15.42","59.3","","14.08","14.08","14.08","1 through 10","2.44","20.4","percent of total billed charges",""
"Blood Count Hemoglobin (Hgb)","PX-30001036","CDM","85018","CPT","0305","RC","","","","outpatient","","","27.00","20.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","16.01","59.3","","14.64","14.64","14.64","1 through 10","2.44","21.18","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","both","","","53.00","39.75","AETNA [1001]","HB CH AETNA HMO / PPO","30.90","58.3","","29.48","29.48","29.48","1 through 10","4.39","38.69","percent of total billed charges",""
"Blood Count Platelet Auto","PX-30001045","CDM","85049","CPT","0305","RC","","","","outpatient","","","53.00","39.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.43","59.3","","30.47","30.47","30.47","1 through 10","4.61","41.58","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","12","3.91","30.66","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","57.74","15","4.12","32.95","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","42.00","31.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","24.03","1 through 10","4.12","32.95","percent of total billed charges",""
"Blood Count Reticulocyte Auto","PX-30001042","CDM","85045","CPT","0305","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","18.68","31.52","1 through 10","4.12","32.95","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","204.00","153.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","120.97","59.3","","116.03","116.03","116.03","1 through 10","19.95","160.04","percent of total billed charges",""
"Blood Gas Ph Po2 &/or Pco2","PX-30000453","CDM","82803","CPT","0301","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.04","78.45","","81.53","81.53","81.53","1 through 10","19.95","160.04","percent of total billed charges",""
"Blood Type Antigen Donor Reagent Serum Each","PX-30000077","CDM","86902","CPT","0302","RC","","","","outpatient","","","167.00","125.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.01","78.45","","124.55","124.55","124.55","1 through 10","3.95","926.86","percent of total billed charges",""
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","139.00","104.25","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","56.04","56.04","427.19","1 through 10","15.1","1456.11","other","OPPS APC"
"Blood Typing RBC Antigens Oth/Thn Abo/Rh D Each","PX-30000079","CDM","86905","CPT","0302","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","418.65","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","384.47","418.65","1 through 10","15.1","1456.11","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","157.67","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.52","157.52","2305.16","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","AETNA [1001]","HB CH AETNA HMO / PPO","54.80","58.3","","51.60","51.60","51.60","78","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","11","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","150.02","150.02","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","FALLON HEALTH [1008]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","68.62","73","","66.43","64.24","66.43","1 through 10","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","54.80","58.3","","51.60","51.60","91.00","1 through 10","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","49.82","53","","96.46","48.23","96.46","12","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","MEDICARE [2001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","95","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","150.02","150.02","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","MOLINA [1014]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","303.71","303.71","303.71","1 through 10","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","TRICARE [160005]","HB BWF TRICARE","145.42","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","145.43","132.44","145.43","1 through 10","11.83","565.41","other","Tricare OPPS"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","450.06","5.28","450.06","18","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.78","44.45","","41.46","41.46","41.46","1 through 10","11.83","565.41","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","both","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","136.64","153.08","22","11.83","565.41","other","OPPS APC"
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","94.00","70.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.74","59.3","","53.33","53.33","159.99","126","3.08","359.9","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","94.00","70.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","139.92","139.92","139.92","1 through 10","3.08","359.9","percent of total billed charges",""
"Blood Typing Serologic Abo","PX-30000075","CDM","86900","CPT","0302","RC","","","","outpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","69.96","41.46","139.92","70","3.08","359.9","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","AETNA [1001]","HB CH AETNA HMO / PPO","2001.15","58.3","","554.95","91.85","1421.75","94","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2505.73","73","","2490.03","2490.03","2490.03","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2001.15","58.3","","750.00","750.00","750.00","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1819.23","53","","1192.50","120.84","4149.90","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2917.63","85","","750.00","75.00","750.00","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3432.50","100","","657.00","121.50","1971.00","14","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3432.50","100","","75.00","75.00","75.00","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3432.50","100","","366.00","144.00","1971.00","45","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2505.73","73","","667.50","667.50","667.50","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1525.75","44.45","","123.77","123.77","123.77","1 through 10","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","both","","","3432.50","2574.37","WELLPOINT [1015]","HB CH WELLPOINT","2674.26","77.91","","483.51","229.32","1316.08","96","1525.75","3432.5","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3432.50","2574.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2035.47","59.3","","439.50","225.34","1872.27","197","1716.25","2692.8","percent of total billed charges",""
"BOLT RECONSTRUCTION 5X85MM SALVATION","SUP-ITM-10192978","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3432.50","2574.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2692.80","78.45","","385.32","55.36","1815.62","58","1716.25","2692.8","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","AETNA [1001]","HB CH AETNA HMO / PPO","820.28","58.3","","554.95","91.85","1421.75","94","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1027.11","73","","2490.03","2490.03","2490.03","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","820.28","58.3","","750.00","750.00","750.00","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","745.71","53","","1192.50","120.84","4149.90","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1195.95","85","","750.00","75.00","750.00","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1407.00","100","","657.00","121.50","1971.00","14","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1407.00","100","","75.00","75.00","75.00","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1407.00","100","","366.00","144.00","1971.00","45","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1027.11","73","","667.50","667.50","667.50","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","625.41","44.45","","123.77","123.77","123.77","1 through 10","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1407.00","1055.25","WELLPOINT [1015]","HB CH WELLPOINT","1096.19","77.91","","483.51","229.32","1316.08","96","625.41","1407","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","834.35","59.3","","439.50","225.34","1872.27","197","703.5","1103.79","percent of total billed charges",""
"BOLT SPINE 18MM LEGION HINGE COUPLING","SUP-ITM-10121386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1407.00","1055.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1103.79","78.45","","385.32","55.36","1815.62","58","703.5","1103.79","percent of total billed charges",""
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","33365.44","25024.08","MEDICARE [2001]","HB BWF MEDICARE","13416.04","","Case rate ($13,416.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,294.34, add-ons for qualifying new technology services are included. If operating cost exceeds $57,818.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,477.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,160.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,955.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $916.43. The transfer capital threshold is the transfer adjustment factor * $916.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13237.33","13237.33","13237.33","1 through 10","12029.39","13416.04","other","Inpatient DRG"
"Bone Diseases And Arthropathies With McC","553","MS-DRG","","","","","","","","inpatient","","","33365.44","25024.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","12029.39","","Case rate ($12,274.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,294.34, add-ons for qualifying new technology services are included. If operating cost exceeds $57,818.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,477.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $11,019.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,955.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $916.43. The transfer capital threshold is the transfer adjustment factor * $916.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11859.05","11859.05","11859.05","1 through 10","12029.39","13416.04","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","26645.56","19984.17","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8221.83","","Case rate ($7,982.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,147.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,056.27 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,655.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.85. The transfer capital threshold is the transfer adjustment factor * $586.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","8070.53","8070.53","8070.53","1 through 10","7822.71","8713.11","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","26645.56","19984.17","HUMANA [1012]","HB BWF MEDICARE","8713.11","","Case rate ($8,713.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,147.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,787.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,655.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.85. The transfer capital threshold is the transfer adjustment factor * $586.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7688.36","7688.36","7688.36","1 through 10","7822.71","8713.11","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","26645.56","19984.17","MEDICARE [2001]","HB BWF MEDICARE","8713.11","","Case rate ($8,713.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,147.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,787.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,655.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.85. The transfer capital threshold is the transfer adjustment factor * $586.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8549.98","8494.02","8549.98","19","7822.71","8713.11","other","Inpatient DRG"
"Bone Diseases And Arthropathies Without McC","554","MS-DRG","","","","","","","","inpatient","","","26645.56","19984.17","WELLSENSE [1003]","HB BWF MEDICARE","8713.11","","Case rate ($8,713.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,994.81, add-ons for qualifying new technology services are included. If operating cost exceeds $53,518.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,147.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $7,787.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,655.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $586.85. The transfer capital threshold is the transfer adjustment factor * $586.85. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7667.36","7667.36","7667.36","1 through 10","7822.71","8713.11","other","Inpatient DRG"
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","AETNA [1001]","HB CH AETNA HMO / PPO","4785.26","58.3","","1634.24","1004.95","1718.99","42","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5991.84","73","","2123.89","1900.92","2123.89","1 through 10","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4785.26","58.3","","3729.00","1254.19","3729.00","1 through 10","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4350.24","53","","939.37","939.37","5593.65","1 through 10","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6976.80","85","","2323.25","1864.50","2882.25","16","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8208.00","100","","2909.44","1772.40","10952.08","45","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8208.00","100","","2323.25","2323.25","2323.25","1 through 10","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8208.00","100","","2882.25","1772.40","10169.17","187","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5991.84","73","","1659.41","1659.41","1659.41","1 through 10","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","both","","","8208.00","6156.00","WELLPOINT [1015]","HB CH WELLPOINT","6394.85","77.91","","2050.91","1468.48","2902.83","52","3648.46","8208","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4867.34","59.3","","1548.60","1092.60","3613.79","82","4104","6439.18","percent of total billed charges",""
"BONE IMPLANT 33X34 10MM SIZE 2 DOME TALARIN II SULCUS","SUP-ITM-10117056","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8208.00","6156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6439.18","78.45","","2085.51","998.68","6202.11","56","4104","6439.18","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","AETNA [1001]","HB CH AETNA HMO / PPO","2178.24","58.3","","554.95","91.85","1421.75","94","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2727.47","73","","2490.03","2490.03","2490.03","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.24","58.3","","750.00","750.00","750.00","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.22","53","","1192.50","120.84","4149.90","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3175.82","85","","750.00","75.00","750.00","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3736.26","100","","657.00","121.50","1971.00","14","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3736.26","100","","75.00","75.00","75.00","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3736.26","100","","366.00","144.00","1971.00","45","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2727.47","73","","667.50","667.50","667.50","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.77","44.45","","123.77","123.77","123.77","1 through 10","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","WELLPOINT [1015]","HB CH WELLPOINT","2910.92","77.91","","483.51","229.32","1316.08","96","1660.77","3736.26","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2215.60","59.3","","439.50","225.34","1872.27","197","1868.13","2931.1","percent of total billed charges",""
"BONE NAIL 235X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2931.10","78.45","","385.32","55.36","1815.62","58","1868.13","2931.1","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","AETNA [1001]","HB CH AETNA HMO / PPO","385.04","58.3","","554.95","91.85","1421.75","94","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","482.13","73","","2490.03","2490.03","2490.03","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","385.04","58.3","","750.00","750.00","750.00","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","350.04","53","","1192.50","120.84","4149.90","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","561.38","85","","750.00","75.00","750.00","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","660.45","100","","657.00","121.50","1971.00","14","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","660.45","100","","75.00","75.00","75.00","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","660.45","100","","366.00","144.00","1971.00","45","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","482.13","73","","667.50","667.50","667.50","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.57","44.45","","123.77","123.77","123.77","1 through 10","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.45","495.34","WELLPOINT [1015]","HB CH WELLPOINT","514.56","77.91","","483.51","229.32","1316.08","96","293.57","660.45","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.45","495.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.65","59.3","","439.50","225.34","1872.27","197","330.23","518.12","percent of total billed charges",""
"BONE NAIL 440X2.5MM FEMORAL TI ELASTIC","SUP-ITM-10030872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.45","495.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","518.12","78.45","","385.32","55.36","1815.62","58","330.23","518.12","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","AETNA [1001]","HB CH AETNA HMO / PPO","2078.91","58.3","","554.95","91.85","1421.75","94","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2603.09","73","","2490.03","2490.03","2490.03","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2078.91","58.3","","750.00","750.00","750.00","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1889.92","53","","1192.50","120.84","4149.90","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3031.00","85","","750.00","75.00","750.00","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3565.88","100","","657.00","121.50","1971.00","14","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3565.88","100","","75.00","75.00","75.00","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3565.88","100","","366.00","144.00","1971.00","45","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2603.09","73","","667.50","667.50","667.50","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.03","44.45","","123.77","123.77","123.77","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","WELLPOINT [1015]","HB CH WELLPOINT","2778.18","77.91","","483.51","229.32","1316.08","96","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","2114.57","59.3","","439.50","225.34","1872.27","197","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 8X160MM HUMERAL TI CANNULATED MULTILOC PROXIMAL RIGHT","SUP-ITM-10097302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2797.43","78.45","","385.32","55.36","1815.62","58","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","AETNA [1001]","HB CH AETNA HMO / PPO","2078.91","58.3","","554.95","91.85","1421.75","94","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2603.09","73","","2490.03","2490.03","2490.03","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2078.91","58.3","","750.00","750.00","750.00","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1889.92","53","","1192.50","120.84","4149.90","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3031.00","85","","750.00","75.00","750.00","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3565.88","100","","657.00","121.50","1971.00","14","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3565.88","100","","75.00","75.00","75.00","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3565.88","100","","366.00","144.00","1971.00","45","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2603.09","73","","667.50","667.50","667.50","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.03","44.45","","123.77","123.77","123.77","1 through 10","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3565.88","2674.41","WELLPOINT [1015]","HB CH WELLPOINT","2778.18","77.91","","483.51","229.32","1316.08","96","1585.03","3565.88","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","2114.57","59.3","","439.50","225.34","1872.27","197","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 9.5MMX160 HUMERAL PROXIMAL CANNULATED TI MULTILOC RIGHT","SUP-ITM-10097304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3565.88","2674.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2797.43","78.45","","385.32","55.36","1815.62","58","1782.94","2797.43","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","AETNA [1001]","HB CH AETNA HMO / PPO","2080.52","58.3","","554.95","91.85","1421.75","94","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2605.11","73","","2490.03","2490.03","2490.03","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2080.52","58.3","","750.00","750.00","750.00","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1891.38","53","","1192.50","120.84","4149.90","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3033.35","85","","750.00","75.00","750.00","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3568.65","100","","657.00","121.50","1971.00","14","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3568.65","100","","75.00","75.00","75.00","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3568.65","100","","366.00","144.00","1971.00","45","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2605.11","73","","667.50","667.50","667.50","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1586.26","44.45","","123.77","123.77","123.77","1 through 10","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.65","2676.49","WELLPOINT [1015]","HB CH WELLPOINT","2780.34","77.91","","483.51","229.32","1316.08","96","1586.26","3568.65","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.65","2676.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","2116.21","59.3","","439.50","225.34","1872.27","197","1784.33","2799.61","percent of total billed charges",""
"BONE NAIL 9X150MM HUMERAL EX CANNULATED TI PROXIMAL","SUP-ITM-10027390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.65","2676.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2799.61","78.45","","385.32","55.36","1815.62","58","1784.33","2799.61","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","AETNA [1001]","HB CH AETNA HMO / PPO","185.01","58.3","","554.95","91.85","1421.75","94","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","231.66","73","","2490.03","2490.03","2490.03","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.01","58.3","","750.00","750.00","750.00","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.19","53","","1192.50","120.84","4149.90","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","269.74","85","","750.00","75.00","750.00","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","317.34","100","","657.00","121.50","1971.00","14","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","317.34","100","","75.00","75.00","75.00","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","317.34","100","","366.00","144.00","1971.00","45","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","231.66","73","","667.50","667.50","667.50","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.06","44.45","","123.77","123.77","123.77","1 through 10","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.34","238.00","WELLPOINT [1015]","HB CH WELLPOINT","247.24","77.91","","483.51","229.32","1316.08","96","141.06","317.34","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.34","238.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.18","59.3","","439.50","225.34","1872.27","197","158.67","248.95","percent of total billed charges",""
"BONE PIN 1.8MM 12 STAINLESS LCP BUTTRESS T8 STARDRIVE RECESS","SUP-ITM-10056533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.34","238.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","248.95","78.45","","385.32","55.36","1815.62","58","158.67","248.95","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","AETNA [1001]","HB CH AETNA HMO / PPO","233.61","58.3","","554.95","91.85","1421.75","94","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","2490.03","2490.03","2490.03","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","233.61","58.3","","750.00","750.00","750.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","212.38","53","","1192.50","120.84","4149.90","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","340.60","85","","750.00","75.00","750.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","400.71","100","","657.00","121.50","1971.00","14","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","400.71","100","","75.00","75.00","75.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","400.71","100","","366.00","144.00","1971.00","45","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","667.50","667.50","667.50","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.12","44.45","","123.77","123.77","123.77","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","WELLPOINT [1015]","HB CH WELLPOINT","312.19","77.91","","483.51","229.32","1316.08","96","178.12","400.71","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.62","59.3","","439.50","225.34","1872.27","197","200.36","314.36","percent of total billed charges",""
"BONE PIN 3.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10016685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.36","78.45","","385.32","55.36","1815.62","58","200.36","314.36","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","AETNA [1001]","HB CH AETNA HMO / PPO","233.61","58.3","","554.95","91.85","1421.75","94","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","2490.03","2490.03","2490.03","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","233.61","58.3","","750.00","750.00","750.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","212.38","53","","1192.50","120.84","4149.90","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","340.60","85","","750.00","75.00","750.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","400.71","100","","657.00","121.50","1971.00","14","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","400.71","100","","75.00","75.00","75.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","400.71","100","","366.00","144.00","1971.00","45","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","667.50","667.50","667.50","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.12","44.45","","123.77","123.77","123.77","1 through 10","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","WELLPOINT [1015]","HB CH WELLPOINT","312.19","77.91","","483.51","229.32","1316.08","96","178.12","400.71","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.62","59.3","","439.50","225.34","1872.27","197","200.36","314.36","percent of total billed charges",""
"BONE PIN 4.5MM POSITIONING CERCLAGE THREADED S/S FOR LOCK COMP PLATE","SUP-ITM-10014473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.36","78.45","","385.32","55.36","1815.62","58","200.36","314.36","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","AETNA [1001]","HB CH AETNA HMO / PPO","118.25","58.3","","554.95","91.85","1421.75","94","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","148.07","73","","2490.03","2490.03","2490.03","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","118.25","58.3","","750.00","750.00","750.00","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","107.50","53","","1192.50","120.84","4149.90","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","172.41","85","","750.00","75.00","750.00","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","202.83","100","","657.00","121.50","1971.00","14","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","202.83","100","","75.00","75.00","75.00","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","202.83","100","","366.00","144.00","1971.00","45","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","148.07","73","","667.50","667.50","667.50","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.16","44.45","","123.77","123.77","123.77","1 through 10","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.83","152.12","WELLPOINT [1015]","HB CH WELLPOINT","158.02","77.91","","483.51","229.32","1316.08","96","90.16","202.83","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.83","152.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","120.28","59.3","","439.50","225.34","1872.27","197","101.42","159.12","percent of total billed charges",""
"BONE PIN 4MM 170MM STERILE PK/2EA","SUP-ITM-10238427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.83","152.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","159.12","78.45","","385.32","55.36","1815.62","58","101.42","159.12","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","AETNA [1001]","HB CH AETNA HMO / PPO","629.15","58.3","","554.95","91.85","1421.75","94","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","787.79","73","","2490.03","2490.03","2490.03","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","629.15","58.3","","750.00","750.00","750.00","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","571.95","53","","1192.50","120.84","4149.90","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","917.29","85","","750.00","75.00","750.00","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1079.16","100","","657.00","121.50","1971.00","14","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1079.16","100","","75.00","75.00","75.00","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1079.16","100","","366.00","144.00","1971.00","45","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","787.79","73","","667.50","667.50","667.50","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","479.69","44.45","","123.77","123.77","123.77","1 through 10","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","both","","","1079.16","809.37","WELLPOINT [1015]","HB CH WELLPOINT","840.77","77.91","","483.51","229.32","1316.08","96","479.69","1079.16","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1079.16","809.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","639.94","59.3","","439.50","225.34","1872.27","197","539.58","846.6","percent of total billed charges",""
"BONE PLATE 0.55X1.2MM XS 5 HOLE SHAFT 90DEG HAND PROFYLE TITANIUM","SUP-ITM-10143670","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1079.16","809.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","846.60","78.45","","385.32","55.36","1815.62","58","539.58","846.6","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","AETNA [1001]","HB CH AETNA HMO / PPO","524.18","58.3","","554.95","91.85","1421.75","94","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","656.34","73","","2490.03","2490.03","2490.03","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.18","58.3","","750.00","750.00","750.00","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","476.52","53","","1192.50","120.84","4149.90","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","764.24","85","","750.00","75.00","750.00","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","899.10","100","","657.00","121.50","1971.00","14","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","899.10","100","","75.00","75.00","75.00","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","899.10","100","","366.00","144.00","1971.00","45","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","656.34","73","","667.50","667.50","667.50","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","399.65","44.45","","123.77","123.77","123.77","1 through 10","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","both","","","899.10","674.32","WELLPOINT [1015]","HB CH WELLPOINT","700.49","77.91","","483.51","229.32","1316.08","96","399.65","899.1","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","899.10","674.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.17","59.3","","439.50","225.34","1872.27","197","449.55","705.34","percent of total billed charges",""
"BONE PLATE 1.3X32MM 3 HOLE HD 8 SHAFT T STRAIGHT MODULAR HAND SYSTEM TI","SUP-ITM-10006271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","899.10","674.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","705.34","78.45","","385.32","55.36","1815.62","58","449.55","705.34","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","AETNA [1001]","HB CH AETNA HMO / PPO","660.07","58.3","","554.95","91.85","1421.75","94","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","826.51","73","","2490.03","2490.03","2490.03","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","660.07","58.3","","750.00","750.00","750.00","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","600.07","53","","1192.50","120.84","4149.90","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","962.37","85","","750.00","75.00","750.00","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1132.20","100","","657.00","121.50","1971.00","14","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1132.20","100","","75.00","75.00","75.00","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1132.20","100","","366.00","144.00","1971.00","45","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","826.51","73","","667.50","667.50","667.50","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.26","44.45","","123.77","123.77","123.77","1 through 10","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","WELLPOINT [1015]","HB CH WELLPOINT","882.10","77.91","","483.51","229.32","1316.08","96","503.26","1132.2","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","671.39","59.3","","439.50","225.34","1872.27","197","566.1","888.21","percent of total billed charges",""
"BONE PLATE 1.5MM 12HOLE STRUT LOCKING VARIABLE ANGLE","SUP-ITM-10164617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","888.21","78.45","","385.32","55.36","1815.62","58","566.1","888.21","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","AETNA [1001]","HB CH AETNA HMO / PPO","602.48","58.3","","554.95","91.85","1421.75","94","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","754.39","73","","2490.03","2490.03","2490.03","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","602.48","58.3","","750.00","750.00","750.00","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","547.71","53","","1192.50","120.84","4149.90","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","878.40","85","","750.00","75.00","750.00","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1033.41","100","","657.00","121.50","1971.00","14","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1033.41","100","","75.00","75.00","75.00","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1033.41","100","","366.00","144.00","1971.00","45","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","754.39","73","","667.50","667.50","667.50","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.35","44.45","","123.77","123.77","123.77","1 through 10","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","both","","","1033.41","775.06","WELLPOINT [1015]","HB CH WELLPOINT","805.13","77.91","","483.51","229.32","1316.08","96","459.35","1033.41","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1033.41","775.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","612.81","59.3","","439.50","225.34","1872.27","197","516.71","810.71","percent of total billed charges",""
"BONE PLATE 1.5MM 14 HOLE WEB VARIABLE ANGLE LOCKING SS","SUP-ITM-10164616","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1033.41","775.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","810.71","78.45","","385.32","55.36","1815.62","58","516.71","810.71","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","AETNA [1001]","HB CH AETNA HMO / PPO","604.42","58.3","","554.95","91.85","1421.75","94","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","756.82","73","","2490.03","2490.03","2490.03","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","604.42","58.3","","750.00","750.00","750.00","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","549.47","53","","1192.50","120.84","4149.90","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","881.23","85","","750.00","75.00","750.00","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1036.74","100","","657.00","121.50","1971.00","14","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1036.74","100","","75.00","75.00","75.00","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1036.74","100","","366.00","144.00","1971.00","45","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","756.82","73","","667.50","667.50","667.50","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","460.83","44.45","","123.77","123.77","123.77","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","both","","","1036.74","777.55","WELLPOINT [1015]","HB CH WELLPOINT","807.72","77.91","","483.51","229.32","1316.08","96","460.83","1036.74","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.74","777.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","614.79","59.3","","439.50","225.34","1872.27","197","518.37","813.32","percent of total billed charges",""
"BONE PLATE 1.5MM 3 HOLE 8 NAME","SUP-ITM-10092344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1036.74","777.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","813.32","78.45","","385.32","55.36","1815.62","58","518.37","813.32","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","AETNA [1001]","HB CH AETNA HMO / PPO","703.43","58.3","","554.95","91.85","1421.75","94","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","880.80","73","","2490.03","2490.03","2490.03","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","703.43","58.3","","750.00","750.00","750.00","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","639.48","53","","1192.50","120.84","4149.90","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1025.58","85","","750.00","75.00","750.00","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1206.57","100","","657.00","121.50","1971.00","14","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1206.57","100","","75.00","75.00","75.00","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1206.57","100","","366.00","144.00","1971.00","45","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","880.80","73","","667.50","667.50","667.50","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","536.32","44.45","","123.77","123.77","123.77","1 through 10","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","both","","","1206.57","904.93","WELLPOINT [1015]","HB CH WELLPOINT","940.04","77.91","","483.51","229.32","1316.08","96","536.32","1206.57","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.57","904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","715.50","59.3","","439.50","225.34","1872.27","197","603.29","946.55","percent of total billed charges",""
"BONE PLATE 1.5MM 6 HOLE LCP STAINLESS CONDYLAR GUIDE","SUP-ITM-10082114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1206.57","904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","946.55","78.45","","385.32","55.36","1815.62","58","603.29","946.55","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","AETNA [1001]","HB CH AETNA HMO / PPO","526.12","58.3","","554.95","91.85","1421.75","94","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","658.77","73","","2490.03","2490.03","2490.03","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","526.12","58.3","","750.00","750.00","750.00","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.29","53","","1192.50","120.84","4149.90","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","767.07","85","","750.00","75.00","750.00","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","902.43","100","","657.00","121.50","1971.00","14","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","902.43","100","","75.00","75.00","75.00","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","902.43","100","","366.00","144.00","1971.00","45","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","658.77","73","","667.50","667.50","667.50","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.13","44.45","","123.77","123.77","123.77","1 through 10","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","both","","","902.43","676.82","WELLPOINT [1015]","HB CH WELLPOINT","703.08","77.91","","483.51","229.32","1316.08","96","401.13","902.43","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","902.43","676.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.14","59.3","","439.50","225.34","1872.27","197","451.22","707.96","percent of total billed charges",""
"BONE PLATE 1.5X46MM 3 8 HOLE SS Y SHAPE","SUP-ITM-10038135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","902.43","676.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","707.96","78.45","","385.32","55.36","1815.62","58","451.22","707.96","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","AETNA [1001]","HB CH AETNA HMO / PPO","1132.84","58.3","","554.95","91.85","1421.75","94","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1418.48","73","","2490.03","2490.03","2490.03","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1132.84","58.3","","750.00","750.00","750.00","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1029.86","53","","1192.50","120.84","4149.90","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1651.66","85","","750.00","75.00","750.00","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1943.13","100","","657.00","121.50","1971.00","14","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1943.13","100","","75.00","75.00","75.00","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1943.13","100","","366.00","144.00","1971.00","45","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1418.48","73","","667.50","667.50","667.50","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","863.72","44.45","","123.77","123.77","123.77","1 through 10","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","both","","","1943.13","1457.35","WELLPOINT [1015]","HB CH WELLPOINT","1513.89","77.91","","483.51","229.32","1316.08","96","863.72","1943.13","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.13","1457.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","1152.28","59.3","","439.50","225.34","1872.27","197","971.57","1524.39","percent of total billed charges",""
"BONE PLATE 1.7MM 6 HOLE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE NARROW","SUP-ITM-10143754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1943.13","1457.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1524.39","78.45","","385.32","55.36","1815.62","58","971.57","1524.39","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","AETNA [1001]","HB CH AETNA HMO / PPO","351.29","58.3","","554.95","91.85","1421.75","94","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","439.86","73","","2490.03","2490.03","2490.03","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","351.29","58.3","","750.00","750.00","750.00","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","319.35","53","","1192.50","120.84","4149.90","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","512.17","85","","750.00","75.00","750.00","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","602.55","100","","657.00","121.50","1971.00","14","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","602.55","100","","75.00","75.00","75.00","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","602.55","100","","366.00","144.00","1971.00","45","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","439.86","73","","667.50","667.50","667.50","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.83","44.45","","123.77","123.77","123.77","1 through 10","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","both","","","602.55","451.91","WELLPOINT [1015]","HB CH WELLPOINT","469.45","77.91","","483.51","229.32","1316.08","96","267.83","602.55","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","602.55","451.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","357.31","59.3","","439.50","225.34","1872.27","197","301.28","472.7","percent of total billed charges",""
"BONE PLATE 111.6X3.5MM SMALL 8 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10041805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","602.55","451.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","472.70","78.45","","385.32","55.36","1815.62","58","301.28","472.7","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","AETNA [1001]","HB CH AETNA HMO / PPO","1791.96","58.3","","554.95","91.85","1421.75","94","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2243.79","73","","2490.03","2490.03","2490.03","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1791.96","58.3","","750.00","750.00","750.00","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1629.05","53","","1192.50","120.84","4149.90","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2612.63","85","","750.00","75.00","750.00","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3073.68","100","","657.00","121.50","1971.00","14","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3073.68","100","","75.00","75.00","75.00","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3073.68","100","","366.00","144.00","1971.00","45","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2243.79","73","","667.50","667.50","667.50","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1366.25","44.45","","123.77","123.77","123.77","1 through 10","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","both","","","3073.68","2305.26","WELLPOINT [1015]","HB CH WELLPOINT","2394.70","77.91","","483.51","229.32","1316.08","96","1366.25","3073.68","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3073.68","2305.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","1822.69","59.3","","439.50","225.34","1872.27","197","1536.84","2411.3","percent of total billed charges",""
"BONE PLATE 115MM VARIAX COMPRESSION 9 HOLE BROAD","SUP-ITM-10144776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3073.68","2305.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2411.30","78.45","","385.32","55.36","1815.62","58","1536.84","2411.3","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","AETNA [1001]","HB CH AETNA HMO / PPO","2132.12","58.3","","554.95","91.85","1421.75","94","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2669.73","73","","2490.03","2490.03","2490.03","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2132.12","58.3","","750.00","750.00","750.00","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1938.29","53","","1192.50","120.84","4149.90","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3108.59","85","","750.00","75.00","750.00","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3657.16","100","","657.00","121.50","1971.00","14","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3657.16","100","","75.00","75.00","75.00","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3657.16","100","","366.00","144.00","1971.00","45","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.73","73","","667.50","667.50","667.50","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.61","44.45","","123.77","123.77","123.77","1 through 10","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","both","","","3657.16","2742.87","WELLPOINT [1015]","HB CH WELLPOINT","2849.29","77.91","","483.51","229.32","1316.08","96","1625.61","3657.16","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.16","2742.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.70","59.3","","439.50","225.34","1872.27","197","1828.58","2869.04","percent of total billed charges",""
"BONE PLATE 118MM 10 HOLE VARIAX TITANIUM ANTERIOR MIDSHAFT","SUP-ITM-10135463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3657.16","2742.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2869.04","78.45","","385.32","55.36","1815.62","58","1828.58","2869.04","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","AETNA [1001]","HB CH AETNA HMO / PPO","919.47","58.3","","554.95","91.85","1421.75","94","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1151.30","73","","2490.03","2490.03","2490.03","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","919.47","58.3","","750.00","750.00","750.00","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","835.88","53","","1192.50","120.84","4149.90","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1340.56","85","","750.00","75.00","750.00","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1577.13","100","","657.00","121.50","1971.00","14","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1577.13","100","","75.00","75.00","75.00","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1577.13","100","","366.00","144.00","1971.00","45","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1151.30","73","","667.50","667.50","667.50","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","701.03","44.45","","123.77","123.77","123.77","1 through 10","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1577.13","1182.85","WELLPOINT [1015]","HB CH WELLPOINT","1228.74","77.91","","483.51","229.32","1316.08","96","701.03","1577.13","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1577.13","1182.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","935.24","59.3","","439.50","225.34","1872.27","197","788.57","1237.26","percent of total billed charges",""
"BONE PLATE 12.9X43.7MM LOCKING FRAGMENT HIGH STRENGTH Y SHAPE","SUP-ITM-10021532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1577.13","1182.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1237.26","78.45","","385.32","55.36","1815.62","58","788.57","1237.26","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","AETNA [1001]","HB CH AETNA HMO / PPO","381.91","58.3","","554.95","91.85","1421.75","94","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","478.21","73","","2490.03","2490.03","2490.03","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","381.91","58.3","","750.00","750.00","750.00","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","347.19","53","","1192.50","120.84","4149.90","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","556.82","85","","750.00","75.00","750.00","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","655.08","100","","657.00","121.50","1971.00","14","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","655.08","100","","75.00","75.00","75.00","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","655.08","100","","366.00","144.00","1971.00","45","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","478.21","73","","667.50","667.50","667.50","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","291.18","44.45","","123.77","123.77","123.77","1 through 10","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.08","491.31","WELLPOINT [1015]","HB CH WELLPOINT","510.37","77.91","","483.51","229.32","1316.08","96","291.18","655.08","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.08","491.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","388.46","59.3","","439.50","225.34","1872.27","197","327.54","513.91","percent of total billed charges",""
"BONE PLATE 137.6X3.5MM SMALL 10 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.08","491.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","513.91","78.45","","385.32","55.36","1815.62","58","327.54","513.91","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","AETNA [1001]","HB CH AETNA HMO / PPO","428.75","58.3","","554.95","91.85","1421.75","94","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","536.86","73","","2490.03","2490.03","2490.03","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","428.75","58.3","","750.00","750.00","750.00","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","389.77","53","","1192.50","120.84","4149.90","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","625.11","85","","750.00","75.00","750.00","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","735.42","100","","657.00","121.50","1971.00","14","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","735.42","100","","75.00","75.00","75.00","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","735.42","100","","366.00","144.00","1971.00","45","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","536.86","73","","667.50","667.50","667.50","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.89","44.45","","123.77","123.77","123.77","1 through 10","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","both","","","735.42","551.56","WELLPOINT [1015]","HB CH WELLPOINT","572.97","77.91","","483.51","229.32","1316.08","96","326.89","735.42","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.42","551.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","436.10","59.3","","439.50","225.34","1872.27","197","367.71","576.94","percent of total billed charges",""
"BONE PLATE 163.6X3.5MM SMALL 12 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","735.42","551.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","576.94","78.45","","385.32","55.36","1815.62","58","367.71","576.94","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","AETNA [1001]","HB CH AETNA HMO / PPO","726.52","58.3","","554.95","91.85","1421.75","94","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","909.70","73","","2490.03","2490.03","2490.03","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","726.52","58.3","","750.00","750.00","750.00","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","660.47","53","","1192.50","120.84","4149.90","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1059.24","85","","750.00","75.00","750.00","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1246.17","100","","657.00","121.50","1971.00","14","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1246.17","100","","75.00","75.00","75.00","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1246.17","100","","366.00","144.00","1971.00","45","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","909.70","73","","667.50","667.50","667.50","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","553.92","44.45","","123.77","123.77","123.77","1 through 10","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.17","934.63","WELLPOINT [1015]","HB CH WELLPOINT","970.89","77.91","","483.51","229.32","1316.08","96","553.92","1246.17","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1246.17","934.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","738.98","59.3","","439.50","225.34","1872.27","197","623.09","977.62","percent of total billed charges",""
"BONE PLATE 173MM 9 HOLE TUBULAR LOCKING COMPRESSION BROAD 427139S","SUP-ITM-10142664","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1246.17","934.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","977.62","78.45","","385.32","55.36","1815.62","58","623.09","977.62","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","AETNA [1001]","HB CH AETNA HMO / PPO","2166.89","58.3","","554.95","91.85","1421.75","94","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2713.26","73","","2490.03","2490.03","2490.03","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2166.89","58.3","","750.00","750.00","750.00","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1969.90","53","","1192.50","120.84","4149.90","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3159.28","85","","750.00","75.00","750.00","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3716.80","100","","657.00","121.50","1971.00","14","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3716.80","100","","75.00","75.00","75.00","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3716.80","100","","366.00","144.00","1971.00","45","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2713.26","73","","667.50","667.50","667.50","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.12","44.45","","123.77","123.77","123.77","1 through 10","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.80","2787.60","WELLPOINT [1015]","HB CH WELLPOINT","2895.76","77.91","","483.51","229.32","1316.08","96","1652.12","3716.8","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3716.80","2787.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","2204.06","59.3","","439.50","225.34","1872.27","197","1858.4","2915.83","percent of total billed charges",""
"BONE PLATE 179.4MM 6 HOLE FEMORAL POLYAX SS RIGHT","SUP-ITM-10030548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3716.80","2787.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2915.83","78.45","","385.32","55.36","1815.62","58","1858.4","2915.83","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","AETNA [1001]","HB CH AETNA HMO / PPO","2428.65","58.3","","554.95","91.85","1421.75","94","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3041.02","73","","2490.03","2490.03","2490.03","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2428.65","58.3","","750.00","750.00","750.00","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2207.86","53","","1192.50","120.84","4149.90","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3540.91","85","","750.00","75.00","750.00","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4165.78","100","","657.00","121.50","1971.00","14","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4165.78","100","","75.00","75.00","75.00","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4165.78","100","","366.00","144.00","1971.00","45","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3041.02","73","","667.50","667.50","667.50","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1851.69","44.45","","123.77","123.77","123.77","1 through 10","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","WELLPOINT [1015]","HB CH WELLPOINT","3245.56","77.91","","483.51","229.32","1316.08","96","1851.69","4165.78","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.78","3124.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","2470.31","59.3","","439.50","225.34","1872.27","197","2082.89","3268.05","percent of total billed charges",""
"BONE PLATE 17MM COMPRESSION 2 HOLE FOOT UNI CP TITANIUM","SUP-ITM-10090115","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.78","3124.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3268.05","78.45","","385.32","55.36","1815.62","58","2082.89","3268.05","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","AETNA [1001]","HB CH AETNA HMO / PPO","457.57","58.3","","554.95","91.85","1421.75","94","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","572.95","73","","2490.03","2490.03","2490.03","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","457.57","58.3","","750.00","750.00","750.00","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","415.98","53","","1192.50","120.84","4149.90","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","667.13","85","","750.00","75.00","750.00","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","784.86","100","","657.00","121.50","1971.00","14","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","784.86","100","","75.00","75.00","75.00","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","784.86","100","","366.00","144.00","1971.00","45","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","572.95","73","","667.50","667.50","667.50","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.87","44.45","","123.77","123.77","123.77","1 through 10","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.86","588.64","WELLPOINT [1015]","HB CH WELLPOINT","611.48","77.91","","483.51","229.32","1316.08","96","348.87","784.86","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.86","588.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","465.42","59.3","","439.50","225.34","1872.27","197","392.43","615.72","percent of total billed charges",""
"BONE PLATE 189.6X3.5MM SMALL 14 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.86","588.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","615.72","78.45","","385.32","55.36","1815.62","58","392.43","615.72","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","AETNA [1001]","HB CH AETNA HMO / PPO","1926.96","58.3","","554.95","91.85","1421.75","94","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2412.83","73","","2490.03","2490.03","2490.03","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1926.96","58.3","","750.00","750.00","750.00","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1751.78","53","","1192.50","120.84","4149.90","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2809.46","85","","750.00","75.00","750.00","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3305.25","100","","657.00","121.50","1971.00","14","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3305.25","100","","75.00","75.00","75.00","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3305.25","100","","366.00","144.00","1971.00","45","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2412.83","73","","667.50","667.50","667.50","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.18","44.45","","123.77","123.77","123.77","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","WELLPOINT [1015]","HB CH WELLPOINT","2575.12","77.91","","483.51","229.32","1316.08","96","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.25","2478.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","1960.01","59.3","","439.50","225.34","1872.27","197","1652.63","2592.97","percent of total billed charges",""
"BONE PLATE 19 HOLE GORILLA ZIGZAG","SUP-ITM-10238091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.25","2478.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2592.97","78.45","","385.32","55.36","1815.62","58","1652.63","2592.97","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","AETNA [1001]","HB CH AETNA HMO / PPO","297.33","58.3","","554.95","91.85","1421.75","94","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","372.30","73","","2490.03","2490.03","2490.03","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","297.33","58.3","","750.00","750.00","750.00","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","270.30","53","","1192.50","120.84","4149.90","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","433.50","85","","750.00","75.00","750.00","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","510.00","100","","657.00","121.50","1971.00","14","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","510.00","100","","75.00","75.00","75.00","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","510.00","100","","366.00","144.00","1971.00","45","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","372.30","73","","667.50","667.50","667.50","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","123.77","123.77","123.77","1 through 10","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","WELLPOINT [1015]","HB CH WELLPOINT","397.34","77.91","","483.51","229.32","1316.08","96","226.7","510","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","302.43","59.3","","439.50","225.34","1872.27","197","255","400.1","percent of total billed charges",""
"BONE PLATE 2.0MM 9 HOLE T SHAPE NON CONTOUR SCR S/ H","SUP-ITM-10072378","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","385.32","55.36","1815.62","58","255","400.1","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","AETNA [1001]","HB CH AETNA HMO / PPO","2079.56","58.3","","554.95","91.85","1421.75","94","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2603.91","73","","2490.03","2490.03","2490.03","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2079.56","58.3","","750.00","750.00","750.00","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1890.51","53","","1192.50","120.84","4149.90","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3031.95","85","","750.00","75.00","750.00","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3567.00","100","","657.00","121.50","1971.00","14","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3567.00","100","","75.00","75.00","75.00","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3567.00","100","","366.00","144.00","1971.00","45","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2603.91","73","","667.50","667.50","667.50","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1585.53","44.45","","123.77","123.77","123.77","1 through 10","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","both","","","3567.00","2675.25","WELLPOINT [1015]","HB CH WELLPOINT","2779.05","77.91","","483.51","229.32","1316.08","96","1585.53","3567","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2115.23","59.3","","439.50","225.34","1872.27","197","1783.5","2798.31","percent of total billed charges",""
"BONE PLATE 2.0MM HALLUX ORTHOLOC 3DI TITANIUM LAPIDUS","SUP-ITM-10132306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3567.00","2675.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2798.31","78.45","","385.32","55.36","1815.62","58","1783.5","2798.31","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","AETNA [1001]","HB CH AETNA HMO / PPO","858.74","58.3","","554.95","91.85","1421.75","94","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1075.27","73","","2490.03","2490.03","2490.03","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","858.74","58.3","","750.00","750.00","750.00","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","780.67","53","","1192.50","120.84","4149.90","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1252.02","85","","750.00","75.00","750.00","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1472.97","100","","657.00","121.50","1971.00","14","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1472.97","100","","75.00","75.00","75.00","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1472.97","100","","366.00","144.00","1971.00","45","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1075.27","73","","667.50","667.50","667.50","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","654.74","44.45","","123.77","123.77","123.77","1 through 10","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","both","","","1472.97","1104.73","WELLPOINT [1015]","HB CH WELLPOINT","1147.59","77.91","","483.51","229.32","1316.08","96","654.74","1472.97","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1472.97","1104.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","873.47","59.3","","439.50","225.34","1872.27","197","736.49","1155.54","percent of total billed charges",""
"BONE PLATE 2.4X1.7 51MM 6 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038163","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1472.97","1104.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1155.54","78.45","","385.32","55.36","1815.62","58","736.49","1155.54","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","AETNA [1001]","HB CH AETNA HMO / PPO","927.98","58.3","","554.95","91.85","1421.75","94","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1161.97","73","","2490.03","2490.03","2490.03","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","927.98","58.3","","750.00","750.00","750.00","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","843.62","53","","1192.50","120.84","4149.90","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1352.98","85","","750.00","75.00","750.00","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1591.74","100","","657.00","121.50","1971.00","14","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1591.74","100","","75.00","75.00","75.00","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1591.74","100","","366.00","144.00","1971.00","45","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1161.97","73","","667.50","667.50","667.50","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","707.53","44.45","","123.77","123.77","123.77","1 through 10","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1591.74","1193.80","WELLPOINT [1015]","HB CH WELLPOINT","1240.12","77.91","","483.51","229.32","1316.08","96","707.53","1591.74","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1591.74","1193.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","943.90","59.3","","439.50","225.34","1872.27","197","795.87","1248.72","percent of total billed charges",""
"BONE PLATE 2.4X1.7 67MM 8 HOLE LC DCP SS STRAIGHT","SUP-ITM-10038164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1591.74","1193.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1248.72","78.45","","385.32","55.36","1815.62","58","795.87","1248.72","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","AETNA [1001]","HB CH AETNA HMO / PPO","907.28","58.3","","554.95","91.85","1421.75","94","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1136.04","73","","2490.03","2490.03","2490.03","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","907.28","58.3","","750.00","750.00","750.00","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","824.80","53","","1192.50","120.84","4149.90","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1322.79","85","","750.00","75.00","750.00","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1556.22","100","","657.00","121.50","1971.00","14","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1556.22","100","","75.00","75.00","75.00","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1556.22","100","","366.00","144.00","1971.00","45","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1136.04","73","","667.50","667.50","667.50","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","691.74","44.45","","123.77","123.77","123.77","1 through 10","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","both","","","1556.22","1167.16","WELLPOINT [1015]","HB CH WELLPOINT","1212.45","77.91","","483.51","229.32","1316.08","96","691.74","1556.22","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1556.22","1167.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","922.84","59.3","","439.50","225.34","1872.27","197","778.11","1220.85","percent of total billed charges",""
"BONE PLATE 2.4X40MM 3 HOLE RADIAL RIM STAINLESS LCP","SUP-ITM-10019086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1556.22","1167.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1220.85","78.45","","385.32","55.36","1815.62","58","778.11","1220.85","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","AETNA [1001]","HB CH AETNA HMO / PPO","1002.51","58.3","","554.95","91.85","1421.75","94","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1255.29","73","","2490.03","2490.03","2490.03","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1002.51","58.3","","750.00","750.00","750.00","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","911.37","53","","1192.50","120.84","4149.90","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1461.63","85","","750.00","75.00","750.00","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1719.57","100","","657.00","121.50","1971.00","14","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1719.57","100","","75.00","75.00","75.00","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1719.57","100","","366.00","144.00","1971.00","45","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1255.29","73","","667.50","667.50","667.50","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","764.35","44.45","","123.77","123.77","123.77","1 through 10","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","both","","","1719.57","1289.68","WELLPOINT [1015]","HB CH WELLPOINT","1339.72","77.91","","483.51","229.32","1316.08","96","764.35","1719.57","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1719.57","1289.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","1019.71","59.3","","439.50","225.34","1872.27","197","859.79","1349","percent of total billed charges",""
"BONE PLATE 2.4X49MM 2 HOLE HD 4 SHAFT 90DEG HUMERAL LCP STAINLESS L SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016913","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1719.57","1289.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1349.00","78.45","","385.32","55.36","1815.62","58","859.79","1349","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","AETNA [1001]","HB CH AETNA HMO / PPO","988.81","58.3","","554.95","91.85","1421.75","94","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1238.14","73","","2490.03","2490.03","2490.03","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","988.81","58.3","","750.00","750.00","750.00","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","898.92","53","","1192.50","120.84","4149.90","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1441.67","85","","750.00","75.00","750.00","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1696.08","100","","657.00","121.50","1971.00","14","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1696.08","100","","75.00","75.00","75.00","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1696.08","100","","366.00","144.00","1971.00","45","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1238.14","73","","667.50","667.50","667.50","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.91","44.45","","123.77","123.77","123.77","1 through 10","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","both","","","1696.08","1272.06","WELLPOINT [1015]","HB CH WELLPOINT","1321.42","77.91","","483.51","229.32","1316.08","96","753.91","1696.08","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.78","59.3","","439.50","225.34","1872.27","197","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 2.4X54MM 2 HOLE HEAD 8 STAINLESS T SHAPE","SUP-ITM-10038155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1696.08","1272.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1330.57","78.45","","385.32","55.36","1815.62","58","848.04","1330.57","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","AETNA [1001]","HB CH AETNA HMO / PPO","816.03","58.3","","554.95","91.85","1421.75","94","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1021.79","73","","2490.03","2490.03","2490.03","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","816.03","58.3","","750.00","750.00","750.00","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","741.85","53","","1192.50","120.84","4149.90","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1189.75","85","","750.00","75.00","750.00","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1399.71","100","","657.00","121.50","1971.00","14","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1399.71","100","","75.00","75.00","75.00","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1399.71","100","","366.00","144.00","1971.00","45","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1021.79","73","","667.50","667.50","667.50","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","622.17","44.45","","123.77","123.77","123.77","1 through 10","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","both","","","1399.71","1049.78","WELLPOINT [1015]","HB CH WELLPOINT","1090.51","77.91","","483.51","229.32","1316.08","96","622.17","1399.71","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1399.71","1049.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.03","59.3","","439.50","225.34","1872.27","197","699.86","1098.07","percent of total billed charges",""
"BONE PLATE 2.4X56MM 3 HOLE 8 STAINLESS Y SHAPE","SUP-ITM-10038157","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1399.71","1049.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1098.07","78.45","","385.32","55.36","1815.62","58","699.86","1098.07","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","AETNA [1001]","HB CH AETNA HMO / PPO","814.74","58.3","","554.95","91.85","1421.75","94","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1020.17","73","","2490.03","2490.03","2490.03","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","814.74","58.3","","750.00","750.00","750.00","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","740.67","53","","1192.50","120.84","4149.90","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1187.87","85","","750.00","75.00","750.00","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1397.49","100","","657.00","121.50","1971.00","14","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1397.49","100","","75.00","75.00","75.00","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1397.49","100","","366.00","144.00","1971.00","45","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1020.17","73","","667.50","667.50","667.50","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","621.18","44.45","","123.77","123.77","123.77","1 through 10","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","both","","","1397.49","1048.12","WELLPOINT [1015]","HB CH WELLPOINT","1088.78","77.91","","483.51","229.32","1316.08","96","621.18","1397.49","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1397.49","1048.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","828.71","59.3","","439.50","225.34","1872.27","197","698.75","1096.33","percent of total billed charges",""
"BONE PLATE 2.4X57MM 8 HOLE LC DCP CONDYLE TITANIUM RIGHT","SUP-ITM-10002253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1397.49","1048.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1096.33","78.45","","385.32","55.36","1815.62","58","698.75","1096.33","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","AETNA [1001]","HB CH AETNA HMO / PPO","903.39","58.3","","554.95","91.85","1421.75","94","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1131.18","73","","2490.03","2490.03","2490.03","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","903.39","58.3","","750.00","750.00","750.00","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","821.27","53","","1192.50","120.84","4149.90","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1317.13","85","","750.00","75.00","750.00","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1549.56","100","","657.00","121.50","1971.00","14","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1549.56","100","","75.00","75.00","75.00","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1549.56","100","","366.00","144.00","1971.00","45","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1131.18","73","","667.50","667.50","667.50","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","688.78","44.45","","123.77","123.77","123.77","1 through 10","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1549.56","1162.17","WELLPOINT [1015]","HB CH WELLPOINT","1207.26","77.91","","483.51","229.32","1316.08","96","688.78","1549.56","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1549.56","1162.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","918.89","59.3","","439.50","225.34","1872.27","197","774.78","1215.63","percent of total billed charges",""
"BONE PLATE 2.4X60MM 3 7 HOLE LCP SS Y SHAPE","SUP-ITM-10021890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1549.56","1162.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1215.63","78.45","","385.32","55.36","1815.62","58","774.78","1215.63","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","AETNA [1001]","HB CH AETNA HMO / PPO","577.24","58.3","","554.95","91.85","1421.75","94","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","722.79","73","","2490.03","2490.03","2490.03","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","577.24","58.3","","750.00","750.00","750.00","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","524.76","53","","1192.50","120.84","4149.90","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","841.60","85","","750.00","75.00","750.00","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","990.12","100","","657.00","121.50","1971.00","14","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","990.12","100","","75.00","75.00","75.00","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","990.12","100","","366.00","144.00","1971.00","45","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","722.79","73","","667.50","667.50","667.50","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","440.11","44.45","","123.77","123.77","123.77","1 through 10","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","both","","","990.12","742.59","WELLPOINT [1015]","HB CH WELLPOINT","771.40","77.91","","483.51","229.32","1316.08","96","440.11","990.12","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.12","742.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","587.14","59.3","","439.50","225.34","1872.27","197","495.06","776.75","percent of total billed charges",""
"BONE PLATE 2.4X72MM 12 HOLE SS STRAIGHT","SUP-ITM-10038154","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","990.12","742.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","776.75","78.45","","385.32","55.36","1815.62","58","495.06","776.75","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","AETNA [1001]","HB CH AETNA HMO / PPO","573.36","58.3","","554.95","91.85","1421.75","94","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","717.93","73","","2490.03","2490.03","2490.03","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","573.36","58.3","","750.00","750.00","750.00","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","521.23","53","","1192.50","120.84","4149.90","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","835.94","85","","750.00","75.00","750.00","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","983.46","100","","657.00","121.50","1971.00","14","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","983.46","100","","75.00","75.00","75.00","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","983.46","100","","366.00","144.00","1971.00","45","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","717.93","73","","667.50","667.50","667.50","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.15","44.45","","123.77","123.77","123.77","1 through 10","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","both","","","983.46","737.59","WELLPOINT [1015]","HB CH WELLPOINT","766.21","77.91","","483.51","229.32","1316.08","96","437.15","983.46","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.46","737.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","583.19","59.3","","439.50","225.34","1872.27","197","491.73","771.52","percent of total billed charges",""
"BONE PLATE 2.4X88MM 12 HOLE LCP SS ADAPTION","SUP-ITM-10025393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","983.46","737.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","771.52","78.45","","385.32","55.36","1815.62","58","491.73","771.52","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","AETNA [1001]","HB CH AETNA HMO / PPO","1369.12","58.3","","554.95","91.85","1421.75","94","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1714.33","73","","2490.03","2490.03","2490.03","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1369.12","58.3","","750.00","750.00","750.00","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1244.65","53","","1192.50","120.84","4149.90","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1996.14","85","","750.00","75.00","750.00","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2348.40","100","","657.00","121.50","1971.00","14","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2348.40","100","","75.00","75.00","75.00","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2348.40","100","","366.00","144.00","1971.00","45","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1714.33","73","","667.50","667.50","667.50","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1043.86","44.45","","123.77","123.77","123.77","1 through 10","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","both","","","2348.40","1761.30","WELLPOINT [1015]","HB CH WELLPOINT","1829.64","77.91","","483.51","229.32","1316.08","96","1043.86","2348.4","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.40","1761.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","1392.60","59.3","","439.50","225.34","1872.27","197","1174.2","1842.32","percent of total billed charges",""
"BONE PLATE 2.5MM A.L.P.S. INLINE FUSION","SUP-ITM-10126734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2348.40","1761.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1842.32","78.45","","385.32","55.36","1815.62","58","1174.2","1842.32","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","AETNA [1001]","HB CH AETNA HMO / PPO","2009.79","58.3","","554.95","91.85","1421.75","94","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2516.55","73","","2490.03","2490.03","2490.03","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2009.79","58.3","","750.00","750.00","750.00","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1827.08","53","","1192.50","120.84","4149.90","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2930.23","85","","750.00","75.00","750.00","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3447.33","100","","657.00","121.50","1971.00","14","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3447.33","100","","75.00","75.00","75.00","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3447.33","100","","366.00","144.00","1971.00","45","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2516.55","73","","667.50","667.50","667.50","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1532.34","44.45","","123.77","123.77","123.77","1 through 10","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","both","","","3447.33","2585.50","WELLPOINT [1015]","HB CH WELLPOINT","2685.81","77.91","","483.51","229.32","1316.08","96","1532.34","3447.33","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3447.33","2585.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2044.27","59.3","","439.50","225.34","1872.27","197","1723.67","2704.43","percent of total billed charges",""
"BONE PLATE 2.7 X108MM 12HOLE BROAD LOCKING","SUP-ITM-10306697","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3447.33","2585.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2704.43","78.45","","385.32","55.36","1815.62","58","1723.67","2704.43","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","AETNA [1001]","HB CH AETNA HMO / PPO","477.13","58.3","","554.95","91.85","1421.75","94","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","597.43","73","","2490.03","2490.03","2490.03","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","477.13","58.3","","750.00","750.00","750.00","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","433.75","53","","1192.50","120.84","4149.90","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","695.64","85","","750.00","75.00","750.00","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","818.40","100","","657.00","121.50","1971.00","14","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","818.40","100","","75.00","75.00","75.00","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","818.40","100","","366.00","144.00","1971.00","45","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","597.43","73","","667.50","667.50","667.50","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.78","44.45","","123.77","123.77","123.77","1 through 10","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.40","613.80","WELLPOINT [1015]","HB CH WELLPOINT","637.62","77.91","","483.51","229.32","1316.08","96","363.78","818.4","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.40","613.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","485.31","59.3","","439.50","225.34","1872.27","197","409.2","642.03","percent of total billed charges",""
"BONE PLATE 2.7MM 2 HOLE T SHAPE MEDIAL CONTOUR","SUP-ITM-10072379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.40","613.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","642.03","78.45","","385.32","55.36","1815.62","58","409.2","642.03","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","AETNA [1001]","HB CH AETNA HMO / PPO","1371.78","58.3","","554.95","91.85","1421.75","94","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1717.66","73","","2490.03","2490.03","2490.03","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1371.78","58.3","","750.00","750.00","750.00","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1247.07","53","","1192.50","120.84","4149.90","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2000.02","85","","750.00","75.00","750.00","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2352.96","100","","657.00","121.50","1971.00","14","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2352.96","100","","75.00","75.00","75.00","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2352.96","100","","366.00","144.00","1971.00","45","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1717.66","73","","667.50","667.50","667.50","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1045.89","44.45","","123.77","123.77","123.77","1 through 10","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","both","","","2352.96","1764.72","WELLPOINT [1015]","HB CH WELLPOINT","1833.19","77.91","","483.51","229.32","1316.08","96","1045.89","2352.96","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2352.96","1764.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","1395.31","59.3","","439.50","225.34","1872.27","197","1176.48","1845.9","percent of total billed charges",""
"BONE PLATE 2.7MM 6 HOLE TIBIA VA LCP STAINLESS T SHAPE DISTAL","SUP-ITM-10124971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2352.96","1764.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1845.90","78.45","","385.32","55.36","1815.62","58","1176.48","1845.9","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","AETNA [1001]","HB CH AETNA HMO / PPO","118.93","58.3","","554.95","91.85","1421.75","94","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","148.92","73","","2490.03","2490.03","2490.03","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","118.93","58.3","","750.00","750.00","750.00","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","108.12","53","","1192.50","120.84","4149.90","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","173.40","85","","750.00","75.00","750.00","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","204.00","100","","657.00","121.50","1971.00","14","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","204.00","100","","75.00","75.00","75.00","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","204.00","100","","366.00","144.00","1971.00","45","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","148.92","73","","667.50","667.50","667.50","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","90.68","44.45","","123.77","123.77","123.77","1 through 10","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","both","","","204.00","153.00","WELLPOINT [1015]","HB CH WELLPOINT","158.94","77.91","","483.51","229.32","1316.08","96","90.68","204","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.00","153.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","120.97","59.3","","439.50","225.34","1872.27","197","102","160.04","percent of total billed charges",""
"BONE PLATE 2.7MM SMALL 3 HOLE 1/4 TUBULAR","SUP-ITM-10072387","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","204.00","153.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.04","78.45","","385.32","55.36","1815.62","58","102","160.04","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","554.95","91.85","1421.75","94","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","2490.03","2490.03","2490.03","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","73.46","58.3","","750.00","750.00","750.00","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","66.78","53","","1192.50","120.84","4149.90","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","107.10","85","","750.00","75.00","750.00","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","126.00","100","","657.00","121.50","1971.00","14","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","126.00","100","","75.00","75.00","75.00","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","126.00","100","","366.00","144.00","1971.00","45","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","667.50","667.50","667.50","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.01","44.45","","123.77","123.77","123.77","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","WELLPOINT [1015]","HB CH WELLPOINT","98.17","77.91","","483.51","229.32","1316.08","96","56.01","126","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","439.50","225.34","1872.27","197","63","98.85","percent of total billed charges",""
"BONE PLATE 2.7MM TIMAX TITANIUM L SHAPE 3 HOLE LEFT","SUP-ITM-10072381","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","385.32","55.36","1815.62","58","63","98.85","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","AETNA [1001]","HB CH AETNA HMO / PPO","190.26","58.3","","554.95","91.85","1421.75","94","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","238.23","73","","2490.03","2490.03","2490.03","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","190.26","58.3","","750.00","750.00","750.00","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","172.96","53","","1192.50","120.84","4149.90","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","277.39","85","","750.00","75.00","750.00","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","326.34","100","","657.00","121.50","1971.00","14","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","326.34","100","","75.00","75.00","75.00","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","326.34","100","","366.00","144.00","1971.00","45","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","238.23","73","","667.50","667.50","667.50","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.06","44.45","","123.77","123.77","123.77","1 through 10","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","WELLPOINT [1015]","HB CH WELLPOINT","254.25","77.91","","483.51","229.32","1316.08","96","145.06","326.34","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.52","59.3","","439.50","225.34","1872.27","197","163.17","256.01","percent of total billed charges",""
"BONE PLATE 2.7X23MM 3 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019147","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","256.01","78.45","","385.32","55.36","1815.62","58","163.17","256.01","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","AETNA [1001]","HB CH AETNA HMO / PPO","218.73","58.3","","554.95","91.85","1421.75","94","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","273.88","73","","2490.03","2490.03","2490.03","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","218.73","58.3","","750.00","750.00","750.00","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.85","53","","1192.50","120.84","4149.90","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","318.90","85","","750.00","75.00","750.00","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","375.18","100","","657.00","121.50","1971.00","14","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","375.18","100","","75.00","75.00","75.00","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","375.18","100","","366.00","144.00","1971.00","45","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.88","73","","667.50","667.50","667.50","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.77","44.45","","123.77","123.77","123.77","1 through 10","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.18","281.38","WELLPOINT [1015]","HB CH WELLPOINT","292.30","77.91","","483.51","229.32","1316.08","96","166.77","375.18","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.18","281.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.48","59.3","","439.50","225.34","1872.27","197","187.59","294.33","percent of total billed charges",""
"BONE PLATE 2.7X31MM 4 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.18","281.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.33","78.45","","385.32","55.36","1815.62","58","187.59","294.33","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","AETNA [1001]","HB CH AETNA HMO / PPO","107.04","58.3","","554.95","91.85","1421.75","94","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","134.03","73","","2490.03","2490.03","2490.03","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","107.04","58.3","","750.00","750.00","750.00","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.31","53","","1192.50","120.84","4149.90","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","156.06","85","","750.00","75.00","750.00","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","183.60","100","","657.00","121.50","1971.00","14","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","183.60","100","","75.00","75.00","75.00","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","183.60","100","","366.00","144.00","1971.00","45","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","134.03","73","","667.50","667.50","667.50","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.61","44.45","","123.77","123.77","123.77","1 through 10","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.60","137.70","WELLPOINT [1015]","HB CH WELLPOINT","143.04","77.91","","483.51","229.32","1316.08","96","81.61","183.6","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.60","137.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.87","59.3","","439.50","225.34","1872.27","197","91.8","144.03","percent of total billed charges",""
"BONE PLATE 2.7X34MM 2 3 HOLE MINI FRAGMENT L SHAPE OBLIQUE LT SS","SUP-ITM-10004182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.60","137.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","144.03","78.45","","385.32","55.36","1815.62","58","91.8","144.03","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","AETNA [1001]","HB CH AETNA HMO / PPO","212.26","58.3","","554.95","91.85","1421.75","94","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","265.78","73","","2490.03","2490.03","2490.03","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","212.26","58.3","","750.00","750.00","750.00","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","192.96","53","","1192.50","120.84","4149.90","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","309.47","85","","750.00","75.00","750.00","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","364.08","100","","657.00","121.50","1971.00","14","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","364.08","100","","75.00","75.00","75.00","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","364.08","100","","366.00","144.00","1971.00","45","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","265.78","73","","667.50","667.50","667.50","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","161.83","44.45","","123.77","123.77","123.77","1 through 10","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","both","","","364.08","273.06","WELLPOINT [1015]","HB CH WELLPOINT","283.65","77.91","","483.51","229.32","1316.08","96","161.83","364.08","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.08","273.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","215.90","59.3","","439.50","225.34","1872.27","197","182.04","285.62","percent of total billed charges",""
"BONE PLATE 2.7X39MM 5 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10002487","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","364.08","273.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","285.62","78.45","","385.32","55.36","1815.62","58","182.04","285.62","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","AETNA [1001]","HB CH AETNA HMO / PPO","229.08","58.3","","554.95","91.85","1421.75","94","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","286.85","73","","2490.03","2490.03","2490.03","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","229.08","58.3","","750.00","750.00","750.00","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","208.26","53","","1192.50","120.84","4149.90","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","334.00","85","","750.00","75.00","750.00","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","392.94","100","","657.00","121.50","1971.00","14","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","392.94","100","","75.00","75.00","75.00","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","392.94","100","","366.00","144.00","1971.00","45","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.85","73","","667.50","667.50","667.50","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.66","44.45","","123.77","123.77","123.77","1 through 10","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.94","294.70","WELLPOINT [1015]","HB CH WELLPOINT","306.14","77.91","","483.51","229.32","1316.08","96","174.66","392.94","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.94","294.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","233.01","59.3","","439.50","225.34","1872.27","197","196.47","308.26","percent of total billed charges",""
"BONE PLATE 2.7X63MM 8 HOLE TUBULAR ONE QUARTER WITH COLLAR LCP SS","SUP-ITM-10019139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.94","294.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","308.26","78.45","","385.32","55.36","1815.62","58","196.47","308.26","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","AETNA [1001]","HB CH AETNA HMO / PPO","805.03","58.3","","554.95","91.85","1421.75","94","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1008.01","73","","2490.03","2490.03","2490.03","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","805.03","58.3","","750.00","750.00","750.00","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","731.85","53","","1192.50","120.84","4149.90","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1173.71","85","","750.00","75.00","750.00","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1380.84","100","","657.00","121.50","1971.00","14","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1380.84","100","","75.00","75.00","75.00","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1380.84","100","","366.00","144.00","1971.00","45","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1008.01","73","","667.50","667.50","667.50","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","613.78","44.45","","123.77","123.77","123.77","1 through 10","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","both","","","1380.84","1035.63","WELLPOINT [1015]","HB CH WELLPOINT","1075.81","77.91","","483.51","229.32","1316.08","96","613.78","1380.84","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.84","1035.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","818.84","59.3","","439.50","225.34","1872.27","197","690.42","1083.27","percent of total billed charges",""
"BONE PLATE 2.7X66MM 7 HOLE SHAFT CONDYLE LCP SS CONDYLAR","SUP-ITM-10027821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1380.84","1035.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1083.27","78.45","","385.32","55.36","1815.62","58","690.42","1083.27","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","AETNA [1001]","HB CH AETNA HMO / PPO","519.65","58.3","","554.95","91.85","1421.75","94","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","650.67","73","","2490.03","2490.03","2490.03","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","519.65","58.3","","750.00","750.00","750.00","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","472.40","53","","1192.50","120.84","4149.90","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","757.63","85","","750.00","75.00","750.00","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","891.33","100","","657.00","121.50","1971.00","14","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","891.33","100","","75.00","75.00","75.00","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","891.33","100","","366.00","144.00","1971.00","45","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","650.67","73","","667.50","667.50","667.50","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.20","44.45","","123.77","123.77","123.77","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","WELLPOINT [1015]","HB CH WELLPOINT","694.44","77.91","","483.51","229.32","1316.08","96","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","528.56","59.3","","439.50","225.34","1872.27","197","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2.7X76MM 8 HOLE LCP SS STRAIGHT","SUP-ITM-10029065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","699.25","78.45","","385.32","55.36","1815.62","58","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","AETNA [1001]","HB CH AETNA HMO / PPO","519.65","58.3","","554.95","91.85","1421.75","94","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","650.67","73","","2490.03","2490.03","2490.03","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","519.65","58.3","","750.00","750.00","750.00","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","472.40","53","","1192.50","120.84","4149.90","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","757.63","85","","750.00","75.00","750.00","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","891.33","100","","657.00","121.50","1971.00","14","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","891.33","100","","75.00","75.00","75.00","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","891.33","100","","366.00","144.00","1971.00","45","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","650.67","73","","667.50","667.50","667.50","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.20","44.45","","123.77","123.77","123.77","1 through 10","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","both","","","891.33","668.50","WELLPOINT [1015]","HB CH WELLPOINT","694.44","77.91","","483.51","229.32","1316.08","96","396.2","891.33","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","528.56","59.3","","439.50","225.34","1872.27","197","445.67","699.25","percent of total billed charges",""
"BONE PLATE 2.7X95MM 10 HOLE LC DCP COMPRESSION SS","SUP-ITM-10038052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","891.33","668.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","699.25","78.45","","385.32","55.36","1815.62","58","445.67","699.25","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","554.95","91.85","1421.75","94","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","2490.03","2490.03","2490.03","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1565.36","58.3","","750.00","750.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","1192.50","120.84","4149.90","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2282.25","85","","750.00","75.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2685.00","100","","657.00","121.50","1971.00","14","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2685.00","100","","75.00","75.00","75.00","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2685.00","100","","366.00","144.00","1971.00","45","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","667.50","667.50","667.50","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","123.77","123.77","123.77","1 through 10","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","483.51","229.32","1316.08","96","1193.48","2685","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","439.50","225.34","1872.27","197","1342.5","2106.38","percent of total billed charges",""
"BONE PLATE 20MMX5 2 HOLE COMPRESSION DOUBLE SS","SUP-ITM-10139184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","385.32","55.36","1815.62","58","1342.5","2106.38","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","AETNA [1001]","HB CH AETNA HMO / PPO","1451.98","58.3","","554.95","91.85","1421.75","94","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1818.09","73","","2490.03","2490.03","2490.03","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1451.98","58.3","","750.00","750.00","750.00","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1319.99","53","","1192.50","120.84","4149.90","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2116.96","85","","750.00","75.00","750.00","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2490.54","100","","657.00","121.50","1971.00","14","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2490.54","100","","75.00","75.00","75.00","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2490.54","100","","366.00","144.00","1971.00","45","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1818.09","73","","667.50","667.50","667.50","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1107.05","44.45","","123.77","123.77","123.77","1 through 10","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","WELLPOINT [1015]","HB CH WELLPOINT","1940.38","77.91","","483.51","229.32","1316.08","96","1107.05","2490.54","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2490.54","1867.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","1476.89","59.3","","439.50","225.34","1872.27","197","1245.27","1953.83","percent of total billed charges",""
"BONE PLATE 24X43MM DVR CROSSLOCK COBALT LOCKED DISTAL RT MINI","SUP-ITM-10135910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2490.54","1867.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1953.83","78.45","","385.32","55.36","1815.62","58","1245.27","1953.83","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","AETNA [1001]","HB CH AETNA HMO / PPO","1765.44","58.3","","554.95","91.85","1421.75","94","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2210.59","73","","2490.03","2490.03","2490.03","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1765.44","58.3","","750.00","750.00","750.00","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1604.95","53","","1192.50","120.84","4149.90","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2573.97","85","","750.00","75.00","750.00","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3028.20","100","","657.00","121.50","1971.00","14","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3028.20","100","","75.00","75.00","75.00","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3028.20","100","","366.00","144.00","1971.00","45","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2210.59","73","","667.50","667.50","667.50","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1346.03","44.45","","123.77","123.77","123.77","1 through 10","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","both","","","3028.20","2271.15","WELLPOINT [1015]","HB CH WELLPOINT","2359.27","77.91","","483.51","229.32","1316.08","96","1346.03","3028.2","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3028.20","2271.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","1795.72","59.3","","439.50","225.34","1872.27","197","1514.1","2375.62","percent of total billed charges",""
"BONE PLATE 24X85MM DVR CROSSLOCK COBALT LOCKED T SHAPED LEFT","SUP-ITM-10135517","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3028.20","2271.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2375.62","78.45","","385.32","55.36","1815.62","58","1514.1","2375.62","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","AETNA [1001]","HB CH AETNA HMO / PPO","997.23","58.3","","554.95","91.85","1421.75","94","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1248.67","73","","2490.03","2490.03","2490.03","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","997.23","58.3","","750.00","750.00","750.00","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","906.57","53","","1192.50","120.84","4149.90","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1453.93","85","","750.00","75.00","750.00","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1710.51","100","","657.00","121.50","1971.00","14","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1710.51","100","","75.00","75.00","75.00","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1710.51","100","","366.00","144.00","1971.00","45","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1248.67","73","","667.50","667.50","667.50","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","760.32","44.45","","123.77","123.77","123.77","1 through 10","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","both","","","1710.51","1282.88","WELLPOINT [1015]","HB CH WELLPOINT","1332.66","77.91","","483.51","229.32","1316.08","96","760.32","1710.51","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.51","1282.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","1014.33","59.3","","439.50","225.34","1872.27","197","855.26","1341.9","percent of total billed charges",""
"BONE PLATE 260X4.5MM 14 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10010149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1710.51","1282.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1341.90","78.45","","385.32","55.36","1815.62","58","855.26","1341.9","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","AETNA [1001]","HB CH AETNA HMO / PPO","1210.78","58.3","","554.95","91.85","1421.75","94","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1516.07","73","","2490.03","2490.03","2490.03","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1210.78","58.3","","750.00","750.00","750.00","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1100.71","53","","1192.50","120.84","4149.90","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1765.29","85","","750.00","75.00","750.00","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2076.81","100","","657.00","121.50","1971.00","14","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2076.81","100","","75.00","75.00","75.00","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2076.81","100","","366.00","144.00","1971.00","45","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1516.07","73","","667.50","667.50","667.50","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","923.14","44.45","","123.77","123.77","123.77","1 through 10","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2076.81","1557.61","WELLPOINT [1015]","HB CH WELLPOINT","1618.04","77.91","","483.51","229.32","1316.08","96","923.14","2076.81","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.81","1557.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","1231.55","59.3","","439.50","225.34","1872.27","197","1038.41","1629.26","percent of total billed charges",""
"BONE PLATE 296X4.5MM 16 HOLE LCP SS BROAD CURVED","SUP-ITM-10011556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2076.81","1557.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1629.26","78.45","","385.32","55.36","1815.62","58","1038.41","1629.26","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","AETNA [1001]","HB CH AETNA HMO / PPO","741.61","58.3","","554.95","91.85","1421.75","94","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","928.60","73","","2490.03","2490.03","2490.03","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","741.61","58.3","","750.00","750.00","750.00","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","674.19","53","","1192.50","120.84","4149.90","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1081.25","85","","750.00","75.00","750.00","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1272.06","100","","657.00","121.50","1971.00","14","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1272.06","100","","75.00","75.00","75.00","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1272.06","100","","366.00","144.00","1971.00","45","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","928.60","73","","667.50","667.50","667.50","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","565.43","44.45","","123.77","123.77","123.77","1 through 10","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","both","","","1272.06","954.04","WELLPOINT [1015]","HB CH WELLPOINT","991.06","77.91","","483.51","229.32","1316.08","96","565.43","1272.06","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1272.06","954.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","754.33","59.3","","439.50","225.34","1872.27","197","636.03","997.93","percent of total billed charges",""
"BONE PLATE 2MM 2 HOLE CONDYLAR","SUP-ITM-10164588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1272.06","954.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","997.93","78.45","","385.32","55.36","1815.62","58","636.03","997.93","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","AETNA [1001]","HB CH AETNA HMO / PPO","543.59","58.3","","554.95","91.85","1421.75","94","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","680.65","73","","2490.03","2490.03","2490.03","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","543.59","58.3","","750.00","750.00","750.00","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","494.17","53","","1192.50","120.84","4149.90","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","792.54","85","","750.00","75.00","750.00","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","932.40","100","","657.00","121.50","1971.00","14","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","932.40","100","","75.00","75.00","75.00","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","932.40","100","","366.00","144.00","1971.00","45","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","680.65","73","","667.50","667.50","667.50","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.45","44.45","","123.77","123.77","123.77","1 through 10","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","both","","","932.40","699.30","WELLPOINT [1015]","HB CH WELLPOINT","726.43","77.91","","483.51","229.32","1316.08","96","414.45","932.4","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","552.91","59.3","","439.50","225.34","1872.27","197","466.2","731.47","percent of total billed charges",""
"BONE PLATE 2MM 3 HOLE HD 7 SHAFT LOCKING T SHAPE","SUP-ITM-10022564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","932.40","699.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","731.47","78.45","","385.32","55.36","1815.62","58","466.2","731.47","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","AETNA [1001]","HB CH AETNA HMO / PPO","491.17","58.3","","554.95","91.85","1421.75","94","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","615.02","73","","2490.03","2490.03","2490.03","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","491.17","58.3","","750.00","750.00","750.00","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","446.52","53","","1192.50","120.84","4149.90","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","716.12","85","","750.00","75.00","750.00","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","842.49","100","","657.00","121.50","1971.00","14","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","842.49","100","","75.00","75.00","75.00","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","842.49","100","","366.00","144.00","1971.00","45","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","615.02","73","","667.50","667.50","667.50","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.49","44.45","","123.77","123.77","123.77","1 through 10","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","both","","","842.49","631.87","WELLPOINT [1015]","HB CH WELLPOINT","656.38","77.91","","483.51","229.32","1316.08","96","374.49","842.49","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.49","631.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","499.60","59.3","","439.50","225.34","1872.27","197","421.25","660.93","percent of total billed charges",""
"BONE PLATE 2MM 53X8 HOLE SS T SHAPE","SUP-ITM-10038137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","842.49","631.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","660.93","78.45","","385.32","55.36","1815.62","58","421.25","660.93","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","AETNA [1001]","HB CH AETNA HMO / PPO","645.84","58.3","","554.95","91.85","1421.75","94","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","808.68","73","","2490.03","2490.03","2490.03","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","645.84","58.3","","750.00","750.00","750.00","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","587.12","53","","1192.50","120.84","4149.90","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","941.61","85","","750.00","75.00","750.00","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1107.78","100","","657.00","121.50","1971.00","14","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1107.78","100","","75.00","75.00","75.00","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1107.78","100","","366.00","144.00","1971.00","45","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","808.68","73","","667.50","667.50","667.50","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","492.41","44.45","","123.77","123.77","123.77","1 through 10","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","both","","","1107.78","830.83","WELLPOINT [1015]","HB CH WELLPOINT","863.07","77.91","","483.51","229.32","1316.08","96","492.41","1107.78","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1107.78","830.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","656.91","59.3","","439.50","225.34","1872.27","197","553.89","869.05","percent of total billed charges",""
"BONE PLATE 2MM 6 HOLE STAINLESS VARIABLE ANGLE LOCKING STRAIGHT","SUP-ITM-10164593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1107.78","830.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","869.05","78.45","","385.32","55.36","1815.62","58","553.89","869.05","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","554.95","91.85","1421.75","94","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","2490.03","2490.03","2490.03","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","73.46","58.3","","750.00","750.00","750.00","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","66.78","53","","1192.50","120.84","4149.90","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","107.10","85","","750.00","75.00","750.00","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","126.00","100","","657.00","121.50","1971.00","14","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","126.00","100","","75.00","75.00","75.00","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","126.00","100","","366.00","144.00","1971.00","45","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","667.50","667.50","667.50","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.01","44.45","","123.77","123.77","123.77","1 through 10","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","WELLPOINT [1015]","HB CH WELLPOINT","98.17","77.91","","483.51","229.32","1316.08","96","56.01","126","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","439.50","225.34","1872.27","197","63","98.85","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM L SHAPE RIGHT","SUP-ITM-10072380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","385.32","55.36","1815.62","58","63","98.85","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","AETNA [1001]","HB CH AETNA HMO / PPO","311.32","58.3","","554.95","91.85","1421.75","94","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","389.82","73","","2490.03","2490.03","2490.03","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","311.32","58.3","","750.00","750.00","750.00","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","283.02","53","","1192.50","120.84","4149.90","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","453.90","85","","750.00","75.00","750.00","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","534.00","100","","657.00","121.50","1971.00","14","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","534.00","100","","75.00","75.00","75.00","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","534.00","100","","366.00","144.00","1971.00","45","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","389.82","73","","667.50","667.50","667.50","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.36","44.45","","123.77","123.77","123.77","1 through 10","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","WELLPOINT [1015]","HB CH WELLPOINT","416.04","77.91","","483.51","229.32","1316.08","96","237.36","534","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.00","400.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.66","59.3","","439.50","225.34","1872.27","197","267","418.92","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 20 HOLE","SUP-ITM-10072374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.92","78.45","","385.32","55.36","1815.62","58","267","418.92","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","AETNA [1001]","HB CH AETNA HMO / PPO","281.59","58.3","","554.95","91.85","1421.75","94","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","352.59","73","","2490.03","2490.03","2490.03","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","281.59","58.3","","750.00","750.00","750.00","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","255.99","53","","1192.50","120.84","4149.90","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","410.55","85","","750.00","75.00","750.00","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","483.00","100","","657.00","121.50","1971.00","14","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","483.00","100","","75.00","75.00","75.00","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","483.00","100","","366.00","144.00","1971.00","45","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","352.59","73","","667.50","667.50","667.50","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.69","44.45","","123.77","123.77","123.77","1 through 10","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.00","362.25","WELLPOINT [1015]","HB CH WELLPOINT","376.31","77.91","","483.51","229.32","1316.08","96","214.69","483","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","286.42","59.3","","439.50","225.34","1872.27","197","241.5","378.91","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM NONCOMPRESSION 3 HOLE","SUP-ITM-10072371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.00","362.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","378.91","78.45","","385.32","55.36","1815.62","58","241.5","378.91","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","AETNA [1001]","HB CH AETNA HMO / PPO","394.57","58.3","","554.95","91.85","1421.75","94","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","494.06","73","","2490.03","2490.03","2490.03","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","394.57","58.3","","750.00","750.00","750.00","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","358.70","53","","1192.50","120.84","4149.90","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","575.28","85","","750.00","75.00","750.00","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","676.80","100","","657.00","121.50","1971.00","14","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","676.80","100","","75.00","75.00","75.00","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","676.80","100","","366.00","144.00","1971.00","45","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","494.06","73","","667.50","667.50","667.50","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.84","44.45","","123.77","123.77","123.77","1 through 10","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","both","","","676.80","507.60","WELLPOINT [1015]","HB CH WELLPOINT","527.29","77.91","","483.51","229.32","1316.08","96","300.84","676.8","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","676.80","507.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","401.34","59.3","","439.50","225.34","1872.27","197","338.4","530.95","percent of total billed charges",""
"BONE PLATE 2MM TIMAX TITANIUM STRAIGHT 5 HOLE","SUP-ITM-10072373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","676.80","507.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","530.95","78.45","","385.32","55.36","1815.62","58","338.4","530.95","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","AETNA [1001]","HB CH AETNA HMO / PPO","760.38","58.3","","554.95","91.85","1421.75","94","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","952.10","73","","2490.03","2490.03","2490.03","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","760.38","58.3","","750.00","750.00","750.00","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","691.25","53","","1192.50","120.84","4149.90","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1108.61","85","","750.00","75.00","750.00","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1304.25","100","","657.00","121.50","1971.00","14","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1304.25","100","","75.00","75.00","75.00","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1304.25","100","","366.00","144.00","1971.00","45","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","952.10","73","","667.50","667.50","667.50","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","579.74","44.45","","123.77","123.77","123.77","1 through 10","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","both","","","1304.25","978.19","WELLPOINT [1015]","HB CH WELLPOINT","1016.14","77.91","","483.51","229.32","1316.08","96","579.74","1304.25","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.25","978.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","773.42","59.3","","439.50","225.34","1872.27","197","652.13","1023.18","percent of total billed charges",""
"BONE PLATE 2X1.3MM 12 HOLE STRUT VARIABLE ANGLE LOCKING SS","SUP-ITM-10164587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1304.25","978.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1023.18","78.45","","385.32","55.36","1815.62","58","652.13","1023.18","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","AETNA [1001]","HB CH AETNA HMO / PPO","693.08","58.3","","554.95","91.85","1421.75","94","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","867.83","73","","2490.03","2490.03","2490.03","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","693.08","58.3","","750.00","750.00","750.00","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","630.07","53","","1192.50","120.84","4149.90","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1010.49","85","","750.00","75.00","750.00","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1188.81","100","","657.00","121.50","1971.00","14","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1188.81","100","","75.00","75.00","75.00","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1188.81","100","","366.00","144.00","1971.00","45","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","867.83","73","","667.50","667.50","667.50","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.43","44.45","","123.77","123.77","123.77","1 through 10","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.81","891.61","WELLPOINT [1015]","HB CH WELLPOINT","926.20","77.91","","483.51","229.32","1316.08","96","528.43","1188.81","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","704.96","59.3","","439.50","225.34","1872.27","197","594.41","932.62","percent of total billed charges",""
"BONE PLATE 2X1.3MM 3 HOLE 7 VARIABLE ANGLE LOCKING Y SHAPE SS","SUP-ITM-10164590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.81","891.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","932.62","78.45","","385.32","55.36","1815.62","58","594.41","932.62","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","AETNA [1001]","HB CH AETNA HMO / PPO","951.28","58.3","","554.95","91.85","1421.75","94","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1191.14","73","","2490.03","2490.03","2490.03","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","951.28","58.3","","750.00","750.00","750.00","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.80","53","","1192.50","120.84","4149.90","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1386.95","85","","750.00","75.00","750.00","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1631.70","100","","657.00","121.50","1971.00","14","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1631.70","100","","75.00","75.00","75.00","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1631.70","100","","366.00","144.00","1971.00","45","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1191.14","73","","667.50","667.50","667.50","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.29","44.45","","123.77","123.77","123.77","1 through 10","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","WELLPOINT [1015]","HB CH WELLPOINT","1271.26","77.91","","483.51","229.32","1316.08","96","725.29","1631.7","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.60","59.3","","439.50","225.34","1872.27","197","815.85","1280.07","percent of total billed charges",""
"BONE PLATE 2X1.3MM 6 HOLE ROTATION CORRECTION VARIABLE ANGLE LOCKING SS","SUP-ITM-10164584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.07","78.45","","385.32","55.36","1815.62","58","815.85","1280.07","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","AETNA [1001]","HB CH AETNA HMO / PPO","374.69","58.3","","554.95","91.85","1421.75","94","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","469.16","73","","2490.03","2490.03","2490.03","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","374.69","58.3","","750.00","750.00","750.00","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","340.63","53","","1192.50","120.84","4149.90","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","546.29","85","","750.00","75.00","750.00","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","642.69","100","","657.00","121.50","1971.00","14","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","642.69","100","","75.00","75.00","75.00","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","642.69","100","","366.00","144.00","1971.00","45","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","469.16","73","","667.50","667.50","667.50","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","285.68","44.45","","123.77","123.77","123.77","1 through 10","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","both","","","642.69","482.02","WELLPOINT [1015]","HB CH WELLPOINT","500.72","77.91","","483.51","229.32","1316.08","96","285.68","642.69","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","642.69","482.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","381.12","59.3","","439.50","225.34","1872.27","197","321.35","504.19","percent of total billed charges",""
"BONE PLATE 2X17MM 3 HOLE MINI FRAGMENT STRAIGHT SS","SUP-ITM-10002417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","642.69","482.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","504.19","78.45","","385.32","55.36","1815.62","58","321.35","504.19","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","AETNA [1001]","HB CH AETNA HMO / PPO","82.19","58.3","","554.95","91.85","1421.75","94","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","102.91","73","","2490.03","2490.03","2490.03","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","82.19","58.3","","750.00","750.00","750.00","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","74.71","53","","1192.50","120.84","4149.90","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","119.82","85","","750.00","75.00","750.00","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","140.97","100","","657.00","121.50","1971.00","14","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","140.97","100","","75.00","75.00","75.00","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","140.97","100","","366.00","144.00","1971.00","45","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","102.91","73","","667.50","667.50","667.50","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","62.66","44.45","","123.77","123.77","123.77","1 through 10","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","both","","","140.97","105.73","WELLPOINT [1015]","HB CH WELLPOINT","109.83","77.91","","483.51","229.32","1316.08","96","62.66","140.97","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.97","105.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.60","59.3","","439.50","225.34","1872.27","197","70.49","110.59","percent of total billed charges",""
"BONE PLATE 2X18MM HOLE 3 MINI FRAGMENT T SHAPE SS","SUP-ITM-10001640","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","140.97","105.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","110.59","78.45","","385.32","55.36","1815.62","58","70.49","110.59","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","AETNA [1001]","HB CH AETNA HMO / PPO","551.35","58.3","","554.95","91.85","1421.75","94","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","690.38","73","","2490.03","2490.03","2490.03","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","551.35","58.3","","750.00","750.00","750.00","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","501.23","53","","1192.50","120.84","4149.90","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","803.86","85","","750.00","75.00","750.00","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","945.72","100","","657.00","121.50","1971.00","14","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","945.72","100","","75.00","75.00","75.00","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","945.72","100","","366.00","144.00","1971.00","45","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","690.38","73","","667.50","667.50","667.50","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.37","44.45","","123.77","123.77","123.77","1 through 10","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.72","709.29","WELLPOINT [1015]","HB CH WELLPOINT","736.81","77.91","","483.51","229.32","1316.08","96","420.37","945.72","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.72","709.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.81","59.3","","439.50","225.34","1872.27","197","472.86","741.92","percent of total billed charges",""
"BONE PLATE 2X27MM 4 HOLE LC DCP SS","SUP-ITM-10038070","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.72","709.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.92","78.45","","385.32","55.36","1815.62","58","472.86","741.92","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","AETNA [1001]","HB CH AETNA HMO / PPO","641.31","58.3","","554.95","91.85","1421.75","94","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","803.01","73","","2490.03","2490.03","2490.03","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","641.31","58.3","","750.00","750.00","750.00","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","583.01","53","","1192.50","120.84","4149.90","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","935.01","85","","750.00","75.00","750.00","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1100.01","100","","657.00","121.50","1971.00","14","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1100.01","100","","75.00","75.00","75.00","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1100.01","100","","366.00","144.00","1971.00","45","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","803.01","73","","667.50","667.50","667.50","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","488.95","44.45","","123.77","123.77","123.77","1 through 10","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1100.01","825.01","WELLPOINT [1015]","HB CH WELLPOINT","857.02","77.91","","483.51","229.32","1316.08","96","488.95","1100.01","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.01","825.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","652.31","59.3","","439.50","225.34","1872.27","197","550.01","862.96","percent of total billed charges",""
"BONE PLATE 2X35MM 6 HOLE SS STRAIGHT 247.031","SUP-ITM-10038136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1100.01","825.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.96","78.45","","385.32","55.36","1815.62","58","550.01","862.96","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","AETNA [1001]","HB CH AETNA HMO / PPO","643.89","58.3","","554.95","91.85","1421.75","94","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","806.25","73","","2490.03","2490.03","2490.03","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","643.89","58.3","","750.00","750.00","750.00","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","585.36","53","","1192.50","120.84","4149.90","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","938.78","85","","750.00","75.00","750.00","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1104.45","100","","657.00","121.50","1971.00","14","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1104.45","100","","75.00","75.00","75.00","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1104.45","100","","366.00","144.00","1971.00","45","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","806.25","73","","667.50","667.50","667.50","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","490.93","44.45","","123.77","123.77","123.77","1 through 10","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1104.45","828.34","WELLPOINT [1015]","HB CH WELLPOINT","860.48","77.91","","483.51","229.32","1316.08","96","490.93","1104.45","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.45","828.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","654.94","59.3","","439.50","225.34","1872.27","197","552.23","866.44","percent of total billed charges",""
"BONE PLATE 2X39MM 6 HOLE LC DCP SS","SUP-ITM-10038072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1104.45","828.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","866.44","78.45","","385.32","55.36","1815.62","58","552.23","866.44","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","AETNA [1001]","HB CH AETNA HMO / PPO","1067.76","58.3","","554.95","91.85","1421.75","94","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1337.00","73","","2490.03","2490.03","2490.03","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1067.76","58.3","","750.00","750.00","750.00","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","970.70","53","","1192.50","120.84","4149.90","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1556.78","85","","750.00","75.00","750.00","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1831.50","100","","657.00","121.50","1971.00","14","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1831.50","100","","75.00","75.00","75.00","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1831.50","100","","366.00","144.00","1971.00","45","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1337.00","73","","667.50","667.50","667.50","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","814.10","44.45","","123.77","123.77","123.77","1 through 10","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","both","","","1831.50","1373.62","WELLPOINT [1015]","HB CH WELLPOINT","1426.92","77.91","","483.51","229.32","1316.08","96","814.1","1831.5","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.50","1373.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1086.08","59.3","","439.50","225.34","1872.27","197","915.75","1436.81","percent of total billed charges",""
"BONE PLATE 2X39MM 7 HOLE CONDYLE VA LCP TITANIUM LOCKING VARIABLE ANGLE RIGHT","SUP-ITM-10002324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1831.50","1373.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1436.81","78.45","","385.32","55.36","1815.62","58","915.75","1436.81","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","AETNA [1001]","HB CH AETNA HMO / PPO","540.35","58.3","","554.95","91.85","1421.75","94","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","676.60","73","","2490.03","2490.03","2490.03","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","540.35","58.3","","750.00","750.00","750.00","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","491.23","53","","1192.50","120.84","4149.90","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","787.82","85","","750.00","75.00","750.00","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","926.85","100","","657.00","121.50","1971.00","14","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","926.85","100","","75.00","75.00","75.00","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","926.85","100","","366.00","144.00","1971.00","45","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","676.60","73","","667.50","667.50","667.50","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","411.98","44.45","","123.77","123.77","123.77","1 through 10","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","both","","","926.85","695.14","WELLPOINT [1015]","HB CH WELLPOINT","722.11","77.91","","483.51","229.32","1316.08","96","411.98","926.85","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.85","695.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","549.62","59.3","","439.50","225.34","1872.27","197","463.43","727.11","percent of total billed charges",""
"BONE PLATE 2X48MM HOLE HD 8 SHAFT T SHAPE MODULAR HAND TI","SUP-ITM-10006481","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","926.85","695.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","727.11","78.45","","385.32","55.36","1815.62","58","463.43","727.11","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","AETNA [1001]","HB CH AETNA HMO / PPO","738.38","58.3","","554.95","91.85","1421.75","94","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","924.55","73","","2490.03","2490.03","2490.03","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","738.38","58.3","","750.00","750.00","750.00","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","671.25","53","","1192.50","120.84","4149.90","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1076.53","85","","750.00","75.00","750.00","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1266.51","100","","657.00","121.50","1971.00","14","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1266.51","100","","75.00","75.00","75.00","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1266.51","100","","366.00","144.00","1971.00","45","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","924.55","73","","667.50","667.50","667.50","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.96","44.45","","123.77","123.77","123.77","1 through 10","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","both","","","1266.51","949.88","WELLPOINT [1015]","HB CH WELLPOINT","986.74","77.91","","483.51","229.32","1316.08","96","562.96","1266.51","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","751.04","59.3","","439.50","225.34","1872.27","197","633.26","993.58","percent of total billed charges",""
"BONE PLATE 2X51MM 8 HOLE LC DCP SS","SUP-ITM-10038074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1266.51","949.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","993.58","78.45","","385.32","55.36","1815.62","58","633.26","993.58","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","AETNA [1001]","HB CH AETNA HMO / PPO","308.03","58.3","","554.95","91.85","1421.75","94","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","385.70","73","","2490.03","2490.03","2490.03","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","308.03","58.3","","750.00","750.00","750.00","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","280.03","53","","1192.50","120.84","4149.90","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","449.11","85","","750.00","75.00","750.00","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","528.36","100","","657.00","121.50","1971.00","14","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","528.36","100","","75.00","75.00","75.00","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","528.36","100","","366.00","144.00","1971.00","45","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","385.70","73","","667.50","667.50","667.50","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.86","44.45","","123.77","123.77","123.77","1 through 10","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","both","","","528.36","396.27","WELLPOINT [1015]","HB CH WELLPOINT","411.65","77.91","","483.51","229.32","1316.08","96","234.86","528.36","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.36","396.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","313.32","59.3","","439.50","225.34","1872.27","197","264.18","414.5","percent of total billed charges",""
"BONE PLATE 2X73MM 10 HOLE LCP SS STRAIGHT","SUP-ITM-10025399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","528.36","396.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","414.50","78.45","","385.32","55.36","1815.62","58","264.18","414.5","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","AETNA [1001]","HB CH AETNA HMO / PPO","876.91","58.3","","554.95","91.85","1421.75","94","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1098.02","73","","2490.03","2490.03","2490.03","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","876.91","58.3","","750.00","750.00","750.00","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","797.19","53","","1192.50","120.84","4149.90","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1278.52","85","","750.00","75.00","750.00","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1504.14","100","","657.00","121.50","1971.00","14","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1504.14","100","","75.00","75.00","75.00","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1504.14","100","","366.00","144.00","1971.00","45","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1098.02","73","","667.50","667.50","667.50","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","668.59","44.45","","123.77","123.77","123.77","1 through 10","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","both","","","1504.14","1128.10","WELLPOINT [1015]","HB CH WELLPOINT","1171.88","77.91","","483.51","229.32","1316.08","96","668.59","1504.14","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.14","1128.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","891.96","59.3","","439.50","225.34","1872.27","197","752.07","1180","percent of total billed charges",""
"BONE PLATE 3.5MM 4.5 4 H LOCKING ATTCHMNT F/LCP/STER","SUP-ITM-10074527","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1504.14","1128.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1180.00","78.45","","385.32","55.36","1815.62","58","752.07","1180","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","554.95","91.85","1421.75","94","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","2490.03","2490.03","2490.03","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","750.00","750.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","1192.50","120.84","4149.90","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3176.88","85","","750.00","75.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3737.50","100","","657.00","121.50","1971.00","14","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3737.50","100","","75.00","75.00","75.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3737.50","100","","366.00","144.00","1971.00","45","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","667.50","667.50","667.50","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","123.77","123.77","123.77","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","483.51","229.32","1316.08","96","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","439.50","225.34","1872.27","197","1868.75","2932.07","percent of total billed charges",""
"BONE PLATE 3.5MM SM 13 HOLE TITANIUM LOW PROFILE MEDIAL COLUMN RIGHT","SUP-ITM-10123986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","385.32","55.36","1815.62","58","1868.75","2932.07","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","AETNA [1001]","HB CH AETNA HMO / PPO","436.17","58.3","","554.95","91.85","1421.75","94","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","546.14","73","","2490.03","2490.03","2490.03","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","436.17","58.3","","750.00","750.00","750.00","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","396.51","53","","1192.50","120.84","4149.90","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","635.92","85","","750.00","75.00","750.00","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","748.14","100","","657.00","121.50","1971.00","14","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","748.14","100","","75.00","75.00","75.00","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","748.14","100","","366.00","144.00","1971.00","45","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","546.14","73","","667.50","667.50","667.50","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","332.55","44.45","","123.77","123.77","123.77","1 through 10","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","both","","","748.14","561.10","WELLPOINT [1015]","HB CH WELLPOINT","582.88","77.91","","483.51","229.32","1316.08","96","332.55","748.14","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.14","561.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","443.65","59.3","","439.50","225.34","1872.27","197","374.07","586.92","percent of total billed charges",""
"BONE PLATE 3.5MM SM 7 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","748.14","561.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","586.92","78.45","","385.32","55.36","1815.62","58","374.07","586.92","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","AETNA [1001]","HB CH AETNA HMO / PPO","2090.06","58.3","","554.95","91.85","1421.75","94","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2617.05","73","","2490.03","2490.03","2490.03","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2090.06","58.3","","750.00","750.00","750.00","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1900.05","53","","1192.50","120.84","4149.90","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3047.25","85","","750.00","75.00","750.00","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3585.00","100","","657.00","121.50","1971.00","14","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3585.00","100","","75.00","75.00","75.00","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3585.00","100","","366.00","144.00","1971.00","45","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2617.05","73","","667.50","667.50","667.50","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1593.53","44.45","","123.77","123.77","123.77","1 through 10","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","both","","","3585.00","2688.75","WELLPOINT [1015]","HB CH WELLPOINT","2793.07","77.91","","483.51","229.32","1316.08","96","1593.53","3585","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.00","2688.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2125.91","59.3","","439.50","225.34","1872.27","197","1792.5","2812.43","percent of total billed charges",""
"BONE PLATE 3.5MMX20 4 HOLE DOUBLE COMPRESSION SS SQUARE","SUP-ITM-10137798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3585.00","2688.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2812.43","78.45","","385.32","55.36","1815.62","58","1792.5","2812.43","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","AETNA [1001]","HB CH AETNA HMO / PPO","458.17","58.3","","554.95","91.85","1421.75","94","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","573.69","73","","2490.03","2490.03","2490.03","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","458.17","58.3","","750.00","750.00","750.00","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","416.52","53","","1192.50","120.84","4149.90","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","668.00","85","","750.00","75.00","750.00","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","785.88","100","","657.00","121.50","1971.00","14","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","785.88","100","","75.00","75.00","75.00","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","785.88","100","","366.00","144.00","1971.00","45","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","573.69","73","","667.50","667.50","667.50","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.32","44.45","","123.77","123.77","123.77","1 through 10","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","both","","","785.88","589.41","WELLPOINT [1015]","HB CH WELLPOINT","612.28","77.91","","483.51","229.32","1316.08","96","349.32","785.88","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.88","589.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","466.03","59.3","","439.50","225.34","1872.27","197","392.94","616.52","percent of total billed charges",""
"BONE PLATE 3.5X103MM 8 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","785.88","589.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","616.52","78.45","","385.32","55.36","1815.62","58","392.94","616.52","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","AETNA [1001]","HB CH AETNA HMO / PPO","476.93","58.3","","554.95","91.85","1421.75","94","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","597.19","73","","2490.03","2490.03","2490.03","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","476.93","58.3","","750.00","750.00","750.00","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","433.58","53","","1192.50","120.84","4149.90","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","695.36","85","","750.00","75.00","750.00","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","818.07","100","","657.00","121.50","1971.00","14","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","818.07","100","","75.00","75.00","75.00","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","818.07","100","","366.00","144.00","1971.00","45","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","597.19","73","","667.50","667.50","667.50","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.63","44.45","","123.77","123.77","123.77","1 through 10","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","both","","","818.07","613.55","WELLPOINT [1015]","HB CH WELLPOINT","637.36","77.91","","483.51","229.32","1316.08","96","363.63","818.07","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.07","613.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","485.12","59.3","","439.50","225.34","1872.27","197","409.04","641.78","percent of total billed charges",""
"BONE PLATE 3.5X116MM 9 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10002232","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","818.07","613.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","641.78","78.45","","385.32","55.36","1815.62","58","409.04","641.78","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","AETNA [1001]","HB CH AETNA HMO / PPO","468.52","58.3","","554.95","91.85","1421.75","94","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","586.66","73","","2490.03","2490.03","2490.03","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","468.52","58.3","","750.00","750.00","750.00","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","425.93","53","","1192.50","120.84","4149.90","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","683.09","85","","750.00","75.00","750.00","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","803.64","100","","657.00","121.50","1971.00","14","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","803.64","100","","75.00","75.00","75.00","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","803.64","100","","366.00","144.00","1971.00","45","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","586.66","73","","667.50","667.50","667.50","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","357.22","44.45","","123.77","123.77","123.77","1 through 10","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","both","","","803.64","602.73","WELLPOINT [1015]","HB CH WELLPOINT","626.12","77.91","","483.51","229.32","1316.08","96","357.22","803.64","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","803.64","602.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","476.56","59.3","","439.50","225.34","1872.27","197","401.82","630.46","percent of total billed charges",""
"BONE PLATE 3.5X137MM 10 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008260","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","803.64","602.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","630.46","78.45","","385.32","55.36","1815.62","58","401.82","630.46","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","AETNA [1001]","HB CH AETNA HMO / PPO","711.20","58.3","","554.95","91.85","1421.75","94","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","890.52","73","","2490.03","2490.03","2490.03","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","711.20","58.3","","750.00","750.00","750.00","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","646.54","53","","1192.50","120.84","4149.90","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1036.91","85","","750.00","75.00","750.00","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1219.89","100","","657.00","121.50","1971.00","14","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1219.89","100","","75.00","75.00","75.00","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1219.89","100","","366.00","144.00","1971.00","45","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","890.52","73","","667.50","667.50","667.50","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","542.24","44.45","","123.77","123.77","123.77","1 through 10","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","both","","","1219.89","914.92","WELLPOINT [1015]","HB CH WELLPOINT","950.42","77.91","","483.51","229.32","1316.08","96","542.24","1219.89","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","723.39","59.3","","439.50","225.34","1872.27","197","609.95","957","percent of total billed charges",""
"BONE PLATE 3.5X140MM 10 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1219.89","914.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","957.00","78.45","","385.32","55.36","1815.62","58","609.95","957","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","AETNA [1001]","HB CH AETNA HMO / PPO","518.35","58.3","","554.95","91.85","1421.75","94","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","649.05","73","","2490.03","2490.03","2490.03","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","518.35","58.3","","750.00","750.00","750.00","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","471.23","53","","1192.50","120.84","4149.90","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","755.74","85","","750.00","75.00","750.00","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","889.11","100","","657.00","121.50","1971.00","14","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","889.11","100","","75.00","75.00","75.00","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","889.11","100","","366.00","144.00","1971.00","45","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","649.05","73","","667.50","667.50","667.50","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.21","44.45","","123.77","123.77","123.77","1 through 10","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.11","666.83","WELLPOINT [1015]","HB CH WELLPOINT","692.71","77.91","","483.51","229.32","1316.08","96","395.21","889.11","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.11","666.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","527.24","59.3","","439.50","225.34","1872.27","197","444.56","697.51","percent of total billed charges",""
"BONE PLATE 3.5X163MM 12 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008261","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.11","666.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","697.51","78.45","","385.32","55.36","1815.62","58","444.56","697.51","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","AETNA [1001]","HB CH AETNA HMO / PPO","1726.54","58.3","","554.95","91.85","1421.75","94","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2161.88","73","","2490.03","2490.03","2490.03","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1726.54","58.3","","750.00","750.00","750.00","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1569.58","53","","1192.50","120.84","4149.90","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2517.26","85","","750.00","75.00","750.00","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2961.48","100","","657.00","121.50","1971.00","14","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2961.48","100","","75.00","75.00","75.00","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2961.48","100","","366.00","144.00","1971.00","45","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2161.88","73","","667.50","667.50","667.50","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1316.38","44.45","","123.77","123.77","123.77","1 through 10","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","both","","","2961.48","2221.11","WELLPOINT [1015]","HB CH WELLPOINT","2307.29","77.91","","483.51","229.32","1316.08","96","1316.38","2961.48","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2961.48","2221.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","1756.16","59.3","","439.50","225.34","1872.27","197","1480.74","2323.28","percent of total billed charges",""
"BONE PLATE 3.5X164MM 12 HOLE METAPHYSEAL LCP TI","SUP-ITM-10040449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2961.48","2221.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2323.28","78.45","","385.32","55.36","1815.62","58","1480.74","2323.28","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","AETNA [1001]","HB CH AETNA HMO / PPO","787.56","58.3","","554.95","91.85","1421.75","94","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","986.14","73","","2490.03","2490.03","2490.03","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","787.56","58.3","","750.00","750.00","750.00","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","715.96","53","","1192.50","120.84","4149.90","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1148.24","85","","750.00","75.00","750.00","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1350.87","100","","657.00","121.50","1971.00","14","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1350.87","100","","75.00","75.00","75.00","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1350.87","100","","366.00","144.00","1971.00","45","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","986.14","73","","667.50","667.50","667.50","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","600.46","44.45","","123.77","123.77","123.77","1 through 10","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","both","","","1350.87","1013.15","WELLPOINT [1015]","HB CH WELLPOINT","1052.46","77.91","","483.51","229.32","1316.08","96","600.46","1350.87","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.87","1013.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","801.07","59.3","","439.50","225.34","1872.27","197","675.44","1059.76","percent of total billed charges",""
"BONE PLATE 3.5X168MM 12 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008165","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1350.87","1013.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1059.76","78.45","","385.32","55.36","1815.62","58","675.44","1059.76","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","AETNA [1001]","HB CH AETNA HMO / PPO","779.79","58.3","","554.95","91.85","1421.75","94","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","976.41","73","","2490.03","2490.03","2490.03","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","779.79","58.3","","750.00","750.00","750.00","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","708.90","53","","1192.50","120.84","4149.90","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1136.92","85","","750.00","75.00","750.00","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1337.55","100","","657.00","121.50","1971.00","14","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1337.55","100","","75.00","75.00","75.00","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1337.55","100","","366.00","144.00","1971.00","45","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","976.41","73","","667.50","667.50","667.50","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.54","44.45","","123.77","123.77","123.77","1 through 10","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.55","1003.16","WELLPOINT [1015]","HB CH WELLPOINT","1042.09","77.91","","483.51","229.32","1316.08","96","594.54","1337.55","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.55","1003.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.17","59.3","","439.50","225.34","1872.27","197","668.78","1049.31","percent of total billed charges",""
"BONE PLATE 3.5X189MM 14 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008168","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.55","1003.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.31","78.45","","385.32","55.36","1815.62","58","668.78","1049.31","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","AETNA [1001]","HB CH AETNA HMO / PPO","2083.69","58.3","","554.95","91.85","1421.75","94","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2609.08","73","","2490.03","2490.03","2490.03","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2083.69","58.3","","750.00","750.00","750.00","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1894.26","53","","1192.50","120.84","4149.90","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3037.97","85","","750.00","75.00","750.00","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3574.08","100","","657.00","121.50","1971.00","14","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3574.08","100","","75.00","75.00","75.00","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3574.08","100","","366.00","144.00","1971.00","45","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2609.08","73","","667.50","667.50","667.50","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1588.68","44.45","","123.77","123.77","123.77","1 through 10","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","both","","","3574.08","2680.56","WELLPOINT [1015]","HB CH WELLPOINT","2784.57","77.91","","483.51","229.32","1316.08","96","1588.68","3574.08","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.08","2680.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2119.43","59.3","","439.50","225.34","1872.27","197","1787.04","2803.87","percent of total billed charges",""
"BONE PLATE 3.5X194MM DISTAL 8 HOLE BONE HUMERUS EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3574.08","2680.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2803.87","78.45","","385.32","55.36","1815.62","58","1787.04","2803.87","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","AETNA [1001]","HB CH AETNA HMO / PPO","1770.55","58.3","","554.95","91.85","1421.75","94","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2216.98","73","","2490.03","2490.03","2490.03","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1770.55","58.3","","750.00","750.00","750.00","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1609.59","53","","1192.50","120.84","4149.90","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2581.42","85","","750.00","75.00","750.00","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3036.96","100","","657.00","121.50","1971.00","14","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3036.96","100","","75.00","75.00","75.00","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3036.96","100","","366.00","144.00","1971.00","45","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2216.98","73","","667.50","667.50","667.50","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1349.93","44.45","","123.77","123.77","123.77","1 through 10","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3036.96","2277.72","WELLPOINT [1015]","HB CH WELLPOINT","2366.10","77.91","","483.51","229.32","1316.08","96","1349.93","3036.96","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3036.96","2277.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","1800.92","59.3","","439.50","225.34","1872.27","197","1518.48","2382.5","percent of total billed charges",""
"BONE PLATE 3.5X213MM DISTAL 12 HOLE BONE LCP SS LOW BEND MEDIAL TIBIA","SUP-ITM-10095116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3036.96","2277.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2382.50","78.45","","385.32","55.36","1815.62","58","1518.48","2382.5","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","AETNA [1001]","HB CH AETNA HMO / PPO","2231.72","58.3","","554.95","91.85","1421.75","94","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2794.44","73","","2490.03","2490.03","2490.03","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2231.72","58.3","","750.00","750.00","750.00","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2028.84","53","","1192.50","120.84","4149.90","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3253.80","85","","750.00","75.00","750.00","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3828.00","100","","657.00","121.50","1971.00","14","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3828.00","100","","75.00","75.00","75.00","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3828.00","100","","366.00","144.00","1971.00","45","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2794.44","73","","667.50","667.50","667.50","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1701.55","44.45","","123.77","123.77","123.77","1 through 10","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","both","","","3828.00","2871.00","WELLPOINT [1015]","HB CH WELLPOINT","2982.39","77.91","","483.51","229.32","1316.08","96","1701.55","3828","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3828.00","2871.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2270.00","59.3","","439.50","225.34","1872.27","197","1914","3003.07","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE CHARLOTTE CLAW SS FOOT COMPRESSION","SUP-ITM-10031100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3828.00","2871.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3003.07","78.45","","385.32","55.36","1815.62","58","1914","3003.07","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","AETNA [1001]","HB CH AETNA HMO / PPO","181.20","58.3","","554.95","91.85","1421.75","94","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","226.88","73","","2490.03","2490.03","2490.03","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.20","58.3","","750.00","750.00","750.00","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","164.72","53","","1192.50","120.84","4149.90","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","264.18","85","","750.00","75.00","750.00","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","310.80","100","","657.00","121.50","1971.00","14","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","310.80","100","","75.00","75.00","75.00","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","310.80","100","","366.00","144.00","1971.00","45","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","226.88","73","","667.50","667.50","667.50","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.15","44.45","","123.77","123.77","123.77","1 through 10","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","both","","","310.80","233.10","WELLPOINT [1015]","HB CH WELLPOINT","242.14","77.91","","483.51","229.32","1316.08","96","138.15","310.8","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.80","233.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","184.30","59.3","","439.50","225.34","1872.27","197","155.4","243.82","percent of total billed charges",""
"BONE PLATE 3.5X25MM 2 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10005258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","310.80","233.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","243.82","78.45","","385.32","55.36","1815.62","58","155.4","243.82","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","AETNA [1001]","HB CH AETNA HMO / PPO","1093.00","58.3","","554.95","91.85","1421.75","94","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1368.60","73","","2490.03","2490.03","2490.03","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1093.00","58.3","","750.00","750.00","750.00","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","993.64","53","","1192.50","120.84","4149.90","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1593.57","85","","750.00","75.00","750.00","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1874.79","100","","657.00","121.50","1971.00","14","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1874.79","100","","75.00","75.00","75.00","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1874.79","100","","366.00","144.00","1971.00","45","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1368.60","73","","667.50","667.50","667.50","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","833.34","44.45","","123.77","123.77","123.77","1 through 10","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","both","","","1874.79","1406.09","WELLPOINT [1015]","HB CH WELLPOINT","1460.65","77.91","","483.51","229.32","1316.08","96","833.34","1874.79","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.79","1406.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1111.75","59.3","","439.50","225.34","1872.27","197","937.4","1470.77","percent of total billed charges",""
"BONE PLATE 3.5X267MM 20 HOLE LCP SS LOCKING STRAIGHT","SUP-ITM-10011606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1874.79","1406.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1470.77","78.45","","385.32","55.36","1815.62","58","937.4","1470.77","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","AETNA [1001]","HB CH AETNA HMO / PPO","185.73","58.3","","554.95","91.85","1421.75","94","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","232.56","73","","2490.03","2490.03","2490.03","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.73","58.3","","750.00","750.00","750.00","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.84","53","","1192.50","120.84","4149.90","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","270.78","85","","750.00","75.00","750.00","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","318.57","100","","657.00","121.50","1971.00","14","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","318.57","100","","75.00","75.00","75.00","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","318.57","100","","366.00","144.00","1971.00","45","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.56","73","","667.50","667.50","667.50","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.60","44.45","","123.77","123.77","123.77","1 through 10","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.57","238.93","WELLPOINT [1015]","HB CH WELLPOINT","248.20","77.91","","483.51","229.32","1316.08","96","141.6","318.57","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.57","238.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.91","59.3","","439.50","225.34","1872.27","197","159.29","249.92","percent of total billed charges",""
"BONE PLATE 3.5X37MM 3 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.57","238.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.92","78.45","","385.32","55.36","1815.62","58","159.29","249.92","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","AETNA [1001]","HB CH AETNA HMO / PPO","214.85","58.3","","554.95","91.85","1421.75","94","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","269.02","73","","2490.03","2490.03","2490.03","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","214.85","58.3","","750.00","750.00","750.00","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","195.32","53","","1192.50","120.84","4149.90","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","313.24","85","","750.00","75.00","750.00","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","368.52","100","","657.00","121.50","1971.00","14","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","368.52","100","","75.00","75.00","75.00","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","368.52","100","","366.00","144.00","1971.00","45","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","269.02","73","","667.50","667.50","667.50","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.81","44.45","","123.77","123.77","123.77","1 through 10","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","both","","","368.52","276.39","WELLPOINT [1015]","HB CH WELLPOINT","287.11","77.91","","483.51","229.32","1316.08","96","163.81","368.52","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","368.52","276.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","218.53","59.3","","439.50","225.34","1872.27","197","184.26","289.1","percent of total billed charges",""
"BONE PLATE 3.5X49MM 4 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","368.52","276.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","289.10","78.45","","385.32","55.36","1815.62","58","184.26","289.1","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","AETNA [1001]","HB CH AETNA HMO / PPO","396.04","58.3","","554.95","91.85","1421.75","94","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","495.90","73","","2490.03","2490.03","2490.03","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","396.04","58.3","","750.00","750.00","750.00","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","360.04","53","","1192.50","120.84","4149.90","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","577.42","85","","750.00","75.00","750.00","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","679.32","100","","657.00","121.50","1971.00","14","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","679.32","100","","75.00","75.00","75.00","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","679.32","100","","366.00","144.00","1971.00","45","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","495.90","73","","667.50","667.50","667.50","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.96","44.45","","123.77","123.77","123.77","1 through 10","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","both","","","679.32","509.49","WELLPOINT [1015]","HB CH WELLPOINT","529.26","77.91","","483.51","229.32","1316.08","96","301.96","679.32","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","679.32","509.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","402.84","59.3","","439.50","225.34","1872.27","197","339.66","532.93","percent of total billed charges",""
"BONE PLATE 3.5X50MM 3 HOLE HD SHAFT T RT ANGLE LCP SS","SUP-ITM-10008264","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","679.32","509.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","532.93","78.45","","385.32","55.36","1815.62","58","339.66","532.93","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","AETNA [1001]","HB CH AETNA HMO / PPO","445.23","58.3","","554.95","91.85","1421.75","94","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","557.49","73","","2490.03","2490.03","2490.03","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","445.23","58.3","","750.00","750.00","750.00","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","404.75","53","","1192.50","120.84","4149.90","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","649.13","85","","750.00","75.00","750.00","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","763.68","100","","657.00","121.50","1971.00","14","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","763.68","100","","75.00","75.00","75.00","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","763.68","100","","366.00","144.00","1971.00","45","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","557.49","73","","667.50","667.50","667.50","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","339.46","44.45","","123.77","123.77","123.77","1 through 10","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","both","","","763.68","572.76","WELLPOINT [1015]","HB CH WELLPOINT","594.98","77.91","","483.51","229.32","1316.08","96","339.46","763.68","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.68","572.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","452.86","59.3","","439.50","225.34","1872.27","197","381.84","599.11","percent of total billed charges",""
"BONE PLATE 3.5X52MM 3 HOLE HD SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","763.68","572.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","599.11","78.45","","385.32","55.36","1815.62","58","381.84","599.11","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","AETNA [1001]","HB CH AETNA HMO / PPO","409.63","58.3","","554.95","91.85","1421.75","94","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","512.92","73","","2490.03","2490.03","2490.03","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.63","58.3","","750.00","750.00","750.00","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.39","53","","1192.50","120.84","4149.90","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","597.24","85","","750.00","75.00","750.00","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","702.63","100","","657.00","121.50","1971.00","14","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","702.63","100","","75.00","75.00","75.00","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","702.63","100","","366.00","144.00","1971.00","45","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.92","73","","667.50","667.50","667.50","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.32","44.45","","123.77","123.77","123.77","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","WELLPOINT [1015]","HB CH WELLPOINT","547.42","77.91","","483.51","229.32","1316.08","96","312.32","702.63","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.66","59.3","","439.50","225.34","1872.27","197","351.32","551.21","percent of total billed charges",""
"BONE PLATE 3.5X56MM 4 HOLE HD SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","551.21","78.45","","385.32","55.36","1815.62","58","351.32","551.21","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","AETNA [1001]","HB CH AETNA HMO / PPO","465.93","58.3","","554.95","91.85","1421.75","94","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","583.42","73","","2490.03","2490.03","2490.03","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","465.93","58.3","","750.00","750.00","750.00","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","423.58","53","","1192.50","120.84","4149.90","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","679.32","85","","750.00","75.00","750.00","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","799.20","100","","657.00","121.50","1971.00","14","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","799.20","100","","75.00","75.00","75.00","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","799.20","100","","366.00","144.00","1971.00","45","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","583.42","73","","667.50","667.50","667.50","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","355.24","44.45","","123.77","123.77","123.77","1 through 10","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","both","","","799.20","599.40","WELLPOINT [1015]","HB CH WELLPOINT","622.66","77.91","","483.51","229.32","1316.08","96","355.24","799.2","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","799.20","599.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","473.93","59.3","","439.50","225.34","1872.27","197","399.6","626.97","percent of total billed charges",""
"BONE PLATE 3.5X63MM 3 HOLE HD 4 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","799.20","599.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","626.97","78.45","","385.32","55.36","1815.62","58","399.6","626.97","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","AETNA [1001]","HB CH AETNA HMO / PPO","449.11","58.3","","554.95","91.85","1421.75","94","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","2490.03","2490.03","2490.03","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","449.11","58.3","","750.00","750.00","750.00","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","408.28","53","","1192.50","120.84","4149.90","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","654.79","85","","750.00","75.00","750.00","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","770.34","100","","657.00","121.50","1971.00","14","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","770.34","100","","75.00","75.00","75.00","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","770.34","100","","366.00","144.00","1971.00","45","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","667.50","667.50","667.50","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.42","44.45","","123.77","123.77","123.77","1 through 10","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","WELLPOINT [1015]","HB CH WELLPOINT","600.17","77.91","","483.51","229.32","1316.08","96","342.42","770.34","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","456.81","59.3","","439.50","225.34","1872.27","197","385.17","604.33","percent of total billed charges",""
"BONE PLATE 3.5X67MM 3 HOLE HD 5 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","604.33","78.45","","385.32","55.36","1815.62","58","385.17","604.33","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","AETNA [1001]","HB CH AETNA HMO / PPO","542.29","58.3","","554.95","91.85","1421.75","94","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","679.03","73","","2490.03","2490.03","2490.03","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","542.29","58.3","","750.00","750.00","750.00","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","493.00","53","","1192.50","120.84","4149.90","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","790.65","85","","750.00","75.00","750.00","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","930.18","100","","657.00","121.50","1971.00","14","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","930.18","100","","75.00","75.00","75.00","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","930.18","100","","366.00","144.00","1971.00","45","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","679.03","73","","667.50","667.50","667.50","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","413.47","44.45","","123.77","123.77","123.77","1 through 10","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","both","","","930.18","697.63","WELLPOINT [1015]","HB CH WELLPOINT","724.70","77.91","","483.51","229.32","1316.08","96","413.47","930.18","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.18","697.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","551.60","59.3","","439.50","225.34","1872.27","197","465.09","729.73","percent of total billed charges",""
"BONE PLATE 3.5X70MM 5 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","930.18","697.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","729.73","78.45","","385.32","55.36","1815.62","58","465.09","729.73","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","AETNA [1001]","HB CH AETNA HMO / PPO","377.92","58.3","","554.95","91.85","1421.75","94","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","473.22","73","","2490.03","2490.03","2490.03","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","377.92","58.3","","750.00","750.00","750.00","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","343.57","53","","1192.50","120.84","4149.90","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","551.00","85","","750.00","75.00","750.00","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","648.24","100","","657.00","121.50","1971.00","14","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","648.24","100","","75.00","75.00","75.00","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","648.24","100","","366.00","144.00","1971.00","45","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","473.22","73","","667.50","667.50","667.50","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","288.14","44.45","","123.77","123.77","123.77","1 through 10","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","both","","","648.24","486.18","WELLPOINT [1015]","HB CH WELLPOINT","505.04","77.91","","483.51","229.32","1316.08","96","288.14","648.24","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.24","486.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","384.41","59.3","","439.50","225.34","1872.27","197","324.12","508.54","percent of total billed charges",""
"BONE PLATE 3.5X72MM 5 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","648.24","486.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","508.54","78.45","","385.32","55.36","1815.62","58","324.12","508.54","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","AETNA [1001]","HB CH AETNA HMO / PPO","138.71","58.3","","554.95","91.85","1421.75","94","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.69","73","","2490.03","2490.03","2490.03","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.71","58.3","","750.00","750.00","750.00","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.10","53","","1192.50","120.84","4149.90","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","202.24","85","","750.00","75.00","750.00","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.93","100","","657.00","121.50","1971.00","14","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.93","100","","75.00","75.00","75.00","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.93","100","","366.00","144.00","1971.00","45","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.69","73","","667.50","667.50","667.50","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.76","44.45","","123.77","123.77","123.77","1 through 10","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","WELLPOINT [1015]","HB CH WELLPOINT","185.37","77.91","","483.51","229.32","1316.08","96","105.76","237.93","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.09","59.3","","439.50","225.34","1872.27","197","118.97","186.66","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE 100DEG A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.66","78.45","","385.32","55.36","1815.62","58","118.97","186.66","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","AETNA [1001]","HB CH AETNA HMO / PPO","139.15","58.3","","554.95","91.85","1421.75","94","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","174.24","73","","2490.03","2490.03","2490.03","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.15","58.3","","750.00","750.00","750.00","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.50","53","","1192.50","120.84","4149.90","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","202.88","85","","750.00","75.00","750.00","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","238.68","100","","657.00","121.50","1971.00","14","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","238.68","100","","75.00","75.00","75.00","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","238.68","100","","366.00","144.00","1971.00","45","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","174.24","73","","667.50","667.50","667.50","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.09","44.45","","123.77","123.77","123.77","1 through 10","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.68","179.01","WELLPOINT [1015]","HB CH WELLPOINT","185.96","77.91","","483.51","229.32","1316.08","96","106.09","238.68","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.68","179.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.54","59.3","","439.50","225.34","1872.27","197","119.34","187.24","percent of total billed charges",""
"BONE PLATE 3.5X73MM 6 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10004177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.68","179.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","187.24","78.45","","385.32","55.36","1815.62","58","119.34","187.24","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","AETNA [1001]","HB CH AETNA HMO / PPO","456.23","58.3","","554.95","91.85","1421.75","94","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","571.26","73","","2490.03","2490.03","2490.03","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","456.23","58.3","","750.00","750.00","750.00","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","414.75","53","","1192.50","120.84","4149.90","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","665.17","85","","750.00","75.00","750.00","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","782.55","100","","657.00","121.50","1971.00","14","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","782.55","100","","75.00","75.00","75.00","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","782.55","100","","366.00","144.00","1971.00","45","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","571.26","73","","667.50","667.50","667.50","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","347.84","44.45","","123.77","123.77","123.77","1 through 10","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","both","","","782.55","586.91","WELLPOINT [1015]","HB CH WELLPOINT","609.68","77.91","","483.51","229.32","1316.08","96","347.84","782.55","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","782.55","586.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","464.05","59.3","","439.50","225.34","1872.27","197","391.28","613.91","percent of total billed charges",""
"BONE PLATE 3.5X73MM SM 6 HOLE DCP SS FRAGMENT","SUP-ITM-10001506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","782.55","586.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","613.91","78.45","","385.32","55.36","1815.62","58","391.28","613.91","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","AETNA [1001]","HB CH AETNA HMO / PPO","486.64","58.3","","554.95","91.85","1421.75","94","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","609.35","73","","2490.03","2490.03","2490.03","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","486.64","58.3","","750.00","750.00","750.00","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","442.40","53","","1192.50","120.84","4149.90","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","709.51","85","","750.00","75.00","750.00","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","834.72","100","","657.00","121.50","1971.00","14","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","834.72","100","","75.00","75.00","75.00","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","834.72","100","","366.00","144.00","1971.00","45","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","609.35","73","","667.50","667.50","667.50","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","371.03","44.45","","123.77","123.77","123.77","1 through 10","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","both","","","834.72","626.04","WELLPOINT [1015]","HB CH WELLPOINT","650.33","77.91","","483.51","229.32","1316.08","96","371.03","834.72","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","834.72","626.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","494.99","59.3","","439.50","225.34","1872.27","197","417.36","654.84","percent of total billed charges",""
"BONE PLATE 3.5X74MM 3 HOLE HD 5 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","834.72","626.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","654.84","78.45","","385.32","55.36","1815.62","58","417.36","654.84","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","AETNA [1001]","HB CH AETNA HMO / PPO","419.99","58.3","","554.95","91.85","1421.75","94","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.88","73","","2490.03","2490.03","2490.03","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.99","58.3","","750.00","750.00","750.00","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.81","53","","1192.50","120.84","4149.90","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.33","85","","750.00","75.00","750.00","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.39","100","","657.00","121.50","1971.00","14","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.39","100","","75.00","75.00","75.00","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.39","100","","366.00","144.00","1971.00","45","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.88","73","","667.50","667.50","667.50","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.21","44.45","","123.77","123.77","123.77","1 through 10","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.39","540.29","WELLPOINT [1015]","HB CH WELLPOINT","561.26","77.91","","483.51","229.32","1316.08","96","320.21","720.39","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.39","540.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","427.19","59.3","","439.50","225.34","1872.27","197","360.2","565.15","percent of total billed charges",""
"BONE PLATE 3.5X77MM 6 HOLE COMPRESSION LC DCP SS BX/2EA","SUP-ITM-10004030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.39","540.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","565.15","78.45","","385.32","55.36","1815.62","58","360.2","565.15","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","AETNA [1001]","HB CH AETNA HMO / PPO","524.82","58.3","","554.95","91.85","1421.75","94","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.15","73","","2490.03","2490.03","2490.03","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.82","58.3","","750.00","750.00","750.00","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.11","53","","1192.50","120.84","4149.90","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.18","85","","750.00","75.00","750.00","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.21","100","","657.00","121.50","1971.00","14","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.21","100","","75.00","75.00","75.00","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.21","100","","366.00","144.00","1971.00","45","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.15","73","","667.50","667.50","667.50","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.14","44.45","","123.77","123.77","123.77","1 through 10","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.21","675.16","WELLPOINT [1015]","HB CH WELLPOINT","701.35","77.91","","483.51","229.32","1316.08","96","400.14","900.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.21","675.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.82","59.3","","439.50","225.34","1872.27","197","450.11","706.21","percent of total billed charges",""
"BONE PLATE 3.5X78MM 4 HOLE HD 6 SHAFT T RT ANGLE LCP SS","SUP-ITM-10008272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.21","675.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.21","78.45","","385.32","55.36","1815.62","58","450.11","706.21","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","AETNA [1001]","HB CH AETNA HMO / PPO","626.42","58.3","","554.95","91.85","1421.75","94","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","784.37","73","","2490.03","2490.03","2490.03","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","626.42","58.3","","750.00","750.00","750.00","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","569.47","53","","1192.50","120.84","4149.90","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","913.31","85","","750.00","75.00","750.00","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1074.48","100","","657.00","121.50","1971.00","14","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1074.48","100","","75.00","75.00","75.00","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1074.48","100","","366.00","144.00","1971.00","45","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","784.37","73","","667.50","667.50","667.50","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","477.61","44.45","","123.77","123.77","123.77","1 through 10","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","both","","","1074.48","805.86","WELLPOINT [1015]","HB CH WELLPOINT","837.13","77.91","","483.51","229.32","1316.08","96","477.61","1074.48","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.48","805.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","637.17","59.3","","439.50","225.34","1872.27","197","537.24","842.93","percent of total billed charges",""
"BONE PLATE 3.5X84MM 6 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008164","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1074.48","805.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","842.93","78.45","","385.32","55.36","1815.62","58","537.24","842.93","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","AETNA [1001]","HB CH AETNA HMO / PPO","656.19","58.3","","554.95","91.85","1421.75","94","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","2490.03","2490.03","2490.03","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","656.19","58.3","","750.00","750.00","750.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.54","53","","1192.50","120.84","4149.90","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","956.71","85","","750.00","75.00","750.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1125.54","100","","657.00","121.50","1971.00","14","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1125.54","100","","75.00","75.00","75.00","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1125.54","100","","366.00","144.00","1971.00","45","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.64","73","","667.50","667.50","667.50","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.30","44.45","","123.77","123.77","123.77","1 through 10","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.54","844.15","WELLPOINT [1015]","HB CH WELLPOINT","876.91","77.91","","483.51","229.32","1316.08","96","500.3","1125.54","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.45","59.3","","439.50","225.34","1872.27","197","562.77","882.99","percent of total billed charges",""
"BONE PLATE 3.5X87MM 3 HOLE HD 7 SHAFT LCP SS T SHAPE RT ANGLE","SUP-ITM-10008266","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.54","844.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.99","78.45","","385.32","55.36","1815.62","58","562.77","882.99","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","AETNA [1001]","HB CH AETNA HMO / PPO","527.41","58.3","","554.95","91.85","1421.75","94","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","660.39","73","","2490.03","2490.03","2490.03","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","527.41","58.3","","750.00","750.00","750.00","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","479.46","53","","1192.50","120.84","4149.90","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","768.95","85","","750.00","75.00","750.00","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","904.65","100","","657.00","121.50","1971.00","14","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","904.65","100","","75.00","75.00","75.00","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","904.65","100","","366.00","144.00","1971.00","45","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","660.39","73","","667.50","667.50","667.50","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","402.12","44.45","","123.77","123.77","123.77","1 through 10","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","both","","","904.65","678.49","WELLPOINT [1015]","HB CH WELLPOINT","704.81","77.91","","483.51","229.32","1316.08","96","402.12","904.65","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","904.65","678.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","536.46","59.3","","439.50","225.34","1872.27","197","452.33","709.7","percent of total billed charges",""
"BONE PLATE 3.5X96MM 3 HOLE HD 7 SHAFT LCP SS OBLIQUE T SHAPE LEFT","SUP-ITM-10008291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","904.65","678.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","709.70","78.45","","385.32","55.36","1815.62","58","452.33","709.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","AETNA [1001]","HB CH AETNA HMO / PPO","498.29","58.3","","554.95","91.85","1421.75","94","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","623.93","73","","2490.03","2490.03","2490.03","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.29","58.3","","750.00","750.00","750.00","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","452.99","53","","1192.50","120.84","4149.90","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","726.50","85","","750.00","75.00","750.00","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","854.70","100","","657.00","121.50","1971.00","14","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","854.70","100","","75.00","75.00","75.00","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","854.70","100","","366.00","144.00","1971.00","45","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","623.93","73","","667.50","667.50","667.50","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.91","44.45","","123.77","123.77","123.77","1 through 10","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","both","","","854.70","641.02","WELLPOINT [1015]","HB CH WELLPOINT","665.90","77.91","","483.51","229.32","1316.08","96","379.91","854.7","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","506.84","59.3","","439.50","225.34","1872.27","197","427.35","670.51","percent of total billed charges",""
"BONE PLATE 3.5X97MM SM 8 HOLE DCP SS FRAGMENT","SUP-ITM-10001539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","854.70","641.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.51","78.45","","385.32","55.36","1815.62","58","427.35","670.51","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","AETNA [1001]","HB CH AETNA HMO / PPO","656.84","58.3","","554.95","91.85","1421.75","94","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","822.45","73","","2490.03","2490.03","2490.03","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","656.84","58.3","","750.00","750.00","750.00","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","597.12","53","","1192.50","120.84","4149.90","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","957.65","85","","750.00","75.00","750.00","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1126.65","100","","657.00","121.50","1971.00","14","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1126.65","100","","75.00","75.00","75.00","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1126.65","100","","366.00","144.00","1971.00","45","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","822.45","73","","667.50","667.50","667.50","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.80","44.45","","123.77","123.77","123.77","1 through 10","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","both","","","1126.65","844.99","WELLPOINT [1015]","HB CH WELLPOINT","877.77","77.91","","483.51","229.32","1316.08","96","500.8","1126.65","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","668.10","59.3","","439.50","225.34","1872.27","197","563.33","883.86","percent of total billed charges",""
"BONE PLATE 3.5X98MM 7 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008262","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1126.65","844.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","883.86","78.45","","385.32","55.36","1815.62","58","563.33","883.86","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","AETNA [1001]","HB CH AETNA HMO / PPO","444.58","58.3","","554.95","91.85","1421.75","94","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","556.68","73","","2490.03","2490.03","2490.03","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","444.58","58.3","","750.00","750.00","750.00","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","404.16","53","","1192.50","120.84","4149.90","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","648.18","85","","750.00","75.00","750.00","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","762.57","100","","657.00","121.50","1971.00","14","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","762.57","100","","75.00","75.00","75.00","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","762.57","100","","366.00","144.00","1971.00","45","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","556.68","73","","667.50","667.50","667.50","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","338.96","44.45","","123.77","123.77","123.77","1 through 10","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","both","","","762.57","571.93","WELLPOINT [1015]","HB CH WELLPOINT","594.12","77.91","","483.51","229.32","1316.08","96","338.96","762.57","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.57","571.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","452.20","59.3","","439.50","225.34","1872.27","197","381.29","598.24","percent of total billed charges",""
"BONE PLATE 3X3.5 52MM HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","762.57","571.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","598.24","78.45","","385.32","55.36","1815.62","58","381.29","598.24","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","AETNA [1001]","HB CH AETNA HMO / PPO","464.64","58.3","","554.95","91.85","1421.75","94","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","581.80","73","","2490.03","2490.03","2490.03","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","464.64","58.3","","750.00","750.00","750.00","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","422.40","53","","1192.50","120.84","4149.90","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","677.43","85","","750.00","75.00","750.00","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","796.98","100","","657.00","121.50","1971.00","14","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","796.98","100","","75.00","75.00","75.00","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","796.98","100","","366.00","144.00","1971.00","45","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","581.80","73","","667.50","667.50","667.50","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.26","44.45","","123.77","123.77","123.77","1 through 10","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","both","","","796.98","597.73","WELLPOINT [1015]","HB CH WELLPOINT","620.93","77.91","","483.51","229.32","1316.08","96","354.26","796.98","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.98","597.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","472.61","59.3","","439.50","225.34","1872.27","197","398.49","625.23","percent of total billed charges",""
"BONE PLATE 3X3.5 63MM 4 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008274","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","796.98","597.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","625.23","78.45","","385.32","55.36","1815.62","58","398.49","625.23","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","AETNA [1001]","HB CH AETNA HMO / PPO","485.35","58.3","","554.95","91.85","1421.75","94","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","607.73","73","","2490.03","2490.03","2490.03","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","485.35","58.3","","750.00","750.00","750.00","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","441.23","53","","1192.50","120.84","4149.90","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","707.63","85","","750.00","75.00","750.00","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","832.50","100","","657.00","121.50","1971.00","14","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","832.50","100","","75.00","75.00","75.00","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","832.50","100","","366.00","144.00","1971.00","45","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","607.73","73","","667.50","667.50","667.50","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","370.05","44.45","","123.77","123.77","123.77","1 through 10","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","both","","","832.50","624.37","WELLPOINT [1015]","HB CH WELLPOINT","648.60","77.91","","483.51","229.32","1316.08","96","370.05","832.5","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","832.50","624.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","493.67","59.3","","439.50","225.34","1872.27","197","416.25","653.1","percent of total billed charges",""
"BONE PLATE 3X3.5 74MM 5 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","832.50","624.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","653.10","78.45","","385.32","55.36","1815.62","58","416.25","653.1","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","AETNA [1001]","HB CH AETNA HMO / PPO","526.76","58.3","","554.95","91.85","1421.75","94","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","659.58","73","","2490.03","2490.03","2490.03","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","526.76","58.3","","750.00","750.00","750.00","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.88","53","","1192.50","120.84","4149.90","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","768.01","85","","750.00","75.00","750.00","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","903.54","100","","657.00","121.50","1971.00","14","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","903.54","100","","75.00","75.00","75.00","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","903.54","100","","366.00","144.00","1971.00","45","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","659.58","73","","667.50","667.50","667.50","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","401.62","44.45","","123.77","123.77","123.77","1 through 10","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","both","","","903.54","677.65","WELLPOINT [1015]","HB CH WELLPOINT","703.95","77.91","","483.51","229.32","1316.08","96","401.62","903.54","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.54","677.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.80","59.3","","439.50","225.34","1872.27","197","451.77","708.83","percent of total billed charges",""
"BONE PLATE 3X3.5 96MM 7 HOLE T OBLIQUE LCP STAINLESS RIGHT","SUP-ITM-10008276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","903.54","677.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","708.83","78.45","","385.32","55.36","1815.62","58","451.77","708.83","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","554.95","91.85","1421.75","94","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2490.03","2490.03","2490.03","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","750.00","750.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","1192.50","120.84","4149.90","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","750.00","75.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","657.00","121.50","1971.00","14","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","75.00","75.00","75.00","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","366.00","144.00","1971.00","45","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","667.50","667.50","667.50","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","123.77","123.77","123.77","1 through 10","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","483.51","229.32","1316.08","96","1066.8","2400","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","439.50","225.34","1872.27","197","1200","1882.8","percent of total billed charges",""
"BONE PLATE 4 HOLE FIBULA POSTERIOR LATERAL DISTAL","SUP-ITM-10208533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","385.32","55.36","1815.62","58","1200","1882.8","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","AETNA [1001]","HB CH AETNA HMO / PPO","871.68","58.3","","554.95","91.85","1421.75","94","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1091.47","73","","2490.03","2490.03","2490.03","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","871.68","58.3","","750.00","750.00","750.00","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","792.44","53","","1192.50","120.84","4149.90","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1270.89","85","","750.00","75.00","750.00","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1495.17","100","","657.00","121.50","1971.00","14","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1495.17","100","","75.00","75.00","75.00","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1495.17","100","","366.00","144.00","1971.00","45","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1091.47","73","","667.50","667.50","667.50","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","664.60","44.45","","123.77","123.77","123.77","1 through 10","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","both","","","1495.17","1121.38","WELLPOINT [1015]","HB CH WELLPOINT","1164.89","77.91","","483.51","229.32","1316.08","96","664.6","1495.17","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.17","1121.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","886.64","59.3","","439.50","225.34","1872.27","197","747.59","1172.96","percent of total billed charges",""
"BONE PLATE 4.5X115MM 6 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1495.17","1121.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1172.96","78.45","","385.32","55.36","1815.62","58","747.59","1172.96","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","AETNA [1001]","HB CH AETNA HMO / PPO","609.60","58.3","","554.95","91.85","1421.75","94","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","763.30","73","","2490.03","2490.03","2490.03","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","609.60","58.3","","750.00","750.00","750.00","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.18","53","","1192.50","120.84","4149.90","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","888.78","85","","750.00","75.00","750.00","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1045.62","100","","657.00","121.50","1971.00","14","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1045.62","100","","75.00","75.00","75.00","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1045.62","100","","366.00","144.00","1971.00","45","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","763.30","73","","667.50","667.50","667.50","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","464.78","44.45","","123.77","123.77","123.77","1 through 10","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","both","","","1045.62","784.21","WELLPOINT [1015]","HB CH WELLPOINT","814.64","77.91","","483.51","229.32","1316.08","96","464.78","1045.62","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1045.62","784.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.05","59.3","","439.50","225.34","1872.27","197","522.81","820.29","percent of total billed charges",""
"BONE PLATE 4.5X124MM 7 HOLE LC DCP SS NARROW","SUP-ITM-10006299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1045.62","784.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","820.29","78.45","","385.32","55.36","1815.62","58","522.81","820.29","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","AETNA [1001]","HB CH AETNA HMO / PPO","1007.58","58.3","","554.95","91.85","1421.75","94","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1261.64","73","","2490.03","2490.03","2490.03","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1007.58","58.3","","750.00","750.00","750.00","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","915.98","53","","1192.50","120.84","4149.90","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1469.03","85","","750.00","75.00","750.00","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1728.27","100","","657.00","121.50","1971.00","14","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1728.27","100","","75.00","75.00","75.00","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1728.27","100","","366.00","144.00","1971.00","45","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1261.64","73","","667.50","667.50","667.50","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","768.22","44.45","","123.77","123.77","123.77","1 through 10","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","both","","","1728.27","1296.20","WELLPOINT [1015]","HB CH WELLPOINT","1346.50","77.91","","483.51","229.32","1316.08","96","768.22","1728.27","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.27","1296.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1024.86","59.3","","439.50","225.34","1872.27","197","864.14","1355.83","percent of total billed charges",""
"BONE PLATE 4.5X147MM 8 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1728.27","1296.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1355.83","78.45","","385.32","55.36","1815.62","58","864.14","1355.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","AETNA [1001]","HB CH AETNA HMO / PPO","681.43","58.3","","554.95","91.85","1421.75","94","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","853.25","73","","2490.03","2490.03","2490.03","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","681.43","58.3","","750.00","750.00","750.00","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","619.48","53","","1192.50","120.84","4149.90","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","993.51","85","","750.00","75.00","750.00","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1168.83","100","","657.00","121.50","1971.00","14","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1168.83","100","","75.00","75.00","75.00","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1168.83","100","","366.00","144.00","1971.00","45","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","853.25","73","","667.50","667.50","667.50","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","519.54","44.45","","123.77","123.77","123.77","1 through 10","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","both","","","1168.83","876.62","WELLPOINT [1015]","HB CH WELLPOINT","910.64","77.91","","483.51","229.32","1316.08","96","519.54","1168.83","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1168.83","876.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.12","59.3","","439.50","225.34","1872.27","197","584.42","916.95","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS BROAD","SUP-ITM-10010148","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1168.83","876.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","916.95","78.45","","385.32","55.36","1815.62","58","584.42","916.95","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","AETNA [1001]","HB CH AETNA HMO / PPO","603.13","58.3","","554.95","91.85","1421.75","94","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","755.20","73","","2490.03","2490.03","2490.03","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","603.13","58.3","","750.00","750.00","750.00","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","548.30","53","","1192.50","120.84","4149.90","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","879.34","85","","750.00","75.00","750.00","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1034.52","100","","657.00","121.50","1971.00","14","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1034.52","100","","75.00","75.00","75.00","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1034.52","100","","366.00","144.00","1971.00","45","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","755.20","73","","667.50","667.50","667.50","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.84","44.45","","123.77","123.77","123.77","1 through 10","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","both","","","1034.52","775.89","WELLPOINT [1015]","HB CH WELLPOINT","805.99","77.91","","483.51","229.32","1316.08","96","459.84","1034.52","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.52","775.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","613.47","59.3","","439.50","225.34","1872.27","197","517.26","811.58","percent of total billed charges",""
"BONE PLATE 4.5X152MM 8 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1034.52","775.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","811.58","78.45","","385.32","55.36","1815.62","58","517.26","811.58","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","AETNA [1001]","HB CH AETNA HMO / PPO","674.96","58.3","","554.95","91.85","1421.75","94","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","845.14","73","","2490.03","2490.03","2490.03","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","674.96","58.3","","750.00","750.00","750.00","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","613.60","53","","1192.50","120.84","4149.90","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","984.07","85","","750.00","75.00","750.00","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1157.73","100","","657.00","121.50","1971.00","14","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1157.73","100","","75.00","75.00","75.00","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1157.73","100","","366.00","144.00","1971.00","45","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","845.14","73","","667.50","667.50","667.50","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","514.61","44.45","","123.77","123.77","123.77","1 through 10","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","both","","","1157.73","868.30","WELLPOINT [1015]","HB CH WELLPOINT","901.99","77.91","","483.51","229.32","1316.08","96","514.61","1157.73","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","686.53","59.3","","439.50","225.34","1872.27","197","578.87","908.24","percent of total billed charges",""
"BONE PLATE 4.5X160MM 9 HOLE LC DCP SS NARROW","SUP-ITM-10006508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1157.73","868.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","908.24","78.45","","385.32","55.36","1815.62","58","578.87","908.24","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","AETNA [1001]","HB CH AETNA HMO / PPO","2063.70","58.3","","554.95","91.85","1421.75","94","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2584.05","73","","2490.03","2490.03","2490.03","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2063.70","58.3","","750.00","750.00","750.00","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1876.09","53","","1192.50","120.84","4149.90","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3008.82","85","","750.00","75.00","750.00","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3539.79","100","","657.00","121.50","1971.00","14","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3539.79","100","","75.00","75.00","75.00","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3539.79","100","","366.00","144.00","1971.00","45","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2584.05","73","","667.50","667.50","667.50","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1573.44","44.45","","123.77","123.77","123.77","1 through 10","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","both","","","3539.79","2654.84","WELLPOINT [1015]","HB CH WELLPOINT","2757.85","77.91","","483.51","229.32","1316.08","96","1573.44","3539.79","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.79","2654.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","2099.10","59.3","","439.50","225.34","1872.27","197","1769.9","2776.97","percent of total billed charges",""
"BONE PLATE 4.5X170MM 6 HOLE CONDYLAR LCP SS LEFT","SUP-ITM-10011554","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3539.79","2654.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2776.97","78.45","","385.32","55.36","1815.62","58","1769.9","2776.97","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","AETNA [1001]","HB CH AETNA HMO / PPO","737.73","58.3","","554.95","91.85","1421.75","94","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","923.74","73","","2490.03","2490.03","2490.03","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","737.73","58.3","","750.00","750.00","750.00","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","670.66","53","","1192.50","120.84","4149.90","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1075.59","85","","750.00","75.00","750.00","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1265.40","100","","657.00","121.50","1971.00","14","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1265.40","100","","75.00","75.00","75.00","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1265.40","100","","366.00","144.00","1971.00","45","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","923.74","73","","667.50","667.50","667.50","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","562.47","44.45","","123.77","123.77","123.77","1 through 10","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","both","","","1265.40","949.05","WELLPOINT [1015]","HB CH WELLPOINT","985.87","77.91","","483.51","229.32","1316.08","96","562.47","1265.4","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.40","949.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","750.38","59.3","","439.50","225.34","1872.27","197","632.7","992.71","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS BROAD","SUP-ITM-10010221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1265.40","949.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","992.71","78.45","","385.32","55.36","1815.62","58","632.7","992.71","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","AETNA [1001]","HB CH AETNA HMO / PPO","630.95","58.3","","554.95","91.85","1421.75","94","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","790.04","73","","2490.03","2490.03","2490.03","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","630.95","58.3","","750.00","750.00","750.00","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","573.59","53","","1192.50","120.84","4149.90","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","919.91","85","","750.00","75.00","750.00","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1082.25","100","","657.00","121.50","1971.00","14","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1082.25","100","","75.00","75.00","75.00","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1082.25","100","","366.00","144.00","1971.00","45","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","790.04","73","","667.50","667.50","667.50","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","481.06","44.45","","123.77","123.77","123.77","1 through 10","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.25","811.69","WELLPOINT [1015]","HB CH WELLPOINT","843.18","77.91","","483.51","229.32","1316.08","96","481.06","1082.25","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.25","811.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","641.77","59.3","","439.50","225.34","1872.27","197","541.13","849.03","percent of total billed charges",""
"BONE PLATE 4.5X170MM 9 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.25","811.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.03","78.45","","385.32","55.36","1815.62","58","541.13","849.03","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","AETNA [1001]","HB CH AETNA HMO / PPO","732.55","58.3","","554.95","91.85","1421.75","94","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","917.26","73","","2490.03","2490.03","2490.03","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","732.55","58.3","","750.00","750.00","750.00","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","665.96","53","","1192.50","120.84","4149.90","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1068.04","85","","750.00","75.00","750.00","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1256.52","100","","657.00","121.50","1971.00","14","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1256.52","100","","75.00","75.00","75.00","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1256.52","100","","366.00","144.00","1971.00","45","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","917.26","73","","667.50","667.50","667.50","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","558.52","44.45","","123.77","123.77","123.77","1 through 10","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","both","","","1256.52","942.39","WELLPOINT [1015]","HB CH WELLPOINT","978.95","77.91","","483.51","229.32","1316.08","96","558.52","1256.52","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.52","942.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","745.12","59.3","","439.50","225.34","1872.27","197","628.26","985.74","percent of total billed charges",""
"BONE PLATE 4.5X178MM 10 HOLE LC DCP SS NARROW","SUP-ITM-10006509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1256.52","942.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","985.74","78.45","","385.32","55.36","1815.62","58","628.26","985.74","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","AETNA [1001]","HB CH AETNA HMO / PPO","793.38","58.3","","554.95","91.85","1421.75","94","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","993.43","73","","2490.03","2490.03","2490.03","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","793.38","58.3","","750.00","750.00","750.00","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","721.26","53","","1192.50","120.84","4149.90","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1156.73","85","","750.00","75.00","750.00","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1360.86","100","","657.00","121.50","1971.00","14","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1360.86","100","","75.00","75.00","75.00","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1360.86","100","","366.00","144.00","1971.00","45","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","993.43","73","","667.50","667.50","667.50","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.90","44.45","","123.77","123.77","123.77","1 through 10","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","both","","","1360.86","1020.64","WELLPOINT [1015]","HB CH WELLPOINT","1060.25","77.91","","483.51","229.32","1316.08","96","604.9","1360.86","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","1020.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","806.99","59.3","","439.50","225.34","1872.27","197","680.43","1067.59","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS BROAD","SUP-ITM-10010222","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1360.86","1020.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1067.59","78.45","","385.32","55.36","1815.62","58","680.43","1067.59","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","AETNA [1001]","HB CH AETNA HMO / PPO","685.31","58.3","","554.95","91.85","1421.75","94","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","858.11","73","","2490.03","2490.03","2490.03","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","685.31","58.3","","750.00","750.00","750.00","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","623.01","53","","1192.50","120.84","4149.90","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","999.17","85","","750.00","75.00","750.00","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1175.49","100","","657.00","121.50","1971.00","14","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1175.49","100","","75.00","75.00","75.00","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1175.49","100","","366.00","144.00","1971.00","45","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","858.11","73","","667.50","667.50","667.50","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","522.51","44.45","","123.77","123.77","123.77","1 through 10","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","both","","","1175.49","881.62","WELLPOINT [1015]","HB CH WELLPOINT","915.82","77.91","","483.51","229.32","1316.08","96","522.51","1175.49","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.49","881.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","697.07","59.3","","439.50","225.34","1872.27","197","587.75","922.17","percent of total billed charges",""
"BONE PLATE 4.5X188MM 10 HOLE LCP SS NARROW","SUP-ITM-10010224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1175.49","881.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","922.17","78.45","","385.32","55.36","1815.62","58","587.75","922.17","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","AETNA [1001]","HB CH AETNA HMO / PPO","844.50","58.3","","554.95","91.85","1421.75","94","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","2490.03","2490.03","2490.03","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.50","58.3","","750.00","750.00","750.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.73","53","","1192.50","120.84","4149.90","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1231.27","85","","750.00","75.00","750.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1448.55","100","","657.00","121.50","1971.00","14","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1448.55","100","","75.00","75.00","75.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1448.55","100","","366.00","144.00","1971.00","45","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","667.50","667.50","667.50","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","123.77","123.77","123.77","1 through 10","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","WELLPOINT [1015]","HB CH WELLPOINT","1128.57","77.91","","483.51","229.32","1316.08","96","643.88","1448.55","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.99","59.3","","439.50","225.34","1872.27","197","724.28","1136.39","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE LCP SS BROAD","SUP-ITM-10011372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","385.32","55.36","1815.62","58","724.28","1136.39","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","AETNA [1001]","HB CH AETNA HMO / PPO","811.50","58.3","","554.95","91.85","1421.75","94","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1016.12","73","","2490.03","2490.03","2490.03","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","811.50","58.3","","750.00","750.00","750.00","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","737.73","53","","1192.50","120.84","4149.90","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1183.15","85","","750.00","75.00","750.00","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1391.94","100","","657.00","121.50","1971.00","14","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1391.94","100","","75.00","75.00","75.00","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1391.94","100","","366.00","144.00","1971.00","45","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1016.12","73","","667.50","667.50","667.50","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","618.72","44.45","","123.77","123.77","123.77","1 through 10","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1391.94","1043.95","WELLPOINT [1015]","HB CH WELLPOINT","1084.46","77.91","","483.51","229.32","1316.08","96","618.72","1391.94","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1391.94","1043.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","825.42","59.3","","439.50","225.34","1872.27","197","695.97","1091.98","percent of total billed charges",""
"BONE PLATE 4.5X206MM 11 HOLE TITANIUM LOCKING COMPRESSION NARROW","SUP-ITM-10040480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1391.94","1043.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1091.98","78.45","","385.32","55.36","1815.62","58","695.97","1091.98","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","AETNA [1001]","HB CH AETNA HMO / PPO","848.39","58.3","","554.95","91.85","1421.75","94","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1062.30","73","","2490.03","2490.03","2490.03","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","848.39","58.3","","750.00","750.00","750.00","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","771.26","53","","1192.50","120.84","4149.90","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1236.93","85","","750.00","75.00","750.00","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1455.21","100","","657.00","121.50","1971.00","14","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1455.21","100","","75.00","75.00","75.00","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1455.21","100","","366.00","144.00","1971.00","45","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.30","73","","667.50","667.50","667.50","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.84","44.45","","123.77","123.77","123.77","1 through 10","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.21","1091.41","WELLPOINT [1015]","HB CH WELLPOINT","1133.75","77.91","","483.51","229.32","1316.08","96","646.84","1455.21","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.21","1091.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.94","59.3","","439.50","225.34","1872.27","197","727.61","1141.61","percent of total billed charges",""
"BONE PLATE 4.5X214MM 12 HOLE LC DCP SS NARROW","SUP-ITM-10006511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.21","1091.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.61","78.45","","385.32","55.36","1815.62","58","727.61","1141.61","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","AETNA [1001]","HB CH AETNA HMO / PPO","896.28","58.3","","554.95","91.85","1421.75","94","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1122.27","73","","2490.03","2490.03","2490.03","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","896.28","58.3","","750.00","750.00","750.00","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","814.80","53","","1192.50","120.84","4149.90","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1306.75","85","","750.00","75.00","750.00","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1537.35","100","","657.00","121.50","1971.00","14","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1537.35","100","","75.00","75.00","75.00","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1537.35","100","","366.00","144.00","1971.00","45","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1122.27","73","","667.50","667.50","667.50","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","683.35","44.45","","123.77","123.77","123.77","1 through 10","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","both","","","1537.35","1153.01","WELLPOINT [1015]","HB CH WELLPOINT","1197.75","77.91","","483.51","229.32","1316.08","96","683.35","1537.35","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.35","1153.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","911.65","59.3","","439.50","225.34","1872.27","197","768.68","1206.05","percent of total billed charges",""
"BONE PLATE 4.5X224MM 12 HOLE LCP SS BROAD CS/1EA","SUP-ITM-10011237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1537.35","1153.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1206.05","78.45","","385.32","55.36","1815.62","58","768.68","1206.05","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","AETNA [1001]","HB CH AETNA HMO / PPO","889.80","58.3","","554.95","91.85","1421.75","94","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1114.16","73","","2490.03","2490.03","2490.03","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","889.80","58.3","","750.00","750.00","750.00","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","808.91","53","","1192.50","120.84","4149.90","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1297.31","85","","750.00","75.00","750.00","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1526.25","100","","657.00","121.50","1971.00","14","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1526.25","100","","75.00","75.00","75.00","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1526.25","100","","366.00","144.00","1971.00","45","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1114.16","73","","667.50","667.50","667.50","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","678.42","44.45","","123.77","123.77","123.77","1 through 10","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","both","","","1526.25","1144.69","WELLPOINT [1015]","HB CH WELLPOINT","1189.10","77.91","","483.51","229.32","1316.08","96","678.42","1526.25","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.25","1144.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","905.07","59.3","","439.50","225.34","1872.27","197","763.13","1197.34","percent of total billed charges",""
"BONE PLATE 4.5X260MM 14 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1526.25","1144.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1197.34","78.45","","385.32","55.36","1815.62","58","763.13","1197.34","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","AETNA [1001]","HB CH AETNA HMO / PPO","1039.29","58.3","","554.95","91.85","1421.75","94","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1301.34","73","","2490.03","2490.03","2490.03","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1039.29","58.3","","750.00","750.00","750.00","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","944.81","53","","1192.50","120.84","4149.90","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1515.26","85","","750.00","75.00","750.00","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1782.66","100","","657.00","121.50","1971.00","14","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1782.66","100","","75.00","75.00","75.00","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1782.66","100","","366.00","144.00","1971.00","45","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1301.34","73","","667.50","667.50","667.50","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","792.39","44.45","","123.77","123.77","123.77","1 through 10","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","both","","","1782.66","1336.99","WELLPOINT [1015]","HB CH WELLPOINT","1388.87","77.91","","483.51","229.32","1316.08","96","792.39","1782.66","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1782.66","1336.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1057.12","59.3","","439.50","225.34","1872.27","197","891.33","1398.5","percent of total billed charges",""
"BONE PLATE 4.5X296MM 16 HOLE LCP SS NARROW","SUP-ITM-10012125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1782.66","1336.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1398.50","78.45","","385.32","55.36","1815.62","58","891.33","1398.5","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","AETNA [1001]","HB CH AETNA HMO / PPO","434.87","58.3","","554.95","91.85","1421.75","94","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","544.52","73","","2490.03","2490.03","2490.03","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","434.87","58.3","","750.00","750.00","750.00","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","395.34","53","","1192.50","120.84","4149.90","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","634.03","85","","750.00","75.00","750.00","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","745.92","100","","657.00","121.50","1971.00","14","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","745.92","100","","75.00","75.00","75.00","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","745.92","100","","366.00","144.00","1971.00","45","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","544.52","73","","667.50","667.50","667.50","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.56","44.45","","123.77","123.77","123.77","1 through 10","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.92","559.44","WELLPOINT [1015]","HB CH WELLPOINT","581.15","77.91","","483.51","229.32","1316.08","96","331.56","745.92","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.92","559.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","442.33","59.3","","439.50","225.34","1872.27","197","372.96","585.17","percent of total billed charges",""
"BONE PLATE 4.5X80MM 4 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10011238","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.92","559.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","585.17","78.45","","385.32","55.36","1815.62","58","372.96","585.17","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","AETNA [1001]","HB CH AETNA HMO / PPO","761.67","58.3","","554.95","91.85","1421.75","94","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","953.72","73","","2490.03","2490.03","2490.03","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","761.67","58.3","","750.00","750.00","750.00","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","692.43","53","","1192.50","120.84","4149.90","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1110.50","85","","750.00","75.00","750.00","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1306.47","100","","657.00","121.50","1971.00","14","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1306.47","100","","75.00","75.00","75.00","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1306.47","100","","366.00","144.00","1971.00","45","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","953.72","73","","667.50","667.50","667.50","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.73","44.45","","123.77","123.77","123.77","1 through 10","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1306.47","979.85","WELLPOINT [1015]","HB CH WELLPOINT","1017.87","77.91","","483.51","229.32","1316.08","96","580.73","1306.47","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1306.47","979.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","774.74","59.3","","439.50","225.34","1872.27","197","653.24","1024.93","percent of total billed charges",""
"BONE PLATE 4.5X83MM 4 HOLE LCP SS BASIC T SHAPE","SUP-ITM-10023134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1306.47","979.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1024.93","78.45","","385.32","55.36","1815.62","58","653.24","1024.93","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","AETNA [1001]","HB CH AETNA HMO / PPO","497.64","58.3","","554.95","91.85","1421.75","94","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","623.12","73","","2490.03","2490.03","2490.03","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","497.64","58.3","","750.00","750.00","750.00","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","452.40","53","","1192.50","120.84","4149.90","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","725.55","85","","750.00","75.00","750.00","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","853.59","100","","657.00","121.50","1971.00","14","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","853.59","100","","75.00","75.00","75.00","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","853.59","100","","366.00","144.00","1971.00","45","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","623.12","73","","667.50","667.50","667.50","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","379.42","44.45","","123.77","123.77","123.77","1 through 10","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","both","","","853.59","640.19","WELLPOINT [1015]","HB CH WELLPOINT","665.03","77.91","","483.51","229.32","1316.08","96","379.42","853.59","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.59","640.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","506.18","59.3","","439.50","225.34","1872.27","197","426.8","669.64","percent of total billed charges",""
"BONE PLATE 4.5X88MM 5 HOLE LC DCP SS NARROW","SUP-ITM-10006502","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","853.59","640.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","669.64","78.45","","385.32","55.36","1815.62","58","426.8","669.64","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","AETNA [1001]","HB CH AETNA HMO / PPO","465.29","58.3","","554.95","91.85","1421.75","94","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","582.61","73","","2490.03","2490.03","2490.03","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","465.29","58.3","","750.00","750.00","750.00","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","422.99","53","","1192.50","120.84","4149.90","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","678.38","85","","750.00","75.00","750.00","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","798.09","100","","657.00","121.50","1971.00","14","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","798.09","100","","75.00","75.00","75.00","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","798.09","100","","366.00","144.00","1971.00","45","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","582.61","73","","667.50","667.50","667.50","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.75","44.45","","123.77","123.77","123.77","1 through 10","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","both","","","798.09","598.57","WELLPOINT [1015]","HB CH WELLPOINT","621.79","77.91","","483.51","229.32","1316.08","96","354.75","798.09","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.09","598.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","473.27","59.3","","439.50","225.34","1872.27","197","399.05","626.1","percent of total billed charges",""
"BONE PLATE 4.5X98MM 5 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10012201","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","798.09","598.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","626.10","78.45","","385.32","55.36","1815.62","58","399.05","626.1","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","AETNA [1001]","HB CH AETNA HMO / PPO","546.18","58.3","","554.95","91.85","1421.75","94","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","683.89","73","","2490.03","2490.03","2490.03","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","546.18","58.3","","750.00","750.00","750.00","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","496.53","53","","1192.50","120.84","4149.90","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","796.31","85","","750.00","75.00","750.00","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","936.84","100","","657.00","121.50","1971.00","14","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","936.84","100","","75.00","75.00","75.00","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","936.84","100","","366.00","144.00","1971.00","45","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","683.89","73","","667.50","667.50","667.50","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","416.43","44.45","","123.77","123.77","123.77","1 through 10","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","both","","","936.84","702.63","WELLPOINT [1015]","HB CH WELLPOINT","729.89","77.91","","483.51","229.32","1316.08","96","416.43","936.84","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.84","702.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","555.55","59.3","","439.50","225.34","1872.27","197","468.42","734.95","percent of total billed charges",""
"BONE PLATE 420MM 7 HOLE BUTTON TI","SUP-ITM-10014137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","936.84","702.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","734.95","78.45","","385.32","55.36","1815.62","58","468.42","734.95","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","AETNA [1001]","HB CH AETNA HMO / PPO","755.20","58.3","","554.95","91.85","1421.75","94","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","945.62","73","","2490.03","2490.03","2490.03","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","755.20","58.3","","750.00","750.00","750.00","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","686.55","53","","1192.50","120.84","4149.90","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1101.06","85","","750.00","75.00","750.00","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1295.37","100","","657.00","121.50","1971.00","14","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1295.37","100","","75.00","75.00","75.00","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1295.37","100","","366.00","144.00","1971.00","45","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","945.62","73","","667.50","667.50","667.50","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","575.79","44.45","","123.77","123.77","123.77","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","WELLPOINT [1015]","HB CH WELLPOINT","1009.22","77.91","","483.51","229.32","1316.08","96","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.37","971.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","768.15","59.3","","439.50","225.34","1872.27","197","647.69","1016.22","percent of total billed charges",""
"BONE PLATE 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL CS/1BX/1EA","SUP-ITM-10002036","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.37","971.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1016.22","78.45","","385.32","55.36","1815.62","58","647.69","1016.22","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","AETNA [1001]","HB CH AETNA HMO / PPO","578.53","58.3","","554.95","91.85","1421.75","94","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","724.41","73","","2490.03","2490.03","2490.03","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","578.53","58.3","","750.00","750.00","750.00","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","525.94","53","","1192.50","120.84","4149.90","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","843.49","85","","750.00","75.00","750.00","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","992.34","100","","657.00","121.50","1971.00","14","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","992.34","100","","75.00","75.00","75.00","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","992.34","100","","366.00","144.00","1971.00","45","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","724.41","73","","667.50","667.50","667.50","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.10","44.45","","123.77","123.77","123.77","1 through 10","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","both","","","992.34","744.25","WELLPOINT [1015]","HB CH WELLPOINT","773.13","77.91","","483.51","229.32","1316.08","96","441.1","992.34","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.34","744.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","588.46","59.3","","439.50","225.34","1872.27","197","496.17","778.49","percent of total billed charges",""
"BONE PLATE 46X1.5MM 3 HOLE HEAD CRANIOFACIAL Y SHAPE MODULAR HAND SYSTEM TI","SUP-ITM-10005539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","992.34","744.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","778.49","78.45","","385.32","55.36","1815.62","58","496.17","778.49","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","AETNA [1001]","HB CH AETNA HMO / PPO","2401.96","58.3","","554.95","91.85","1421.75","94","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3007.60","73","","2490.03","2490.03","2490.03","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2401.96","58.3","","750.00","750.00","750.00","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2183.60","53","","1192.50","120.84","4149.90","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3502.00","85","","750.00","75.00","750.00","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4120.00","100","","657.00","121.50","1971.00","14","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4120.00","100","","75.00","75.00","75.00","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4120.00","100","","366.00","144.00","1971.00","45","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3007.60","73","","667.50","667.50","667.50","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1831.34","44.45","","123.77","123.77","123.77","1 through 10","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4120.00","3090.00","WELLPOINT [1015]","HB CH WELLPOINT","3209.89","77.91","","483.51","229.32","1316.08","96","1831.34","4120","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.00","3090.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2443.16","59.3","","439.50","225.34","1872.27","197","2060","3232.14","percent of total billed charges",""
"BONE PLATE 5 HOLE A.L.P.S. PROXIMALIMAL LOCKING STANDARD CURVE LEFT","SUP-ITM-10139172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4120.00","3090.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3232.14","78.45","","385.32","55.36","1815.62","58","2060","3232.14","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","AETNA [1001]","HB CH AETNA HMO / PPO","967.46","58.3","","554.95","91.85","1421.75","94","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1211.40","73","","2490.03","2490.03","2490.03","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","967.46","58.3","","750.00","750.00","750.00","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","879.51","53","","1192.50","120.84","4149.90","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1410.53","85","","750.00","75.00","750.00","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1659.45","100","","657.00","121.50","1971.00","14","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1659.45","100","","75.00","75.00","75.00","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1659.45","100","","366.00","144.00","1971.00","45","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1211.40","73","","667.50","667.50","667.50","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","737.63","44.45","","123.77","123.77","123.77","1 through 10","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","both","","","1659.45","1244.59","WELLPOINT [1015]","HB CH WELLPOINT","1292.88","77.91","","483.51","229.32","1316.08","96","737.63","1659.45","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.45","1244.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","984.05","59.3","","439.50","225.34","1872.27","197","829.73","1301.84","percent of total billed charges",""
"BONE PLATE 54X2MM 7 HOLE CONDYLE LCP STAINLESS 2","SUP-ITM-10022562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1659.45","1244.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1301.84","78.45","","385.32","55.36","1815.62","58","829.73","1301.84","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","AETNA [1001]","HB CH AETNA HMO / PPO","216.14","58.3","","554.95","91.85","1421.75","94","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","270.64","73","","2490.03","2490.03","2490.03","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","216.14","58.3","","750.00","750.00","750.00","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","196.49","53","","1192.50","120.84","4149.90","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","315.13","85","","750.00","75.00","750.00","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","370.74","100","","657.00","121.50","1971.00","14","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","370.74","100","","75.00","75.00","75.00","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","370.74","100","","366.00","144.00","1971.00","45","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","270.64","73","","667.50","667.50","667.50","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","164.79","44.45","","123.77","123.77","123.77","1 through 10","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","both","","","370.74","278.05","WELLPOINT [1015]","HB CH WELLPOINT","288.84","77.91","","483.51","229.32","1316.08","96","164.79","370.74","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.74","278.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","219.85","59.3","","439.50","225.34","1872.27","197","185.37","290.85","percent of total billed charges",""
"BONE PLATE 57X3.5MM 5 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","370.74","278.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","290.85","78.45","","385.32","55.36","1815.62","58","185.37","290.85","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","AETNA [1001]","HB CH AETNA HMO / PPO","520.94","58.3","","554.95","91.85","1421.75","94","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","652.29","73","","2490.03","2490.03","2490.03","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","520.94","58.3","","750.00","750.00","750.00","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","473.58","53","","1192.50","120.84","4149.90","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","759.52","85","","750.00","75.00","750.00","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","893.55","100","","657.00","121.50","1971.00","14","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","893.55","100","","75.00","75.00","75.00","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","893.55","100","","366.00","144.00","1971.00","45","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","652.29","73","","667.50","667.50","667.50","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","397.18","44.45","","123.77","123.77","123.77","1 through 10","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","both","","","893.55","670.16","WELLPOINT [1015]","HB CH WELLPOINT","696.16","77.91","","483.51","229.32","1316.08","96","397.18","893.55","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","893.55","670.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","529.88","59.3","","439.50","225.34","1872.27","197","446.78","700.99","percent of total billed charges",""
"BONE PLATE 59X1.5MM 12 HOLE TI STRAIGHT","SUP-ITM-10005468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","893.55","670.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","700.99","78.45","","385.32","55.36","1815.62","58","446.78","700.99","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","AETNA [1001]","HB CH AETNA HMO / PPO","739.02","58.3","","554.95","91.85","1421.75","94","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","925.36","73","","2490.03","2490.03","2490.03","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","739.02","58.3","","750.00","750.00","750.00","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","671.84","53","","1192.50","120.84","4149.90","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1077.48","85","","750.00","75.00","750.00","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1267.62","100","","657.00","121.50","1971.00","14","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1267.62","100","","75.00","75.00","75.00","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1267.62","100","","366.00","144.00","1971.00","45","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","925.36","73","","667.50","667.50","667.50","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","563.46","44.45","","123.77","123.77","123.77","1 through 10","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","both","","","1267.62","950.71","WELLPOINT [1015]","HB CH WELLPOINT","987.60","77.91","","483.51","229.32","1316.08","96","563.46","1267.62","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1267.62","950.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","751.70","59.3","","439.50","225.34","1872.27","197","633.81","994.45","percent of total billed charges",""
"BONE PLATE 59X2.4MM 7 HOLE CONDYLE LCP STAINLESS","SUP-ITM-10022566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1267.62","950.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","994.45","78.45","","385.32","55.36","1815.62","58","633.81","994.45","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","AETNA [1001]","HB CH AETNA HMO / PPO","2156.48","58.3","","554.95","91.85","1421.75","94","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2700.22","73","","2490.03","2490.03","2490.03","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2156.48","58.3","","750.00","750.00","750.00","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1960.43","53","","1192.50","120.84","4149.90","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3144.09","85","","750.00","75.00","750.00","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3698.93","100","","657.00","121.50","1971.00","14","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3698.93","100","","75.00","75.00","75.00","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3698.93","100","","366.00","144.00","1971.00","45","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2700.22","73","","667.50","667.50","667.50","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1644.17","44.45","","123.77","123.77","123.77","1 through 10","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","both","","","3698.93","2774.20","WELLPOINT [1015]","HB CH WELLPOINT","2881.84","77.91","","483.51","229.32","1316.08","96","1644.17","3698.93","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3698.93","2774.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","2193.47","59.3","","439.50","225.34","1872.27","197","1849.47","2901.81","percent of total billed charges",""
"BONE PLATE 60MM MD DORSAL SMARTLOCK STANDARD LEFT","SUP-ITM-10113952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3698.93","2774.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2901.81","78.45","","385.32","55.36","1815.62","58","1849.47","2901.81","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","AETNA [1001]","HB CH AETNA HMO / PPO","320.66","58.3","","554.95","91.85","1421.75","94","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","401.51","73","","2490.03","2490.03","2490.03","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","320.66","58.3","","750.00","750.00","750.00","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","291.51","53","","1192.50","120.84","4149.90","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","467.52","85","","750.00","75.00","750.00","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","550.02","100","","657.00","121.50","1971.00","14","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","550.02","100","","75.00","75.00","75.00","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","550.02","100","","366.00","144.00","1971.00","45","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","401.51","73","","667.50","667.50","667.50","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.48","44.45","","123.77","123.77","123.77","1 through 10","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","WELLPOINT [1015]","HB CH WELLPOINT","428.52","77.91","","483.51","229.32","1316.08","96","244.48","550.02","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","326.16","59.3","","439.50","225.34","1872.27","197","275.01","431.49","percent of total billed charges",""
"BONE PLATE 72.6X3.5MM SMALL 5 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072306","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","431.49","78.45","","385.32","55.36","1815.62","58","275.01","431.49","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","AETNA [1001]","HB CH AETNA HMO / PPO","1220.85","58.3","","554.95","91.85","1421.75","94","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1528.69","73","","2490.03","2490.03","2490.03","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1220.85","58.3","","750.00","750.00","750.00","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1109.87","53","","1192.50","120.84","4149.90","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1779.98","85","","750.00","75.00","750.00","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2094.09","100","","657.00","121.50","1971.00","14","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2094.09","100","","75.00","75.00","75.00","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2094.09","100","","366.00","144.00","1971.00","45","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1528.69","73","","667.50","667.50","667.50","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","930.82","44.45","","123.77","123.77","123.77","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","WELLPOINT [1015]","HB CH WELLPOINT","1631.51","77.91","","483.51","229.32","1316.08","96","930.82","2094.09","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2094.09","1570.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","1241.80","59.3","","439.50","225.34","1872.27","197","1047.05","1642.81","percent of total billed charges",""
"BONE PLATE 72MM 7 HOLE COMPRESSION VARIAX NARROW STRAIGHT 629507","SUP-ITM-10144750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2094.09","1570.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1642.81","78.45","","385.32","55.36","1815.62","58","1047.05","1642.81","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","AETNA [1001]","HB CH AETNA HMO / PPO","2605.86","58.3","","554.95","91.85","1421.75","94","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3262.92","73","","2490.03","2490.03","2490.03","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2605.86","58.3","","750.00","750.00","750.00","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2368.97","53","","1192.50","120.84","4149.90","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3799.29","85","","750.00","75.00","750.00","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4469.75","100","","657.00","121.50","1971.00","14","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4469.75","100","","75.00","75.00","75.00","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4469.75","100","","366.00","144.00","1971.00","45","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3262.92","73","","667.50","667.50","667.50","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.80","44.45","","123.77","123.77","123.77","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","WELLPOINT [1015]","HB CH WELLPOINT","3482.38","77.91","","483.51","229.32","1316.08","96","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4469.75","3352.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2650.56","59.3","","439.50","225.34","1872.27","197","2234.88","3506.52","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VARIAX VOLAR INTERMEDIATE RIGHT","SUP-ITM-10186190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4469.75","3352.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3506.52","78.45","","385.32","55.36","1815.62","58","2234.88","3506.52","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","AETNA [1001]","HB CH AETNA HMO / PPO","2605.86","58.3","","554.95","91.85","1421.75","94","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3262.92","73","","2490.03","2490.03","2490.03","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2605.86","58.3","","750.00","750.00","750.00","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2368.97","53","","1192.50","120.84","4149.90","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3799.29","85","","750.00","75.00","750.00","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4469.75","100","","657.00","121.50","1971.00","14","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4469.75","100","","75.00","75.00","75.00","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4469.75","100","","366.00","144.00","1971.00","45","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3262.92","73","","667.50","667.50","667.50","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.80","44.45","","123.77","123.77","123.77","1 through 10","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","both","","","4469.75","3352.31","WELLPOINT [1015]","HB CH WELLPOINT","3482.38","77.91","","483.51","229.32","1316.08","96","1986.8","4469.75","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4469.75","3352.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2650.56","59.3","","439.50","225.34","1872.27","197","2234.88","3506.52","percent of total billed charges",""
"BONE PLATE 76MM LONG 14 HOLE VOLAR VARIAX INTERMEDIATE LEFT 54-25677","SUP-ITM-10186192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4469.75","3352.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3506.52","78.45","","385.32","55.36","1815.62","58","2234.88","3506.52","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","AETNA [1001]","HB CH AETNA HMO / PPO","755.20","58.3","","554.95","91.85","1421.75","94","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","945.62","73","","2490.03","2490.03","2490.03","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","755.20","58.3","","750.00","750.00","750.00","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","686.55","53","","1192.50","120.84","4149.90","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1101.06","85","","750.00","75.00","750.00","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1295.37","100","","657.00","121.50","1971.00","14","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1295.37","100","","75.00","75.00","75.00","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1295.37","100","","366.00","144.00","1971.00","45","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","945.62","73","","667.50","667.50","667.50","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","575.79","44.45","","123.77","123.77","123.77","1 through 10","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","both","","","1295.37","971.53","WELLPOINT [1015]","HB CH WELLPOINT","1009.22","77.91","","483.51","229.32","1316.08","96","575.79","1295.37","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.37","971.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","768.15","59.3","","439.50","225.34","1872.27","197","647.69","1016.22","percent of total billed charges",""
"BONE PLATE 78MM SHORT 4 HOLE 135DEG DHS SS COMPRESSION BARREL","SUP-ITM-10004200","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1295.37","971.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1016.22","78.45","","385.32","55.36","1815.62","58","647.69","1016.22","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","AETNA [1001]","HB CH AETNA HMO / PPO","1926.96","58.3","","554.95","91.85","1421.75","94","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2412.83","73","","2490.03","2490.03","2490.03","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1926.96","58.3","","750.00","750.00","750.00","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1751.78","53","","1192.50","120.84","4149.90","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2809.46","85","","750.00","75.00","750.00","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3305.25","100","","657.00","121.50","1971.00","14","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3305.25","100","","75.00","75.00","75.00","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3305.25","100","","366.00","144.00","1971.00","45","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2412.83","73","","667.50","667.50","667.50","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1469.18","44.45","","123.77","123.77","123.77","1 through 10","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","both","","","3305.25","2478.94","WELLPOINT [1015]","HB CH WELLPOINT","2575.12","77.91","","483.51","229.32","1316.08","96","1469.18","3305.25","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.25","2478.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","1960.01","59.3","","439.50","225.34","1872.27","197","1652.63","2592.97","percent of total billed charges",""
"BONE PLATE 8 HOLE LG ZIGZAG SPANNING","SUP-ITM-10238088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3305.25","2478.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2592.97","78.45","","385.32","55.36","1815.62","58","1652.63","2592.97","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","AETNA [1001]","HB CH AETNA HMO / PPO","520.29","58.3","","554.95","91.85","1421.75","94","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","651.48","73","","2490.03","2490.03","2490.03","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","520.29","58.3","","750.00","750.00","750.00","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","472.99","53","","1192.50","120.84","4149.90","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","758.57","85","","750.00","75.00","750.00","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","892.44","100","","657.00","121.50","1971.00","14","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","892.44","100","","75.00","75.00","75.00","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","892.44","100","","366.00","144.00","1971.00","45","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","651.48","73","","667.50","667.50","667.50","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","396.69","44.45","","123.77","123.77","123.77","1 through 10","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","both","","","892.44","669.33","WELLPOINT [1015]","HB CH WELLPOINT","695.30","77.91","","483.51","229.32","1316.08","96","396.69","892.44","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.44","669.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","529.22","59.3","","439.50","225.34","1872.27","197","446.22","700.12","percent of total billed charges",""
"BONE PLATE 81X2MM 12 HOLE LCP STAINLESS ADAPTION","SUP-ITM-10025398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","892.44","669.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","700.12","78.45","","385.32","55.36","1815.62","58","446.22","700.12","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","AETNA [1001]","HB CH AETNA HMO / PPO","392.81","58.3","","554.95","91.85","1421.75","94","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","491.85","73","","2490.03","2490.03","2490.03","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","392.81","58.3","","750.00","750.00","750.00","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.10","53","","1192.50","120.84","4149.90","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","572.70","85","","750.00","75.00","750.00","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","673.77","100","","657.00","121.50","1971.00","14","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","673.77","100","","75.00","75.00","75.00","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","673.77","100","","366.00","144.00","1971.00","45","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","491.85","73","","667.50","667.50","667.50","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.49","44.45","","123.77","123.77","123.77","1 through 10","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.77","505.33","WELLPOINT [1015]","HB CH WELLPOINT","524.93","77.91","","483.51","229.32","1316.08","96","299.49","673.77","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.77","505.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","399.55","59.3","","439.50","225.34","1872.27","197","336.89","528.57","percent of total billed charges",""
"BONE PLATE 85X3.5MM 6 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10007883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.77","505.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","528.57","78.45","","385.32","55.36","1815.62","58","336.89","528.57","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","AETNA [1001]","HB CH AETNA HMO / PPO","557.74","58.3","","554.95","91.85","1421.75","94","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","698.37","73","","2490.03","2490.03","2490.03","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","557.74","58.3","","750.00","750.00","750.00","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","507.04","53","","1192.50","120.84","4149.90","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","813.17","85","","750.00","75.00","750.00","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","956.67","100","","657.00","121.50","1971.00","14","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","956.67","100","","75.00","75.00","75.00","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","956.67","100","","366.00","144.00","1971.00","45","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","698.37","73","","667.50","667.50","667.50","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.24","44.45","","123.77","123.77","123.77","1 through 10","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.67","717.50","WELLPOINT [1015]","HB CH WELLPOINT","745.34","77.91","","483.51","229.32","1316.08","96","425.24","956.67","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.67","717.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","567.31","59.3","","439.50","225.34","1872.27","197","478.34","750.51","percent of total billed charges",""
"BONE PLATE 92MM 7 HOLE A.L.P.S. TITANIUM LOCKING BILATERAL FIBULA COMPOSITE","SUP-ITM-10149075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.67","717.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","750.51","78.45","","385.32","55.36","1815.62","58","478.34","750.51","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","AETNA [1001]","HB CH AETNA HMO / PPO","231.03","58.3","","554.95","91.85","1421.75","94","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","289.28","73","","2490.03","2490.03","2490.03","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","231.03","58.3","","750.00","750.00","750.00","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","210.02","53","","1192.50","120.84","4149.90","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","336.83","85","","750.00","75.00","750.00","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","396.27","100","","657.00","121.50","1971.00","14","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","396.27","100","","75.00","75.00","75.00","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","396.27","100","","366.00","144.00","1971.00","45","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","289.28","73","","667.50","667.50","667.50","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.14","44.45","","123.77","123.77","123.77","1 through 10","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.27","297.20","WELLPOINT [1015]","HB CH WELLPOINT","308.73","77.91","","483.51","229.32","1316.08","96","176.14","396.27","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","234.99","59.3","","439.50","225.34","1872.27","197","198.14","310.87","percent of total billed charges",""
"BONE PLATE 93X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.27","297.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","310.87","78.45","","385.32","55.36","1815.62","58","198.14","310.87","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","AETNA [1001]","HB CH AETNA HMO / PPO","144.50","58.3","","554.95","91.85","1421.75","94","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","180.94","73","","2490.03","2490.03","2490.03","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","144.50","58.3","","750.00","750.00","750.00","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","131.37","53","","1192.50","120.84","4149.90","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","210.68","85","","750.00","75.00","750.00","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","247.86","100","","657.00","121.50","1971.00","14","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","247.86","100","","75.00","75.00","75.00","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","247.86","100","","366.00","144.00","1971.00","45","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","180.94","73","","667.50","667.50","667.50","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","110.17","44.45","","123.77","123.77","123.77","1 through 10","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","both","","","247.86","185.89","WELLPOINT [1015]","HB CH WELLPOINT","193.11","77.91","","483.51","229.32","1316.08","96","110.17","247.86","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.86","185.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.98","59.3","","439.50","225.34","1872.27","197","123.93","194.45","percent of total billed charges",""
"BONE PLATE 97X3.5MM 8 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10002276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","247.86","185.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.45","78.45","","385.32","55.36","1815.62","58","123.93","194.45","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","AETNA [1001]","HB CH AETNA HMO / PPO","336.87","58.3","","554.95","91.85","1421.75","94","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","421.82","73","","2490.03","2490.03","2490.03","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","336.87","58.3","","750.00","750.00","750.00","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","306.25","53","","1192.50","120.84","4149.90","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","491.16","85","","750.00","75.00","750.00","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","577.83","100","","657.00","121.50","1971.00","14","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","577.83","100","","75.00","75.00","75.00","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","577.83","100","","366.00","144.00","1971.00","45","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","421.82","73","","667.50","667.50","667.50","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.85","44.45","","123.77","123.77","123.77","1 through 10","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.83","433.37","WELLPOINT [1015]","HB CH WELLPOINT","450.19","77.91","","483.51","229.32","1316.08","96","256.85","577.83","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.83","433.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","342.65","59.3","","439.50","225.34","1872.27","197","288.92","453.31","percent of total billed charges",""
"BONE PLATE 98.6X3.5MM SMALL 7 HOLE COMPRESSION TITANIUM LOCKING FRAGMENT","SUP-ITM-10072308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.83","433.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","453.31","78.45","","385.32","55.36","1815.62","58","288.92","453.31","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","AETNA [1001]","HB CH AETNA HMO / PPO","409.63","58.3","","554.95","91.85","1421.75","94","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","512.92","73","","2490.03","2490.03","2490.03","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.63","58.3","","750.00","750.00","750.00","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.39","53","","1192.50","120.84","4149.90","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","597.24","85","","750.00","75.00","750.00","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","702.63","100","","657.00","121.50","1971.00","14","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","702.63","100","","75.00","75.00","75.00","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","702.63","100","","366.00","144.00","1971.00","45","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.92","73","","667.50","667.50","667.50","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.32","44.45","","123.77","123.77","123.77","1 through 10","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.63","526.97","WELLPOINT [1015]","HB CH WELLPOINT","547.42","77.91","","483.51","229.32","1316.08","96","312.32","702.63","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.66","59.3","","439.50","225.34","1872.27","197","351.32","551.21","percent of total billed charges",""
"BONE PLATE 98X3.5MM 7 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10027656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.63","526.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","551.21","78.45","","385.32","55.36","1815.62","58","351.32","551.21","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","AETNA [1001]","HB CH AETNA HMO / PPO","426.93","58.3","","554.95","91.85","1421.75","94","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","534.58","73","","2490.03","2490.03","2490.03","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","426.93","58.3","","750.00","750.00","750.00","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","388.12","53","","1192.50","120.84","4149.90","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","622.46","85","","750.00","75.00","750.00","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","732.30","100","","657.00","121.50","1971.00","14","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","732.30","100","","75.00","75.00","75.00","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","732.30","100","","366.00","144.00","1971.00","45","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","534.58","73","","667.50","667.50","667.50","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","325.51","44.45","","123.77","123.77","123.77","1 through 10","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.30","549.22","WELLPOINT [1015]","HB CH WELLPOINT","570.53","77.91","","483.51","229.32","1316.08","96","325.51","732.3","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","732.30","549.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","434.25","59.3","","439.50","225.34","1872.27","197","366.15","574.49","percent of total billed charges",""
"BONE PLATE COMPRESSION 128MM 7 HOLE NARROW STANDARD SS","SUP-ITM-10142766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","732.30","549.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","574.49","78.45","","385.32","55.36","1815.62","58","366.15","574.49","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","554.95","91.85","1421.75","94","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","2490.03","2490.03","2490.03","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1661.55","58.3","","750.00","750.00","750.00","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","1192.50","120.84","4149.90","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2422.50","85","","750.00","75.00","750.00","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2850.00","100","","657.00","121.50","1971.00","14","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2850.00","100","","75.00","75.00","75.00","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2850.00","100","","366.00","144.00","1971.00","45","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","667.50","667.50","667.50","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1266.83","44.45","","123.77","123.77","123.77","1 through 10","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","483.51","229.32","1316.08","96","1266.83","2850","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","439.50","225.34","1872.27","197","1425","2235.83","percent of total billed charges",""
"BONE PLATE CPR FIBERWIRE PLANTER NEEDLE PIGTAIL SCREW MINI SCORPION DX","SUP-ITM-10115068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","385.32","55.36","1815.62","58","1425","2235.83","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","AETNA [1001]","HB CH AETNA HMO / PPO","2261.02","58.3","","554.95","91.85","1421.75","94","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2831.12","73","","2490.03","2490.03","2490.03","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2261.02","58.3","","750.00","750.00","750.00","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2055.47","53","","1192.50","120.84","4149.90","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3296.51","85","","750.00","75.00","750.00","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3878.25","100","","657.00","121.50","1971.00","14","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3878.25","100","","75.00","75.00","75.00","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3878.25","100","","366.00","144.00","1971.00","45","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2831.12","73","","667.50","667.50","667.50","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.88","44.45","","123.77","123.77","123.77","1 through 10","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","WELLPOINT [1015]","HB CH WELLPOINT","3021.54","77.91","","483.51","229.32","1316.08","96","1723.88","3878.25","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2299.80","59.3","","439.50","225.34","1872.27","197","1939.13","3042.49","percent of total billed charges",""
"BONE PLATE EXTRA SHORT 8 HOLE VOLAR VARIAC INTERMEDIATE DISTAL NARROW LEFT","SUP-ITM-10186195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3042.49","78.45","","385.32","55.36","1815.62","58","1939.13","3042.49","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","AETNA [1001]","HB CH AETNA HMO / PPO","883.25","58.3","","554.95","91.85","1421.75","94","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1105.95","73","","2490.03","2490.03","2490.03","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","883.25","58.3","","750.00","750.00","750.00","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","802.95","53","","1192.50","120.84","4149.90","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1287.75","85","","750.00","75.00","750.00","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1515.00","100","","657.00","121.50","1971.00","14","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1515.00","100","","75.00","75.00","75.00","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1515.00","100","","366.00","144.00","1971.00","45","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1105.95","73","","667.50","667.50","667.50","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","673.42","44.45","","123.77","123.77","123.77","1 through 10","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","both","","","1515.00","1136.25","WELLPOINT [1015]","HB CH WELLPOINT","1180.34","77.91","","483.51","229.32","1316.08","96","673.42","1515","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1515.00","1136.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","898.40","59.3","","439.50","225.34","1872.27","197","757.5","1188.52","percent of total billed charges",""
"BONE PLATE HOOK DISTAL RADIAL VOLAR GEMINUS TITANIUM IMPLANTABLE","SUP-ITM-10130619","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1515.00","1136.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1188.52","78.45","","385.32","55.36","1815.62","58","757.5","1188.52","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","AETNA [1001]","HB CH AETNA HMO / PPO","2496.84","58.3","","554.95","91.85","1421.75","94","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3126.41","73","","2490.03","2490.03","2490.03","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2496.84","58.3","","750.00","750.00","750.00","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2269.86","53","","1192.50","120.84","4149.90","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3640.34","85","","750.00","75.00","750.00","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4282.75","100","","657.00","121.50","1971.00","14","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4282.75","100","","75.00","75.00","75.00","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4282.75","100","","366.00","144.00","1971.00","45","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3126.41","73","","667.50","667.50","667.50","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1903.68","44.45","","123.77","123.77","123.77","1 through 10","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","both","","","4282.75","3212.06","WELLPOINT [1015]","HB CH WELLPOINT","3336.69","77.91","","483.51","229.32","1316.08","96","1903.68","4282.75","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.75","3212.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","2539.67","59.3","","439.50","225.34","1872.27","197","2141.38","3359.82","percent of total billed charges",""
"BONE PLATE LG 13HOLE PROXIMAL TIBIAL RIGHT","SUP-ITM-10204017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4282.75","3212.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3359.82","78.45","","385.32","55.36","1815.62","58","2141.38","3359.82","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","AETNA [1001]","HB CH AETNA HMO / PPO","2445.15","58.3","","554.95","91.85","1421.75","94","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3061.68","73","","2490.03","2490.03","2490.03","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2445.15","58.3","","750.00","750.00","750.00","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2222.86","53","","1192.50","120.84","4149.90","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3564.97","85","","750.00","75.00","750.00","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4194.08","100","","657.00","121.50","1971.00","14","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4194.08","100","","75.00","75.00","75.00","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4194.08","100","","366.00","144.00","1971.00","45","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3061.68","73","","667.50","667.50","667.50","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1864.27","44.45","","123.77","123.77","123.77","1 through 10","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","both","","","4194.08","3145.56","WELLPOINT [1015]","HB CH WELLPOINT","3267.61","77.91","","483.51","229.32","1316.08","96","1864.27","4194.08","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4194.08","3145.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2487.09","59.3","","439.50","225.34","1872.27","197","2097.04","3290.26","percent of total billed charges",""
"BONE PLATE LONG 14 HOLE VARIAX RADIUS ARM TITANIUM ANATOMICAL VOLAR DISTAL LT STANDARD","SUP-ITM-10143622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4194.08","3145.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3290.26","78.45","","385.32","55.36","1815.62","58","2097.04","3290.26","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","AETNA [1001]","HB CH AETNA HMO / PPO","1302.03","58.3","","554.95","91.85","1421.75","94","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1630.32","73","","2490.03","2490.03","2490.03","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1302.03","58.3","","750.00","750.00","750.00","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1183.66","53","","1192.50","120.84","4149.90","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1898.32","85","","750.00","75.00","750.00","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2233.32","100","","657.00","121.50","1971.00","14","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2233.32","100","","75.00","75.00","75.00","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2233.32","100","","366.00","144.00","1971.00","45","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1630.32","73","","667.50","667.50","667.50","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","992.71","44.45","","123.77","123.77","123.77","1 through 10","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","both","","","2233.32","1674.99","WELLPOINT [1015]","HB CH WELLPOINT","1739.98","77.91","","483.51","229.32","1316.08","96","992.71","2233.32","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2233.32","1674.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1324.36","59.3","","439.50","225.34","1872.27","197","1116.66","1752.04","percent of total billed charges",""
"BONE PLATE LONG 2 HOLE LCP SS COMPRESSION LOCKING VARIABLE ANGLE TMT FUSION","SUP-ITM-10092004","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2233.32","1674.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1752.04","78.45","","385.32","55.36","1815.62","58","1116.66","1752.04","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","AETNA [1001]","HB CH AETNA HMO / PPO","1724.51","58.3","","554.95","91.85","1421.75","94","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2159.34","73","","2490.03","2490.03","2490.03","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1724.51","58.3","","750.00","750.00","750.00","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1567.74","53","","1192.50","120.84","4149.90","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2514.30","85","","750.00","75.00","750.00","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2958.00","100","","657.00","121.50","1971.00","14","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2958.00","100","","75.00","75.00","75.00","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2958.00","100","","366.00","144.00","1971.00","45","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2159.34","73","","667.50","667.50","667.50","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1314.83","44.45","","123.77","123.77","123.77","1 through 10","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","both","","","2958.00","2218.50","WELLPOINT [1015]","HB CH WELLPOINT","2304.58","77.91","","483.51","229.32","1316.08","96","1314.83","2958","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2958.00","2218.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1754.09","59.3","","439.50","225.34","1872.27","197","1479","2320.55","percent of total billed charges",""
"BONE PLATE MINI PROTEAN FRAGMENT","SUP-ITM-10157783","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2958.00","2218.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2320.55","78.45","","385.32","55.36","1815.62","58","1479","2320.55","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","AETNA [1001]","HB CH AETNA HMO / PPO","1025.04","58.3","","554.95","91.85","1421.75","94","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1283.49","73","","2490.03","2490.03","2490.03","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1025.04","58.3","","750.00","750.00","750.00","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","931.85","53","","1192.50","120.84","4149.90","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1494.48","85","","750.00","75.00","750.00","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1758.21","100","","657.00","121.50","1971.00","14","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1758.21","100","","75.00","75.00","75.00","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1758.21","100","","366.00","144.00","1971.00","45","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1283.49","73","","667.50","667.50","667.50","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","781.52","44.45","","123.77","123.77","123.77","1 through 10","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","both","","","1758.21","1318.66","WELLPOINT [1015]","HB CH WELLPOINT","1369.82","77.91","","483.51","229.32","1316.08","96","781.52","1758.21","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1758.21","1318.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","1042.62","59.3","","439.50","225.34","1872.27","197","879.11","1379.32","percent of total billed charges",""
"BONE PLATE NAVICULAR SM LT A.L.P.S.","SUP-ITM-10117376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1758.21","1318.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1379.32","78.45","","385.32","55.36","1815.62","58","879.11","1379.32","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","AETNA [1001]","HB CH AETNA HMO / PPO","2311.89","58.3","","554.95","91.85","1421.75","94","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2894.82","73","","2490.03","2490.03","2490.03","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2311.89","58.3","","750.00","750.00","750.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2101.72","53","","1192.50","120.84","4149.90","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3370.68","85","","750.00","75.00","750.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3965.50","100","","657.00","121.50","1971.00","14","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3965.50","100","","75.00","75.00","75.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3965.50","100","","366.00","144.00","1971.00","45","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2894.82","73","","667.50","667.50","667.50","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.66","44.45","","123.77","123.77","123.77","1 through 10","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","WELLPOINT [1015]","HB CH WELLPOINT","3089.52","77.91","","483.51","229.32","1316.08","96","1762.66","3965.5","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3965.50","2974.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2351.54","59.3","","439.50","225.34","1872.27","197","1982.75","3110.93","percent of total billed charges",""
"BONE PLATE RIGH 80MM 3HOLE HUMERAL PROXIMALIMAL HI PROXIMALIAML T","SUP-ITM-10175170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3965.50","2974.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3110.93","78.45","","385.32","55.36","1815.62","58","1982.75","3110.93","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","554.95","91.85","1421.75","94","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","2490.03","2490.03","2490.03","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","750.00","750.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","1192.50","120.84","4149.90","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3176.88","85","","750.00","75.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3737.50","100","","657.00","121.50","1971.00","14","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3737.50","100","","75.00","75.00","75.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3737.50","100","","366.00","144.00","1971.00","45","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","667.50","667.50","667.50","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","123.77","123.77","123.77","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","483.51","229.32","1316.08","96","1661.32","3737.5","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","439.50","225.34","1872.27","197","1868.75","2932.07","percent of total billed charges",""
"BONE PLATE SHORT PLANTAR LAPIDUS RIGHT","SUP-ITM-10212046","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","385.32","55.36","1815.62","58","1868.75","2932.07","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","554.95","91.85","1421.75","94","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","2490.03","2490.03","2490.03","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","134.67","58.3","","750.00","750.00","750.00","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","122.43","53","","1192.50","120.84","4149.90","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","196.35","85","","750.00","75.00","750.00","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","231.00","100","","657.00","121.50","1971.00","14","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","231.00","100","","75.00","75.00","75.00","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","231.00","100","","366.00","144.00","1971.00","45","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","667.50","667.50","667.50","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.68","44.45","","123.77","123.77","123.77","1 through 10","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","WELLPOINT [1015]","HB CH WELLPOINT","179.97","77.91","","483.51","229.32","1316.08","96","102.68","231","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","439.50","225.34","1872.27","197","115.5","181.22","percent of total billed charges",""
"BONE PLATE SM 2.7MM TIMAX 1/4 TUBULAR 8 HOLE","SUP-ITM-10072389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","385.32","55.36","1815.62","58","115.5","181.22","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","AETNA [1001]","HB CH AETNA HMO / PPO","2154.33","58.3","","554.95","91.85","1421.75","94","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2697.53","73","","2490.03","2490.03","2490.03","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2154.33","58.3","","750.00","750.00","750.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1958.48","53","","1192.50","120.84","4149.90","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3140.96","85","","750.00","75.00","750.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3695.25","100","","657.00","121.50","1971.00","14","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3695.25","100","","75.00","75.00","75.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3695.25","100","","366.00","144.00","1971.00","45","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2697.53","73","","667.50","667.50","667.50","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1642.54","44.45","","123.77","123.77","123.77","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","WELLPOINT [1015]","HB CH WELLPOINT","2878.97","77.91","","483.51","229.32","1316.08","96","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3695.25","2771.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2191.28","59.3","","439.50","225.34","1872.27","197","1847.63","2898.92","percent of total billed charges",""
"BONE PLATE SM LEFT MEDIAL NECK TALAR","SUP-ITM-10238101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3695.25","2771.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2898.92","78.45","","385.32","55.36","1815.62","58","1847.63","2898.92","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","AETNA [1001]","HB CH AETNA HMO / PPO","2154.33","58.3","","554.95","91.85","1421.75","94","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2697.53","73","","2490.03","2490.03","2490.03","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2154.33","58.3","","750.00","750.00","750.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1958.48","53","","1192.50","120.84","4149.90","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3140.96","85","","750.00","75.00","750.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3695.25","100","","657.00","121.50","1971.00","14","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3695.25","100","","75.00","75.00","75.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3695.25","100","","366.00","144.00","1971.00","45","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2697.53","73","","667.50","667.50","667.50","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1642.54","44.45","","123.77","123.77","123.77","1 through 10","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","WELLPOINT [1015]","HB CH WELLPOINT","2878.97","77.91","","483.51","229.32","1316.08","96","1642.54","3695.25","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3695.25","2771.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2191.28","59.3","","439.50","225.34","1872.27","197","1847.63","2898.92","percent of total billed charges",""
"BONE PLATE SM RIGHT MEDIAL NECK TALAR","SUP-ITM-10238099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3695.25","2771.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2898.92","78.45","","385.32","55.36","1815.62","58","1847.63","2898.92","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","AETNA [1001]","HB CH AETNA HMO / PPO","2724.65","58.3","","554.95","91.85","1421.75","94","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3411.66","73","","2490.03","2490.03","2490.03","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2724.65","58.3","","750.00","750.00","750.00","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2476.96","53","","1192.50","120.84","4149.90","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3972.48","85","","750.00","75.00","750.00","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4673.50","100","","657.00","121.50","1971.00","14","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4673.50","100","","75.00","75.00","75.00","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4673.50","100","","366.00","144.00","1971.00","45","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3411.66","73","","667.50","667.50","667.50","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2077.37","44.45","","123.77","123.77","123.77","1 through 10","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","both","","","4673.50","3505.12","WELLPOINT [1015]","HB CH WELLPOINT","3641.12","77.91","","483.51","229.32","1316.08","96","2077.37","4673.5","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4673.50","3505.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2771.39","59.3","","439.50","225.34","1872.27","197","2336.75","3666.36","percent of total billed charges",""
"BONE PLATE STD RT ANTERIOR TT","SUP-ITM-10238066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4673.50","3505.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3666.36","78.45","","385.32","55.36","1815.62","58","2336.75","3666.36","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","AETNA [1001]","HB CH AETNA HMO / PPO","1978.56","58.3","","554.95","91.85","1421.75","94","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2477.44","73","","2490.03","2490.03","2490.03","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1978.56","58.3","","750.00","750.00","750.00","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1798.69","53","","1192.50","120.84","4149.90","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2884.69","85","","750.00","75.00","750.00","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3393.75","100","","657.00","121.50","1971.00","14","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3393.75","100","","75.00","75.00","75.00","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3393.75","100","","366.00","144.00","1971.00","45","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2477.44","73","","667.50","667.50","667.50","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1508.52","44.45","","123.77","123.77","123.77","1 through 10","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.75","2545.31","WELLPOINT [1015]","HB CH WELLPOINT","2644.07","77.91","","483.51","229.32","1316.08","96","1508.52","3393.75","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.75","2545.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2012.49","59.3","","439.50","225.34","1872.27","197","1696.88","2662.4","percent of total billed charges",""
"BONE PLATE TROCHANTER 2 2.0MM CABLE 150 MD VITALLIUM GRIP","SUP-ITM-10074804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.75","2545.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2662.40","78.45","","385.32","55.36","1815.62","58","1696.88","2662.4","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","AETNA [1001]","HB CH AETNA HMO / PPO","2449.33","58.3","","554.95","91.85","1421.75","94","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.91","73","","2490.03","2490.03","2490.03","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2449.33","58.3","","750.00","750.00","750.00","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.66","53","","1192.50","120.84","4149.90","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3571.06","85","","750.00","75.00","750.00","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4201.25","100","","657.00","121.50","1971.00","14","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4201.25","100","","75.00","75.00","75.00","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4201.25","100","","366.00","144.00","1971.00","45","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.91","73","","667.50","667.50","667.50","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1867.46","44.45","","123.77","123.77","123.77","1 through 10","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","both","","","4201.25","3150.94","WELLPOINT [1015]","HB CH WELLPOINT","3273.19","77.91","","483.51","229.32","1316.08","96","1867.46","4201.25","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4201.25","3150.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2491.34","59.3","","439.50","225.34","1872.27","197","2100.63","3295.88","percent of total billed charges",""
"BONE PLATE TROCHANTER 2MM CABLE 200 MD VITALLIUM GRIP","SUP-ITM-10088645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4201.25","3150.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3295.88","78.45","","385.32","55.36","1815.62","58","2100.63","3295.88","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","AETNA [1001]","HB CH AETNA HMO / PPO","1220.85","58.3","","554.95","91.85","1421.75","94","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1528.69","73","","2490.03","2490.03","2490.03","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1220.85","58.3","","750.00","750.00","750.00","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1109.87","53","","1192.50","120.84","4149.90","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1779.98","85","","750.00","75.00","750.00","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2094.09","100","","657.00","121.50","1971.00","14","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2094.09","100","","75.00","75.00","75.00","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2094.09","100","","366.00","144.00","1971.00","45","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1528.69","73","","667.50","667.50","667.50","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","930.82","44.45","","123.77","123.77","123.77","1 through 10","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","both","","","2094.09","1570.57","WELLPOINT [1015]","HB CH WELLPOINT","1631.51","77.91","","483.51","229.32","1316.08","96","930.82","2094.09","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2094.09","1570.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","1241.80","59.3","","439.50","225.34","1872.27","197","1047.05","1642.81","percent of total billed charges",""
"BONE PLATE VARIAX COMPRESSION NARROW 629506","SUP-ITM-10144748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2094.09","1570.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1642.81","78.45","","385.32","55.36","1815.62","58","1047.05","1642.81","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","554.95","91.85","1421.75","94","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","2490.03","2490.03","2490.03","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","750.00","750.00","750.00","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","1192.50","120.84","4149.90","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","267.75","85","","750.00","75.00","750.00","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","315.00","100","","657.00","121.50","1971.00","14","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","315.00","100","","75.00","75.00","75.00","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","315.00","100","","366.00","144.00","1971.00","45","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","667.50","667.50","667.50","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","123.77","123.77","123.77","1 through 10","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","483.51","229.32","1316.08","96","140.02","315","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","439.50","225.34","1872.27","197","157.5","247.12","percent of total billed charges",""
"BONE PLATE WIRE SM VIROFORM FRAGMENT","SUP-ITM-10087514","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","385.32","55.36","1815.62","58","157.5","247.12","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","AETNA [1001]","HB CH AETNA HMO / PPO","404.46","58.3","","554.95","91.85","1421.75","94","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","506.44","73","","2490.03","2490.03","2490.03","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","404.46","58.3","","750.00","750.00","750.00","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","367.69","53","","1192.50","120.84","4149.90","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","589.69","85","","750.00","75.00","750.00","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","693.75","100","","657.00","121.50","1971.00","14","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","693.75","100","","75.00","75.00","75.00","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","693.75","100","","366.00","144.00","1971.00","45","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","506.44","73","","667.50","667.50","667.50","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","308.37","44.45","","123.77","123.77","123.77","1 through 10","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","both","","","693.75","520.31","WELLPOINT [1015]","HB CH WELLPOINT","540.50","77.91","","483.51","229.32","1316.08","96","308.37","693.75","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.75","520.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","411.39","59.3","","439.50","225.34","1872.27","197","346.88","544.25","percent of total billed charges",""
"BONE POST 3MM PIN EXTERNAL FIXATION EASYCLIP REARFOOT","SUP-ITM-10051899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","693.75","520.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","544.25","78.45","","385.32","55.36","1815.62","58","346.88","544.25","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.74","777.55","AETNA [1001]","HB CH AETNA HMO / PPO","604.42","58.3","","1830.28","315.58","1830.28","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.74","777.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","756.82","73","","4170.85","4170.85","4170.85","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.74","777.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","460.83","44.45","","649.55","649.55","649.55","1 through 10","460.83","1036.74","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","both","","","1036.74","777.55","WELLPOINT [1015]","HB CH WELLPOINT","807.72","77.91","","8998.38","2542.37","8998.38","20","460.83","1036.74","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.74","777.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","614.79","59.3","","1891.61","1609.14","3664.18","25","518.37","813.32","percent of total billed charges",""
"BONE RING 0.75X140MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1036.74","777.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","813.32","78.45","","1470.68","1310.06","2481.69","19","518.37","813.32","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.91","816.68","AETNA [1001]","HB CH AETNA HMO / PPO","634.83","58.3","","1830.28","315.58","1830.28","1 through 10","484.02","1088.91","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.91","816.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","794.90","73","","4170.85","4170.85","4170.85","1 through 10","484.02","1088.91","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.91","816.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","484.02","44.45","","649.55","649.55","649.55","1 through 10","484.02","1088.91","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","both","","","1088.91","816.68","WELLPOINT [1015]","HB CH WELLPOINT","848.37","77.91","","8998.38","2542.37","8998.38","20","484.02","1088.91","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1088.91","816.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","645.72","59.3","","1891.61","1609.14","3664.18","25","544.46","854.25","percent of total billed charges",""
"BONE RING 0.75X165MM EXTERNAL FIXATION HYBRID CARBON","SUP-ITM-10004043","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1088.91","816.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","854.25","78.45","","1470.68","1310.06","2481.69","19","544.46","854.25","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","AETNA [1001]","HB CH AETNA HMO / PPO","2155.64","58.3","","554.95","91.85","1421.75","94","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2699.18","73","","2490.03","2490.03","2490.03","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2155.64","58.3","","750.00","750.00","750.00","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1959.68","53","","1192.50","120.84","4149.90","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3142.88","85","","750.00","75.00","750.00","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3697.50","100","","657.00","121.50","1971.00","14","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3697.50","100","","75.00","75.00","75.00","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3697.50","100","","366.00","144.00","1971.00","45","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2699.18","73","","667.50","667.50","667.50","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1643.54","44.45","","123.77","123.77","123.77","1 through 10","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","both","","","3697.50","2773.12","WELLPOINT [1015]","HB CH WELLPOINT","2880.72","77.91","","483.51","229.32","1316.08","96","1643.54","3697.5","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3697.50","2773.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2192.62","59.3","","439.50","225.34","1872.27","197","1848.75","2900.69","percent of total billed charges",""
"BONE ROD 5MMX24.5CM PROSTHESIS TENDON HUNTER POLYESTER REINFORCED SYNTHETIC PASSIVE TEMPORARY HAND","SUP-ITM-10072467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3697.50","2773.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2900.69","78.45","","385.32","55.36","1815.62","58","1848.75","2900.69","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","AETNA [1001]","HB CH AETNA HMO / PPO","210.96","58.3","","554.95","91.85","1421.75","94","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","264.16","73","","2490.03","2490.03","2490.03","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","210.96","58.3","","750.00","750.00","750.00","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","191.79","53","","1192.50","120.84","4149.90","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","307.58","85","","750.00","75.00","750.00","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","361.86","100","","657.00","121.50","1971.00","14","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","361.86","100","","75.00","75.00","75.00","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","361.86","100","","366.00","144.00","1971.00","45","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","264.16","73","","667.50","667.50","667.50","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.85","44.45","","123.77","123.77","123.77","1 through 10","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","both","","","361.86","271.39","WELLPOINT [1015]","HB CH WELLPOINT","281.93","77.91","","483.51","229.32","1316.08","96","160.85","361.86","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","361.86","271.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.58","59.3","","439.50","225.34","1872.27","197","180.93","283.88","percent of total billed charges",""
"BONE SCREW 20MM 4X80 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10019470","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","361.86","271.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.88","78.45","","385.32","55.36","1815.62","58","180.93","283.88","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","AETNA [1001]","HB CH AETNA HMO / PPO","205.40","58.3","","554.95","91.85","1421.75","94","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","257.19","73","","2490.03","2490.03","2490.03","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","205.40","58.3","","750.00","750.00","750.00","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.73","53","","1192.50","120.84","4149.90","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","299.47","85","","750.00","75.00","750.00","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","352.32","100","","657.00","121.50","1971.00","14","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","352.32","100","","75.00","75.00","75.00","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","352.32","100","","366.00","144.00","1971.00","45","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","257.19","73","","667.50","667.50","667.50","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.61","44.45","","123.77","123.77","123.77","1 through 10","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","both","","","352.32","264.24","WELLPOINT [1015]","HB CH WELLPOINT","274.49","77.91","","483.51","229.32","1316.08","96","156.61","352.32","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","352.32","264.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.93","59.3","","439.50","225.34","1872.27","197","176.16","276.4","percent of total billed charges",""
"BONE SCREW 60MM 175X5 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","352.32","264.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.40","78.45","","385.32","55.36","1815.62","58","176.16","276.4","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","AETNA [1001]","HB CH AETNA HMO / PPO","219.39","58.3","","554.95","91.85","1421.75","94","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","274.71","73","","2490.03","2490.03","2490.03","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","219.39","58.3","","750.00","750.00","750.00","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","199.45","53","","1192.50","120.84","4149.90","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","319.87","85","","750.00","75.00","750.00","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","376.32","100","","657.00","121.50","1971.00","14","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","376.32","100","","75.00","75.00","75.00","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","376.32","100","","366.00","144.00","1971.00","45","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","274.71","73","","667.50","667.50","667.50","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.27","44.45","","123.77","123.77","123.77","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","WELLPOINT [1015]","HB CH WELLPOINT","293.19","77.91","","483.51","229.32","1316.08","96","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.16","59.3","","439.50","225.34","1872.27","197","188.16","295.22","percent of total billed charges",""
"BONE SCREW 60MM 6X150 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004345","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.22","78.45","","385.32","55.36","1815.62","58","188.16","295.22","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","AETNA [1001]","HB CH AETNA HMO / PPO","219.39","58.3","","554.95","91.85","1421.75","94","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","274.71","73","","2490.03","2490.03","2490.03","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","219.39","58.3","","750.00","750.00","750.00","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","199.45","53","","1192.50","120.84","4149.90","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","319.87","85","","750.00","75.00","750.00","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","376.32","100","","657.00","121.50","1971.00","14","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","376.32","100","","75.00","75.00","75.00","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","376.32","100","","366.00","144.00","1971.00","45","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","274.71","73","","667.50","667.50","667.50","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.27","44.45","","123.77","123.77","123.77","1 through 10","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","both","","","376.32","282.24","WELLPOINT [1015]","HB CH WELLPOINT","293.19","77.91","","483.51","229.32","1316.08","96","167.27","376.32","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.16","59.3","","439.50","225.34","1872.27","197","188.16","295.22","percent of total billed charges",""
"BONE SCREW 60MM 6X175 FIXATION EXTERNAL SCHANZ STAINLESS SELF DRILLING THREAD","SUP-ITM-10004346","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","376.32","282.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.22","78.45","","385.32","55.36","1815.62","58","188.16","295.22","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","AETNA [1001]","HB CH AETNA HMO / PPO","100.17","58.3","","554.95","91.85","1421.75","94","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","125.42","73","","2490.03","2490.03","2490.03","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.17","58.3","","750.00","750.00","750.00","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.06","53","","1192.50","120.84","4149.90","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","146.04","85","","750.00","75.00","750.00","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","171.81","100","","657.00","121.50","1971.00","14","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","171.81","100","","75.00","75.00","75.00","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","171.81","100","","366.00","144.00","1971.00","45","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","125.42","73","","667.50","667.50","667.50","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.37","44.45","","123.77","123.77","123.77","1 through 10","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","WELLPOINT [1015]","HB CH WELLPOINT","133.86","77.91","","483.51","229.32","1316.08","96","76.37","171.81","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.81","128.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.88","59.3","","439.50","225.34","1872.27","197","85.91","134.78","percent of total billed charges",""
"BONE SCREW 6X1.5MM MATRIXMIDFACE TI SELF DRILLING SILVER","SUP-ITM-10115522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.81","128.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.78","78.45","","385.32","55.36","1815.62","58","85.91","134.78","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","AETNA [1001]","HB CH AETNA HMO / PPO","2355.32","58.3","","554.95","91.85","1421.75","94","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2949.20","73","","2490.03","2490.03","2490.03","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2355.32","58.3","","750.00","750.00","750.00","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2141.20","53","","1192.50","120.84","4149.90","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3434.00","85","","750.00","75.00","750.00","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4040.00","100","","657.00","121.50","1971.00","14","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4040.00","100","","75.00","75.00","75.00","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4040.00","100","","366.00","144.00","1971.00","45","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2949.20","73","","667.50","667.50","667.50","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1795.78","44.45","","123.77","123.77","123.77","1 through 10","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","both","","","4040.00","3030.00","WELLPOINT [1015]","HB CH WELLPOINT","3147.56","77.91","","483.51","229.32","1316.08","96","1795.78","4040","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4040.00","3030.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2395.72","59.3","","439.50","225.34","1872.27","197","2020","3169.38","percent of total billed charges",""
"BONE SUBSTITUTE 5CC ORTHO PRO DENSE","SUP-ITM-10239272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4040.00","3030.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3169.38","78.45","","385.32","55.36","1815.62","58","2020","3169.38","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","554.95","91.85","1421.75","94","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","2490.03","2490.03","2490.03","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","750.00","750.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","1192.50","120.84","4149.90","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3176.88","85","","750.00","75.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3737.50","100","","657.00","121.50","1971.00","14","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3737.50","100","","75.00","75.00","75.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3737.50","100","","366.00","144.00","1971.00","45","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","667.50","667.50","667.50","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","123.77","123.77","123.77","1 through 10","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","483.51","229.32","1316.08","96","1661.32","3737.5","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","439.50","225.34","1872.27","197","1868.75","2932.07","percent of total billed charges",""
"BRACE INTERNAL MINI IMPLANT LOW PROFILE","SUP-ITM-10268618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","385.32","55.36","1815.62","58","1868.75","2932.07","percent of total billed charges",""
"BRACE KNEE ONE SIZE FITS MOST UNIVERSAL 10DEG POST OP UNISEX WRAPAROUND HINGED FLEX EXTEND INCREMENTS STRAP CLOSURE FOAM ADU","SUP-ITM-10079506","CDM","L1832","HCPCS","0274","RC","","","","both","","","312.84","234.63","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","180.51","57.7","","188.64","188.64","375.40","1 through 10","139.06","2695.78","percent of total billed charges",""
"BRACE KNEE ONE SIZE FITS MOST UNIVERSAL 10DEG POST OP UNISEX WRAPAROUND HINGED FLEX EXTEND INCREMENTS STRAP CLOSURE FOAM ADU","SUP-ITM-10079506","CDM","L1832","HCPCS","0274","RC","","","","both","","","312.84","234.63","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","189.27","60.5","","594.09","198.03","594.09","1 through 10","139.06","2695.78","percent of total billed charges",""
"BRACE KNEE ONE SIZE FITS MOST UNIVERSAL 10DEG POST OP UNISEX WRAPAROUND HINGED FLEX EXTEND INCREMENTS STRAP CLOSURE FOAM ADU","SUP-ITM-10079506","CDM","L1832","HCPCS","0274","RC","","","","outpatient","","","312.84","234.63","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","180.51","57.7","","188.64","188.64","375.40","1 through 10","156.42","1893.14","percent of total billed charges",""
"BRACE KNEE ONE SIZE FITS MOST UNIVERSAL 10DEG POST OP UNISEX WRAPAROUND HINGED FLEX EXTEND INCREMENTS STRAP CLOSURE FOAM ADU","SUP-ITM-10079506","CDM","L1832","HCPCS","0274","RC","","","","outpatient","","","312.84","234.63","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","189.27","60.5","","594.09","198.03","594.09","1 through 10","156.42","1893.14","percent of total billed charges",""
"BRACE KNEE ONE SIZE FITS MOST UNIVERSAL 10DEG POST OP UNISEX WRAPAROUND HINGED FLEX EXTEND INCREMENTS STRAP CLOSURE FOAM ADU","SUP-ITM-10079506","CDM","L1832","HCPCS","0274","RC","","","","outpatient","","","312.84","234.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","245.42","78.45","","240.51","240.51","240.51","1 through 10","156.42","1893.14","percent of total billed charges",""
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/McC","584","MS-DRG","","","","","","","","inpatient","","","32105.16","24078.87","ELDER SERVICES [1037]","HB BWF MEDICARE","20049.66","","Case rate ($20,049.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,081.79, add-ons for qualifying new technology services are included. If operating cost exceeds $65,605.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,074.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $18,197.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,742.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,513.39. The transfer capital threshold is the transfer adjustment factor * $1,513.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19018.13","19018.13","19018.13","1 through 10","19648.67","20651.15","other","Inpatient Replacement Plans DRG"
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/McC","585","MS-DRG","","","","","","","","inpatient","","","43021.15","32265.86","MEDICARE [2001]","HB BWF MEDICARE","19799.57","","Case rate ($19,799.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,130.31, add-ons for qualifying new technology services are included. If operating cost exceeds $63,654.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $18,096.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,791.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.80. The transfer capital threshold is the transfer adjustment factor * $1,363.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19989.93","19989.93","19989.93","1 through 10","17739.33","19802.21","other","Inpatient DRG"
"BREAST EXPANDER 350CC 6.6CM 11.7CMX10CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125960","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","AETNA [1001]","HB CH AETNA HMO / PPO","2188.00","58.3","","1830.28","315.58","1830.28","1 through 10","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 350CC 6.6CM 11.7CMX10CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125960","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2739.69","73","","4170.85","4170.85","4170.85","1 through 10","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 350CC 6.6CM 11.7CMX10CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125960","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1668.21","44.45","","649.55","649.55","649.55","1 through 10","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 350CC 6.6CM 11.7CMX10CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125960","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","WELLPOINT [1015]","HB CH WELLPOINT","2923.96","77.91","","8998.38","2542.37","8998.38","20","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 350CC 6.6CM 11.7CMX10CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2225.53","59.3","","1891.61","1609.14","3664.18","25","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 350CC 6.6CM 11.7CMX10CM TISSUE SALINE TEXTURED ROUND 9200 MEDIUM HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2944.23","78.45","","1470.68","1310.06","2481.69","19","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","AETNA [1001]","HB CH AETNA HMO / PPO","2188.00","58.3","","1830.28","315.58","1830.28","1 through 10","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2739.69","73","","4170.85","4170.85","4170.85","1 through 10","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1668.21","44.45","","649.55","649.55","649.55","1 through 10","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","both","","","3753.00","2814.75","WELLPOINT [1015]","HB CH WELLPOINT","2923.96","77.91","","8998.38","2542.37","8998.38","20","1668.21","3753","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2225.53","59.3","","1891.61","1609.14","3664.18","25","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 450CC 7CM 12.7CMX10.8CM TISSUE SALINE TEXTURED ROUND 9200 MED HEIGHT SILTEX SURFACE SUTURE TAB CPX4","SUP-ITM-10125961","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3753.00","2814.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2944.23","78.45","","1470.68","1310.06","2481.69","19","1876.5","2944.23","percent of total billed charges",""
"BREAST EXPANDER 550CC 13.5X11.7CM 7.4 TISSUE MED CONTOUR PROFILE CPX4 8200 CENTERSCOPE SILTEX","SUP-ITM-10133036","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","AETNA [1001]","HB CH AETNA HMO / PPO","2072.57","58.3","","1830.28","315.58","1830.28","1 through 10","1580.2","3555","percent of total billed charges",""
"BREAST EXPANDER 550CC 13.5X11.7CM 7.4 TISSUE MED CONTOUR PROFILE CPX4 8200 CENTERSCOPE SILTEX","SUP-ITM-10133036","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2595.15","73","","4170.85","4170.85","4170.85","1 through 10","1580.2","3555","percent of total billed charges",""
"BREAST EXPANDER 550CC 13.5X11.7CM 7.4 TISSUE MED CONTOUR PROFILE CPX4 8200 CENTERSCOPE SILTEX","SUP-ITM-10133036","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1580.20","44.45","","649.55","649.55","649.55","1 through 10","1580.2","3555","percent of total billed charges",""
"BREAST EXPANDER 550CC 13.5X11.7CM 7.4 TISSUE MED CONTOUR PROFILE CPX4 8200 CENTERSCOPE SILTEX","SUP-ITM-10133036","CDM","C1889","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","WELLPOINT [1015]","HB CH WELLPOINT","2769.70","77.91","","8998.38","2542.37","8998.38","20","1580.2","3555","percent of total billed charges",""
"BREAST EXPANDER 550CC 13.5X11.7CM 7.4 TISSUE MED CONTOUR PROFILE CPX4 8200 CENTERSCOPE SILTEX","SUP-ITM-10133036","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2108.12","59.3","","1891.61","1609.14","3664.18","25","1777.5","2788.9","percent of total billed charges",""
"BREAST EXPANDER 550CC 13.5X11.7CM 7.4 TISSUE MED CONTOUR PROFILE CPX4 8200 CENTERSCOPE SILTEX","SUP-ITM-10133036","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","1470.68","1310.06","2481.69","19","1777.5","2788.9","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1179.00","884.25","AETNA [1001]","HB CH AETNA HMO / PPO","687.36","58.3","","1770.74","1285.96","2571.91","24","524.07","1179","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","both","","","1179.00","884.25","WELLPOINT [1015]","HB CH WELLPOINT","918.56","77.91","","2459.68","1786.28","4054.28","11","524.07","1179","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1179.00","884.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","699.15","59.3","","4926.10","1830.08","18282.10","21","589.5","924.93","percent of total billed charges",""
"BREAST IMPLANT 170 TO 200CC 9.0X4.0CM SALINE SMOOTH ROUND HIGH NOMINAL FILL","SUP-ITM-10017543","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1179.00","884.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","924.93","78.45","","1743.64","1033.30","4801.93","1 through 10","589.5","924.93","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3123.00","2342.25","AETNA [1001]","HB CH AETNA HMO / PPO","1820.71","58.3","","1770.74","1285.96","2571.91","24","1388.17","3123","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","both","","","3123.00","2342.25","WELLPOINT [1015]","HB CH WELLPOINT","2433.13","77.91","","2459.68","1786.28","4054.28","11","1388.17","3123","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3123.00","2342.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1851.94","59.3","","4926.10","1830.08","18282.10","21","1561.5","2449.99","percent of total billed charges",""
"BREAST IMPLANT 195CC SOFTTOUCH SILICONE SMOOTH ROUND MODERATE NATRELLE INSPIRA","SUP-ITM-10191871","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3123.00","2342.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2449.99","78.45","","1743.64","1033.30","4801.93","1 through 10","1561.5","2449.99","percent of total billed charges",""
"BREAST IMPLANT 200CC 9.7X4.0CM GEL SMOOTH ROUND HIGH MEMORYGEL","SUP-ITM-10016931","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","AETNA [1001]","HB CH AETNA HMO / PPO","1353.73","58.3","","1770.74","1285.96","2571.91","24","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 200CC 9.7X4.0CM GEL SMOOTH ROUND HIGH MEMORYGEL","SUP-ITM-10016931","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","WELLPOINT [1015]","HB CH WELLPOINT","1809.07","77.91","","2459.68","1786.28","4054.28","11","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 200CC 9.7X4.0CM GEL SMOOTH ROUND HIGH MEMORYGEL","SUP-ITM-10016931","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1376.95","59.3","","4926.10","1830.08","18282.10","21","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 200CC 9.7X4.0CM GEL SMOOTH ROUND HIGH MEMORYGEL","SUP-ITM-10016931","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1821.61","78.45","","1743.64","1033.30","4801.93","1 through 10","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 205CC GEL SMOOTH ROUND HIGH","SUP-ITM-10139977","CDM","C1789","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","1770.74","1285.96","2571.91","24","866.78","1950","percent of total billed charges",""
"BREAST IMPLANT 205CC GEL SMOOTH ROUND HIGH","SUP-ITM-10139977","CDM","C1789","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","2459.68","1786.28","4054.28","11","866.78","1950","percent of total billed charges",""
"BREAST IMPLANT 205CC GEL SMOOTH ROUND HIGH","SUP-ITM-10139977","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","4926.10","1830.08","18282.10","21","975","1529.78","percent of total billed charges",""
"BREAST IMPLANT 205CC GEL SMOOTH ROUND HIGH","SUP-ITM-10139977","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","1743.64","1033.30","4801.93","1 through 10","975","1529.78","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","1770.74","1285.96","2571.91","24","380.05","855","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","2459.68","1786.28","4054.28","11","380.05","855","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","4926.10","1830.08","18282.10","21","427.5","670.75","percent of total billed charges",""
"BREAST IMPLANT 240CC SALINE SMOOTH ROUND MODERATE STYLE 68 NATRELLE","SUP-ITM-10241108","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","1743.64","1033.30","4801.93","1 through 10","427.5","670.75","percent of total billed charges",""
"BREAST IMPLANT 270CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114482","CDM","C1789","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","1770.74","1285.96","2571.91","24","866.78","1950","percent of total billed charges",""
"BREAST IMPLANT 270CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114482","CDM","C1789","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","2459.68","1786.28","4054.28","11","866.78","1950","percent of total billed charges",""
"BREAST IMPLANT 270CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114482","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","4926.10","1830.08","18282.10","21","975","1529.78","percent of total billed charges",""
"BREAST IMPLANT 270CC GEL SMOOTH ROUND MODERATE","SUP-ITM-10114482","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","1743.64","1033.30","4801.93","1 through 10","975","1529.78","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","AETNA [1001]","HB CH AETNA HMO / PPO","1322.24","58.3","","1770.74","1285.96","2571.91","24","1008.13","2268","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","WELLPOINT [1015]","HB CH WELLPOINT","1767.00","77.91","","2459.68","1786.28","4054.28","11","1008.13","2268","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1344.92","59.3","","4926.10","1830.08","18282.10","21","1134","1779.25","percent of total billed charges",""
"BREAST IMPLANT 300CC RESPONSIVE SILICONE SMOOTH ROUND LOW PLUS NATRELLE INSPIRA","SUP-ITM-10157882","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1779.25","78.45","","1743.64","1033.30","4801.93","1 through 10","1134","1779.25","percent of total billed charges",""
"BREAST IMPLANT 305CC TALL HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10157828","CDM","C1789","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","AETNA [1001]","HB CH AETNA HMO / PPO","1909.33","58.3","","1770.74","1285.96","2571.91","24","1455.74","3275","percent of total billed charges",""
"BREAST IMPLANT 305CC TALL HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10157828","CDM","C1789","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","WELLPOINT [1015]","HB CH WELLPOINT","2551.55","77.91","","2459.68","1786.28","4054.28","11","1455.74","3275","percent of total billed charges",""
"BREAST IMPLANT 305CC TALL HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10157828","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1942.08","59.3","","4926.10","1830.08","18282.10","21","1637.5","2569.24","percent of total billed charges",""
"BREAST IMPLANT 305CC TALL HEIGHT MODERATE PLUS PROFILE MEMORYSHAPE","SUP-ITM-10157828","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2569.24","78.45","","1743.64","1033.30","4801.93","1 through 10","1637.5","2569.24","percent of total billed charges",""
"BREAST IMPLANT 350CC XTRA MODERATE PLUS PROFILE EXTRA SMOOTH ROUND","SUP-ITM-10233381","CDM","C1789","HCPCS","0278","RC","","","","both","","","2859.00","2144.25","AETNA [1001]","HB CH AETNA HMO / PPO","1666.80","58.3","","1770.74","1285.96","2571.91","24","1270.83","2859","percent of total billed charges",""
"BREAST IMPLANT 350CC XTRA MODERATE PLUS PROFILE EXTRA SMOOTH ROUND","SUP-ITM-10233381","CDM","C1789","HCPCS","0278","RC","","","","both","","","2859.00","2144.25","WELLPOINT [1015]","HB CH WELLPOINT","2227.45","77.91","","2459.68","1786.28","4054.28","11","1270.83","2859","percent of total billed charges",""
"BREAST IMPLANT 350CC XTRA MODERATE PLUS PROFILE EXTRA SMOOTH ROUND","SUP-ITM-10233381","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2859.00","2144.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1695.39","59.3","","4926.10","1830.08","18282.10","21","1429.5","2242.89","percent of total billed charges",""
"BREAST IMPLANT 350CC XTRA MODERATE PLUS PROFILE EXTRA SMOOTH ROUND","SUP-ITM-10233381","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2859.00","2144.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2242.89","78.45","","1743.64","1033.30","4801.93","1 through 10","1429.5","2242.89","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","both","","","3123.00","2342.25","AETNA [1001]","HB CH AETNA HMO / PPO","1820.71","58.3","","1770.74","1285.96","2571.91","24","1388.17","3123","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","both","","","3123.00","2342.25","WELLPOINT [1015]","HB CH WELLPOINT","2433.13","77.91","","2459.68","1786.28","4054.28","11","1388.17","3123","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3123.00","2342.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1851.94","59.3","","4926.10","1830.08","18282.10","21","1561.5","2449.99","percent of total billed charges",""
"BREAST IMPLANT 375CC HIGHLY COHESIVE SILICONE SMOOTH ROUND EXTRA FULL NATRELLE INSPIRA","SUP-ITM-10171788","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3123.00","2342.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2449.99","78.45","","1743.64","1033.30","4801.93","1 through 10","1561.5","2449.99","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","1770.74","1285.96","2571.91","24","380.05","855","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","2459.68","1786.28","4054.28","11","380.05","855","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","4926.10","1830.08","18282.10","21","427.5","670.75","percent of total billed charges",""
"BREAST IMPLANT 425-455CC SALINE SMOOTH ROUND HIGH ANTERIOR VALVE STYLE 68HP NATRELLE","SUP-ITM-10023007","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","1743.64","1033.30","4801.93","1 through 10","427.5","670.75","percent of total billed charges",""
"BREAST IMPLANT 455CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216971","CDM","C1789","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1770.74","1285.96","2571.91","24","1200.15","2700","percent of total billed charges",""
"BREAST IMPLANT 455CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216971","CDM","C1789","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2459.68","1786.28","4054.28","11","1200.15","2700","percent of total billed charges",""
"BREAST IMPLANT 455CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216971","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","4926.10","1830.08","18282.10","21","1350","2118.15","percent of total billed charges",""
"BREAST IMPLANT 455CC GEL SMOOTH ROUND MODERATE PLUS HSC PLUS","SUP-ITM-10216971","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","1743.64","1033.30","4801.93","1 through 10","1350","2118.15","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","AETNA [1001]","HB CH AETNA HMO / PPO","1353.73","58.3","","1770.74","1285.96","2571.91","24","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","WELLPOINT [1015]","HB CH WELLPOINT","1809.07","77.91","","2459.68","1786.28","4054.28","11","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1376.95","59.3","","4926.10","1830.08","18282.10","21","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 575CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL","SUP-ITM-10093822","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1821.61","78.45","","1743.64","1033.30","4801.93","1 through 10","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","AETNA [1001]","HB CH AETNA HMO / PPO","1189.32","58.3","","1770.74","1285.96","2571.91","24","906.78","2040","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","WELLPOINT [1015]","HB CH WELLPOINT","1589.36","77.91","","2459.68","1786.28","4054.28","11","906.78","2040","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1209.72","59.3","","4926.10","1830.08","18282.10","21","1020","1600.38","percent of total billed charges",""
"BREAST IMPLANT 600CC SILICONE SMOOTH ROUND EXTRA HIGH STYLE 45 NATRELLE","SUP-ITM-10019994","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1600.38","78.45","","1743.64","1033.30","4801.93","1 through 10","1020","1600.38","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","AETNA [1001]","HB CH AETNA HMO / PPO","1322.24","58.3","","1770.74","1285.96","2571.91","24","1008.13","2268","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","both","","","2268.00","1701.00","WELLPOINT [1015]","HB CH WELLPOINT","1767.00","77.91","","2459.68","1786.28","4054.28","11","1008.13","2268","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1344.92","59.3","","4926.10","1830.08","18282.10","21","1134","1779.25","percent of total billed charges",""
"BREAST IMPLANT 650CC RESPONSIVE SILICONE SMOOTH ROUND FULL NATRELLE INSPIRA","SUP-ITM-10157912","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2268.00","1701.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1779.25","78.45","","1743.64","1033.30","4801.93","1 through 10","1134","1779.25","percent of total billed charges",""
"BREAST IMPLANT 700CC 14.7X6.0CM GEL TEXTURED ROUND HIGH MEMORYGEL SILTEX COHESIVE I","SUP-ITM-10073156","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","AETNA [1001]","HB CH AETNA HMO / PPO","1353.73","58.3","","1770.74","1285.96","2571.91","24","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 700CC 14.7X6.0CM GEL TEXTURED ROUND HIGH MEMORYGEL SILTEX COHESIVE I","SUP-ITM-10073156","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","WELLPOINT [1015]","HB CH WELLPOINT","1809.07","77.91","","2459.68","1786.28","4054.28","11","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 700CC 14.7X6.0CM GEL TEXTURED ROUND HIGH MEMORYGEL SILTEX COHESIVE I","SUP-ITM-10073156","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1376.95","59.3","","4926.10","1830.08","18282.10","21","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 700CC 14.7X6.0CM GEL TEXTURED ROUND HIGH MEMORYGEL SILTEX COHESIVE I","SUP-ITM-10073156","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1821.61","78.45","","1743.64","1033.30","4801.93","1 through 10","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","AETNA [1001]","HB CH AETNA HMO / PPO","1353.73","58.3","","1770.74","1285.96","2571.91","24","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","both","","","2322.00","1741.50","WELLPOINT [1015]","HB CH WELLPOINT","1809.07","77.91","","2459.68","1786.28","4054.28","11","1032.13","2322","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1376.95","59.3","","4926.10","1830.08","18282.10","21","1161","1821.61","percent of total billed charges",""
"BREAST IMPLANT 750CC SILICONE SMOOTH ROUND COHESIVE SILICONE SHELL OD16.1CM P5CM","SUP-ITM-10075314","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2322.00","1741.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1821.61","78.45","","1743.64","1033.30","4801.93","1 through 10","1161","1821.61","percent of total billed charges",""
"Breast Procedures Except Mastectomy,MINOR","363","DRG","","","","","","","","inpatient","","","31257.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26976.55","","Standard inlier is a Case rate ($26,976.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,410, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,829.21) for the length of stay and the standard reimbursement.","25750.34","25750.34","25750.34","1 through 10","11151.78","63025.16","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","52388.19","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","46225.48","","Standard inlier is a Case rate ($46,225.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,410, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,561.89) for the length of stay and the standard reimbursement.","44124.92","44124.92","44124.92","1 through 10","11151.78","63025.16","case rate",""
"Breast Procedures Except Mastectomy,MODERATE","363","DRG","","","","","","","","inpatient","","","52388.19","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16655.6466","","Fee schedule rate ($27,192.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16655.6466","27192.70","27192.70","1 through 10","11151.78","63025.16","case rate",""
"Brnchsc Ebus Guided Sampl 3/> Node Station/Strux","PX-76002180","CDM","31653","CPT","0750","RC","","","","outpatient","","","1315.00","986.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3134.10","","Case rate ($3,134.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4525.64","4525.64","4525.64","1 through 10","657.5","12722.53","other","ASC "
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","44638.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15802.37","","Standard inlier is a Case rate ($15,802.37). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,859, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,243.21) for the length of stay and the standard reimbursement.","15084.28","15084.28","15084.28","1 through 10","5173.25","41243.3","case rate",""
"Bronchiolitis And Rsv Pneumonia,MAJOR","138","DRG","","","","","","","","inpatient","","","44638.60","","FALLON HEALTH [1008]","HB BWF MEDICAID","6763.95","","Case rate ($7,478.71). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,908.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","448.61","448.61","448.61","1 through 10","5173.25","41243.3","case rate",""
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","24815.42","18611.56","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9095.90","","Case rate ($9,281.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,296.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,819.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,247.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,255.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,956.87 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.60. The transfer capital threshold is the transfer adjustment factor * $686.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8875.51","8875.51","15760.00","1 through 10","9095.9","9559.98","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","24815.42","18611.56","MEDICARE [2001]","HB BWF MEDICARE","9281.53","","Case rate ($9,281.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,296.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,819.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,247.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,255.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,956.87 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.60. The transfer capital threshold is the transfer adjustment factor * $686.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9798.70","0.03","9863.51","28","9095.9","9559.98","other","Inpatient Replacement Plans DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","24815.42","18611.56","MOLINA [1014]","HB BWF MEDICARE","9281.53","","Case rate ($9,281.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,296.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,819.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,247.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,255.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,956.87 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.60. The transfer capital threshold is the transfer adjustment factor * $686.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17946.23","17946.23","17946.23","1 through 10","9095.9","9559.98","other","Inpatient Replacement Plans DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","24815.42","18611.56","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9095.90","","Case rate ($9,281.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,296.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,819.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,247.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,255.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,956.87 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.60. The transfer capital threshold is the transfer adjustment factor * $686.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8875.52","8875.52","8875.52","1 through 10","9095.9","9559.98","other","Inpatient DRG"
"Bronchitis And Asthma With Cc/McC","202","MS-DRG","","","","","","","","inpatient","","","24815.42","18611.56","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9095.90","","Case rate ($9,281.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,296.11, add-ons for qualifying new technology services are included. If operating cost exceeds $54,819.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,247.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,255.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,956.87 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $686.60. The transfer capital threshold is the transfer adjustment factor * $686.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8898.96","8898.96","10512.97","1 through 10","9095.9","9559.98","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","21835.89","16376.92","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6378.08","","Case rate ($6,508.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,518.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,042.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,034.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,695.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,179.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.66. The transfer capital threshold is the transfer adjustment factor * $473.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6473.82","6473.82","6473.82","1 through 10","6378.08","6877.55","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","21835.89","16376.92","MEDICARE [2001]","HB BWF MEDICARE","6508.24","","Case rate ($6,508.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,518.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,042.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,034.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,695.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,179.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.66. The transfer capital threshold is the transfer adjustment factor * $473.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7131.07","7131.07","7177.80","1 through 10","6378.08","6877.55","other","Inpatient Replacement Plans DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","21835.89","16376.92","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6378.08","","Case rate ($6,508.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,518.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,042.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,034.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,695.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,179.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.66. The transfer capital threshold is the transfer adjustment factor * $473.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6473.82","6473.82","6473.82","1 through 10","6378.08","6877.55","other","Inpatient DRG"
"Bronchitis And Asthma Without Cc/McC","203","MS-DRG","","","","","","","","inpatient","","","21835.89","16376.92","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6378.08","","Case rate ($6,508.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,518.30, add-ons for qualifying new technology services are included. If operating cost exceeds $52,042.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,034.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,695.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,179.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $473.66. The transfer capital threshold is the transfer adjustment factor * $473.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6473.61","6473.61","6473.61","1 through 10","6378.08","6877.55","other","Inpatient DRG"
"Bronchoscopy W/Bx Sgl/Multi Sites","PX-76000786","CDM","31625","CPT","0761","RC","","","","outpatient","","","2917.00","2187.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1130.55","1130.55","1130.55","1 through 10","1232.36","4472.66","other","ASC "
"Bronchoscopy W/Lav Bronch Alveolar","PX-76000785","CDM","31624","CPT","0761","RC","","","","outpatient","","","2822.00","2116.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1565.86","","Case rate ($1,565.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1130.55","1130.55","1130.55","1 through 10","1210.64","2213.86","other","ASC "
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","both","","","919.42","689.56","AETNA [1001]","HB CH AETNA HMO / PPO","536.02","58.3","","1786.05","1786.05","1786.05","1 through 10","487.29","778.64","percent of total billed charges",""
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","both","","","919.42","689.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","536.02","58.3","","3150.00","3150.00","3150.00","1 through 10","487.29","778.64","percent of total billed charges",""
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","both","","","919.42","689.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","487.29","53","","1669.50","1669.50","1669.50","1 through 10","487.29","778.64","percent of total billed charges",""
"Bulk Agent Synthetic 1ml T1","PX-27000562","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","919.42","689.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","545.22","59.3","","1845.90","1845.90","1845.90","1 through 10","408.68","721.28","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","AETNA [1001]","HB CH AETNA HMO / PPO","456.49","58.3","","1634.24","1004.95","1718.99","42","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","571.59","73","","2123.89","1900.92","2123.89","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","456.49","58.3","","3729.00","1254.19","3729.00","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","414.99","53","","939.37","939.37","5593.65","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","665.55","85","","2323.25","1864.50","2882.25","16","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","783.00","100","","2909.44","1772.40","10952.08","45","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","783.00","100","","2323.25","2323.25","2323.25","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","783.00","100","","2882.25","1772.40","10169.17","187","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","571.59","73","","1659.41","1659.41","1659.41","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","WELLPOINT [1015]","HB CH WELLPOINT","610.04","77.91","","2050.91","1468.48","2902.83","52","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","464.32","59.3","","1548.60","1092.60","3613.79","82","391.5","614.26","percent of total billed charges",""
"BUSHING FEMORAL SMALL IMPLANT HIP GMRS DISTAL GLOBAL ONC 16B CS/1BX/1EA","SUP-ITM-10013903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","614.26","78.45","","2085.51","998.68","6202.11","56","391.5","614.26","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","AETNA [1001]","HB CH AETNA HMO / PPO","456.49","58.3","","1634.24","1004.95","1718.99","42","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","571.59","73","","2123.89","1900.92","2123.89","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","456.49","58.3","","3729.00","1254.19","3729.00","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","414.99","53","","939.37","939.37","5593.65","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","665.55","85","","2323.25","1864.50","2882.25","16","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","783.00","100","","2909.44","1772.40","10952.08","45","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","783.00","100","","2323.25","2323.25","2323.25","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","783.00","100","","2882.25","1772.40","10169.17","187","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","571.59","73","","1659.41","1659.41","1659.41","1 through 10","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","both","","","783.00","587.25","WELLPOINT [1015]","HB CH WELLPOINT","610.04","77.91","","2050.91","1468.48","2902.83","52","348.04","783","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","464.32","59.3","","1548.60","1092.60","3613.79","82","391.5","614.26","percent of total billed charges",""
"BUSHING FEMORAL UNIVERSAL ROTATING HINGE DISTAL","SUP-ITM-10006903","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","783.00","587.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","614.26","78.45","","2085.51","998.68","6202.11","56","391.5","614.26","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","AETNA [1001]","HB CH AETNA HMO / PPO","3789.50","58.3","","1634.24","1004.95","1718.99","42","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4745.00","73","","2123.89","1900.92","2123.89","1 through 10","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3789.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3445.00","53","","939.37","939.37","5593.65","1 through 10","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5525.00","85","","2323.25","1864.50","2882.25","16","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6500.00","100","","2909.44","1772.40","10952.08","45","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6500.00","100","","2323.25","2323.25","2323.25","1 through 10","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6500.00","100","","2882.25","1772.40","10169.17","187","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4745.00","73","","1659.41","1659.41","1659.41","1 through 10","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","WELLPOINT [1015]","HB CH WELLPOINT","5064.15","77.91","","2050.91","1468.48","2902.83","52","2889.25","6500","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3854.50","59.3","","1548.60","1092.60","3613.79","82","3250","5099.25","percent of total billed charges",""
"BUTTON ARTICULAR 40X9 10MM COMPONENT HUMERAL HEAD HEMICAP SHOULDER","SUP-ITM-10041867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5099.25","78.45","","2085.51","998.68","6202.11","56","3250","5099.25","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","AETNA [1001]","HB CH AETNA HMO / PPO","247.78","58.3","","554.95","91.85","1421.75","94","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.26","73","","2490.03","2490.03","2490.03","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","247.78","58.3","","750.00","750.00","750.00","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","225.26","53","","1192.50","120.84","4149.90","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","361.26","85","","750.00","75.00","750.00","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","425.01","100","","657.00","121.50","1971.00","14","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","425.01","100","","75.00","75.00","75.00","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","425.01","100","","366.00","144.00","1971.00","45","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.26","73","","667.50","667.50","667.50","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.92","44.45","","123.77","123.77","123.77","1 through 10","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","both","","","425.01","318.76","WELLPOINT [1015]","HB CH WELLPOINT","331.13","77.91","","483.51","229.32","1316.08","96","188.92","425.01","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","425.01","318.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.03","59.3","","439.50","225.34","1872.27","197","212.51","333.42","percent of total billed charges",""
"BUTTON BIT 40X12MM DRILL BONE ACUFEX SS CANNULATED","SUP-ITM-10005015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","425.01","318.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","333.42","78.45","","385.32","55.36","1815.62","58","212.51","333.42","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","AETNA [1001]","HB CH AETNA HMO / PPO","233.61","58.3","","554.95","91.85","1421.75","94","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","2490.03","2490.03","2490.03","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","233.61","58.3","","750.00","750.00","750.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","212.38","53","","1192.50","120.84","4149.90","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","340.60","85","","750.00","75.00","750.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","400.71","100","","657.00","121.50","1971.00","14","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","400.71","100","","75.00","75.00","75.00","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","400.71","100","","366.00","144.00","1971.00","45","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","292.52","73","","667.50","667.50","667.50","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.12","44.45","","123.77","123.77","123.77","1 through 10","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","both","","","400.71","300.53","WELLPOINT [1015]","HB CH WELLPOINT","312.19","77.91","","483.51","229.32","1316.08","96","178.12","400.71","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.62","59.3","","439.50","225.34","1872.27","197","200.36","314.36","percent of total billed charges",""
"BUTTON CERCLAGE 3.5MM SS HEX T25 STARDRIVE","SUP-ITM-10012045","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","400.71","300.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.36","78.45","","385.32","55.36","1815.62","58","200.36","314.36","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","AETNA [1001]","HB CH AETNA HMO / PPO","865.76","58.3","","554.95","91.85","1421.75","94","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1084.05","73","","2490.03","2490.03","2490.03","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","865.76","58.3","","750.00","750.00","750.00","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","787.05","53","","1192.50","120.84","4149.90","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1262.25","85","","750.00","75.00","750.00","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1485.00","100","","657.00","121.50","1971.00","14","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1485.00","100","","75.00","75.00","75.00","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1485.00","100","","366.00","144.00","1971.00","45","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1084.05","73","","667.50","667.50","667.50","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.08","44.45","","123.77","123.77","123.77","1 through 10","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","both","","","1485.00","1113.75","WELLPOINT [1015]","HB CH WELLPOINT","1156.96","77.91","","483.51","229.32","1316.08","96","660.08","1485","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","880.61","59.3","","439.50","225.34","1872.27","197","742.5","1164.98","percent of total billed charges",""
"BUTTON FIBERTAK","SUP-ITM-10280231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1485.00","1113.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1164.98","78.45","","385.32","55.36","1815.62","58","742.5","1164.98","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","AETNA [1001]","HB CH AETNA HMO / PPO","250.11","58.3","","554.95","91.85","1421.75","94","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","313.17","73","","2490.03","2490.03","2490.03","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","250.11","58.3","","750.00","750.00","750.00","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","227.37","53","","1192.50","120.84","4149.90","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","364.65","85","","750.00","75.00","750.00","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","429.00","100","","657.00","121.50","1971.00","14","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","429.00","100","","75.00","75.00","75.00","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","429.00","100","","366.00","144.00","1971.00","45","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","313.17","73","","667.50","667.50","667.50","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","190.69","44.45","","123.77","123.77","123.77","1 through 10","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","both","","","429.00","321.75","WELLPOINT [1015]","HB CH WELLPOINT","334.23","77.91","","483.51","229.32","1316.08","96","190.69","429","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","254.40","59.3","","439.50","225.34","1872.27","197","214.5","336.55","percent of total billed charges",""
"BUTTON FIXATION 8.0X12MM TIGHTROPE ABS IMPLANTABLE ACL RECONSTRUCTION","SUP-ITM-10117082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","429.00","321.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","336.55","78.45","","385.32","55.36","1815.62","58","214.5","336.55","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","AETNA [1001]","HB CH AETNA HMO / PPO","760.82","58.3","","554.95","91.85","1421.75","94","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","952.65","73","","2490.03","2490.03","2490.03","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","760.82","58.3","","750.00","750.00","750.00","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","691.65","53","","1192.50","120.84","4149.90","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1109.25","85","","750.00","75.00","750.00","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1305.00","100","","657.00","121.50","1971.00","14","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1305.00","100","","75.00","75.00","75.00","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1305.00","100","","366.00","144.00","1971.00","45","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","952.65","73","","667.50","667.50","667.50","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","580.07","44.45","","123.77","123.77","123.77","1 through 10","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","both","","","1305.00","978.75","WELLPOINT [1015]","HB CH WELLPOINT","1016.73","77.91","","483.51","229.32","1316.08","96","580.07","1305","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","773.87","59.3","","439.50","225.34","1872.27","197","652.5","1023.77","percent of total billed charges",""
"BUTTON SUTURE 2.6X10.9MM LG TRACTION FIXATION PEC","SUP-ITM-10124399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1023.77","78.45","","385.32","55.36","1815.62","58","652.5","1023.77","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","AETNA [1001]","HB CH AETNA HMO / PPO","391.78","58.3","","554.95","91.85","1421.75","94","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","2490.03","2490.03","2490.03","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","391.78","58.3","","750.00","750.00","750.00","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","356.16","53","","1192.50","120.84","4149.90","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","571.20","85","","750.00","75.00","750.00","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","672.00","100","","657.00","121.50","1971.00","14","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","672.00","100","","75.00","75.00","75.00","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","672.00","100","","366.00","144.00","1971.00","45","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","490.56","73","","667.50","667.50","667.50","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","298.70","44.45","","123.77","123.77","123.77","1 through 10","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","both","","","672.00","504.00","WELLPOINT [1015]","HB CH WELLPOINT","523.56","77.91","","483.51","229.32","1316.08","96","298.7","672","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","398.50","59.3","","439.50","225.34","1872.27","197","336","527.18","percent of total billed charges",""
"BUTTON TRACTION 14MM FIXATION TIGHTROPE ABS CONCAVE","SUP-ITM-10210667","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","672.00","504.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","527.18","78.45","","385.32","55.36","1815.62","58","336","527.18","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","554.95","91.85","1421.75","94","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","2490.03","2490.03","2490.03","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","750.00","750.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","1192.50","120.84","4149.90","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","752.25","85","","750.00","75.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","885.00","100","","657.00","121.50","1971.00","14","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","885.00","100","","75.00","75.00","75.00","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","885.00","100","","366.00","144.00","1971.00","45","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","667.50","667.50","667.50","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","123.77","123.77","123.77","1 through 10","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","483.51","229.32","1316.08","96","393.38","885","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","439.50","225.34","1872.27","197","442.5","694.28","percent of total billed charges",""
"BUTTON TRACTION 2.6X12MM FIXATION BICEPS TITANIUM","SUP-ITM-10026969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","385.32","55.36","1815.62","58","442.5","694.28","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","AETNA [1001]","HB CH AETNA HMO / PPO","610.40","58.3","","554.95","91.85","1421.75","94","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","2490.03","2490.03","2490.03","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","610.40","58.3","","750.00","750.00","750.00","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","554.91","53","","1192.50","120.84","4149.90","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","889.95","85","","750.00","75.00","750.00","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1047.00","100","","657.00","121.50","1971.00","14","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1047.00","100","","75.00","75.00","75.00","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1047.00","100","","366.00","144.00","1971.00","45","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","764.31","73","","667.50","667.50","667.50","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","465.39","44.45","","123.77","123.77","123.77","1 through 10","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","both","","","1047.00","785.25","WELLPOINT [1015]","HB CH WELLPOINT","815.72","77.91","","483.51","229.32","1316.08","96","465.39","1047","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","620.87","59.3","","439.50","225.34","1872.27","197","523.5","821.37","percent of total billed charges",""
"BUTTON TRACTION 5.5X14MM FIXATION TIGHTROPE POSTERIOR CRUCIATE LIGAMENT","SUP-ITM-10094937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1047.00","785.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","821.37","78.45","","385.32","55.36","1815.62","58","523.5","821.37","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","554.95","91.85","1421.75","94","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","2490.03","2490.03","2490.03","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","750.00","750.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","1192.50","120.84","4149.90","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","892.50","85","","750.00","75.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1050.00","100","","657.00","121.50","1971.00","14","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1050.00","100","","75.00","75.00","75.00","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1050.00","100","","366.00","144.00","1971.00","45","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","667.50","667.50","667.50","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","123.77","123.77","123.77","1 through 10","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","483.51","229.32","1316.08","96","466.73","1050","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","439.50","225.34","1872.27","197","525","823.73","percent of total billed charges",""
"BUTTON TRACTION FIXATION TITANIUM DOG BONE","SUP-ITM-10092014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","385.32","55.36","1815.62","58","525","823.73","percent of total billed charges",""
"Bwf Trofile Co-Rec Tropism Assay","PX-30001757","CDM","87999","CPT","0300","RC","","","","both","","","143.00","107.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","90.66","63.4","","84.20","84.20","84.20","1 through 10","61.35","143","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","100.93","100.93","100.93","1 through 10","38.35","174.03","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","96.99","53","","94.34","89.04","94.34","1 through 10","38.35","174.03","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.59","73","","158.42","158.42","158.42","1 through 10","38.35","174.03","percent of total billed charges",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","38.48","32.77","40.64","84","38.35","174.03","fee schedule",""
"Bwh Therapeutic Ambulation 1 on 1 per 15 Min","PX-41000020","CDM","97530","CPT","0410","RC","","","","outpatient","","","183.00","137.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","110.72","60.5","","178.00","178.00","178.00","1 through 10","91.5","254.62","percent of total billed charges",""
"Bwh Transoral Gastric Vol Reduction","PX-75000432","CDM","43999","CPT","0750","RC","","","","both","","","2493.00","1869.75","WELLPOINT [1015]","HB CH WELLPOINT","1942.30","77.91","","2383.28","2383.28","2383.28","1 through 10","1057.74","2370.84","percent of total billed charges",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","2359.00","1769.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2481.72","2481.72","2481.72","1 through 10","1237.95","1981.86","other","Multiple Surgery"
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","2359.00","1769.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1237.95","1981.86","per diem",""
"Bx Breast 1st Lesion Strtctc","PX-76001930","CDM","19081","CPT","0761","RC","","","","both","","","2359.00","1769.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1885.65","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1741.12","3046.25","1 through 10","1237.95","1981.86","other","OPPS APC"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","2359.00","1769.25","ELDER SERVICES [1037]","HB BWF MEDICARE","1924.13","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","1981.86","other","OPPS APC"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","2359.00","1769.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2375.23","2375.23","2375.23","1 through 10","1237.95","1981.86","other","Multiple Surgery"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","both","","","2359.00","1769.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1885.65","","APC Price ($1,924.13). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.35","1893.15","1893.55","1 through 10","1237.95","1981.86","other","OPPS APC"
"Bx Breast 1st Lesion US Imag","PX-76001932","CDM","19083","CPT","0761","RC","","","","outpatient","","","2359.00","1769.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3060.06","3057.74","3060.06","1 through 10","1048.58","2959.67","other","Multiple Surgery"
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","243.00","182.25","AETNA [1001]","HB CH AETNA HMO / PPO","141.67","58.3","","133.81","133.81","133.81","1 through 10","20.39","177.39","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","both","","","243.00","182.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.01","44.45","","107.52","107.52","107.52","1 through 10","20.39","177.39","percent of total billed charges",""
"C-Peptide","PX-30000740","CDM","84681","CPT","0301","RC","","","","outpatient","","","243.00","182.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.10","59.3","","138.30","138.30","138.30","1 through 10","21.45","190.63","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.45","68","5.08","44.53","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","44.53","73","","43.07","43.07","43.07","1 through 10","5.08","44.53","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.33","53","","31.27","31.27","31.27","1 through 10","5.08","44.53","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","45.36","45.36","45.36","1 through 10","5.08","44.53","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","34.57","52","5.34","47.85","percent of total billed charges",""
"C-Reactive Protein","PX-30000787","CDM","86140","CPT","0302","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","76","5.34","47.85","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","31","12.69","78.11","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","56.71","53","","55.12","55.12","55.12","1 through 10","12.69","78.11","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","both","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.56","44.45","","46.70","46.70","46.70","1 through 10","12.69","78.11","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","182.82","24","13.35","83.94","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","107.00","80.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","76.59","76.59","76.59","1 through 10","13.35","83.94","percent of total billed charges",""
"C-Reactive Protein High Sensitivity","PX-30000788","CDM","86141","CPT","0302","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","79.96","47.38","79.96","32","13.35","83.94","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.82","78.82","78.82","30","11.76","104.39","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.79","53","","147.34","73.67","221.01","1 through 10","11.76","104.39","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.46","81.46","81.46","12","12.38","112.18","percent of total billed charges",""
"C3 Antigen","PX-30003348","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.87","63.33","213.73","17","12.38","112.18","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.82","78.82","78.82","30","11.76","104.39","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.79","53","","147.34","73.67","221.01","1 through 10","11.76","104.39","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.46","81.46","81.46","12","12.38","112.18","percent of total billed charges",""
"C4 Antigen","PX-30003349","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.87","63.33","213.73","17","12.38","112.18","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","AETNA [1001]","HB CH AETNA HMO / PPO","1822.46","58.3","","554.95","91.85","1421.75","94","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2281.98","73","","2490.03","2490.03","2490.03","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1822.46","58.3","","750.00","750.00","750.00","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1656.78","53","","1192.50","120.84","4149.90","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2657.10","85","","750.00","75.00","750.00","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3126.00","100","","657.00","121.50","1971.00","14","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3126.00","100","","75.00","75.00","75.00","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3126.00","100","","366.00","144.00","1971.00","45","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2281.98","73","","667.50","667.50","667.50","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1389.51","44.45","","123.77","123.77","123.77","1 through 10","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","both","","","3126.00","2344.50","WELLPOINT [1015]","HB CH WELLPOINT","2435.47","77.91","","483.51","229.32","1316.08","96","1389.51","3126","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3126.00","2344.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1853.72","59.3","","439.50","225.34","1872.27","197","1563","2452.35","percent of total billed charges",""
"CABLE 2.0X100MM MD PLATE BONE VITALLIUM TROCHANTERIC TITANIUM GRIP 2","SUP-ITM-10075275","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3126.00","2344.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2452.35","78.45","","385.32","55.36","1815.62","58","1563","2452.35","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","AETNA [1001]","HB CH AETNA HMO / PPO","853.51","58.3","","554.95","91.85","1421.75","94","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1068.72","73","","2490.03","2490.03","2490.03","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","853.51","58.3","","750.00","750.00","750.00","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","775.92","53","","1192.50","120.84","4149.90","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1244.40","85","","750.00","75.00","750.00","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1464.00","100","","657.00","121.50","1971.00","14","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1464.00","100","","75.00","75.00","75.00","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1464.00","100","","366.00","144.00","1971.00","45","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1068.72","73","","667.50","667.50","667.50","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","650.75","44.45","","123.77","123.77","123.77","1 through 10","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","both","","","1464.00","1098.00","WELLPOINT [1015]","HB CH WELLPOINT","1140.60","77.91","","483.51","229.32","1316.08","96","650.75","1464","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1464.00","1098.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","868.15","59.3","","439.50","225.34","1872.27","197","732","1148.51","percent of total billed charges",""
"CABLE GRIP 2.0MM MED BONE DALL MILES VITALIUM ALLOY","SUP-ITM-10004989","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1148.51","78.45","","385.32","55.36","1815.62","58","732","1148.51","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","AETNA [1001]","HB CH AETNA HMO / PPO","434.63","58.3","","554.95","91.85","1421.75","94","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","544.22","73","","2490.03","2490.03","2490.03","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","434.63","58.3","","750.00","750.00","750.00","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","395.12","53","","1192.50","120.84","4149.90","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","633.68","85","","750.00","75.00","750.00","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","745.50","100","","657.00","121.50","1971.00","14","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","745.50","100","","75.00","75.00","75.00","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","745.50","100","","366.00","144.00","1971.00","45","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","544.22","73","","667.50","667.50","667.50","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","331.37","44.45","","123.77","123.77","123.77","1 through 10","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","both","","","745.50","559.12","WELLPOINT [1015]","HB CH WELLPOINT","580.82","77.91","","483.51","229.32","1316.08","96","331.37","745.5","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","442.08","59.3","","439.50","225.34","1872.27","197","372.75","584.84","percent of total billed charges",""
"CABLE HIP 1.6X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","745.50","559.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","584.84","78.45","","385.32","55.36","1815.62","58","372.75","584.84","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","AETNA [1001]","HB CH AETNA HMO / PPO","237.86","58.3","","554.95","91.85","1421.75","94","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","297.84","73","","2490.03","2490.03","2490.03","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","237.86","58.3","","750.00","750.00","750.00","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.24","53","","1192.50","120.84","4149.90","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","346.80","85","","750.00","75.00","750.00","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","408.00","100","","657.00","121.50","1971.00","14","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","408.00","100","","75.00","75.00","75.00","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","408.00","100","","366.00","144.00","1971.00","45","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.84","73","","667.50","667.50","667.50","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.36","44.45","","123.77","123.77","123.77","1 through 10","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.00","306.00","WELLPOINT [1015]","HB CH WELLPOINT","317.87","77.91","","483.51","229.32","1316.08","96","181.36","408","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.94","59.3","","439.50","225.34","1872.27","197","204","320.08","percent of total billed charges",""
"CABLE HIP 2.0X750MM DALL MILES VITALIUM COBALT","SUP-ITM-10004990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.00","306.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.08","78.45","","385.32","55.36","1815.62","58","204","320.08","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","AETNA [1001]","HB CH AETNA HMO / PPO","624.48","58.3","","554.95","91.85","1421.75","94","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","781.94","73","","2490.03","2490.03","2490.03","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","624.48","58.3","","750.00","750.00","750.00","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","567.71","53","","1192.50","120.84","4149.90","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","910.48","85","","750.00","75.00","750.00","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1071.15","100","","657.00","121.50","1971.00","14","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1071.15","100","","75.00","75.00","75.00","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1071.15","100","","366.00","144.00","1971.00","45","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","781.94","73","","667.50","667.50","667.50","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","476.13","44.45","","123.77","123.77","123.77","1 through 10","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1071.15","803.36","WELLPOINT [1015]","HB CH WELLPOINT","834.53","77.91","","483.51","229.32","1316.08","96","476.13","1071.15","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.15","803.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","635.19","59.3","","439.50","225.34","1872.27","197","535.58","840.32","percent of total billed charges",""
"CABLE ORTHOPEDIC 750X1.7MM SS CRIMP","SUP-ITM-10014476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1071.15","803.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","840.32","78.45","","385.32","55.36","1815.62","58","535.58","840.32","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","AETNA [1001]","HB CH AETNA HMO / PPO","303.45","58.3","","554.95","91.85","1421.75","94","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","379.97","73","","2490.03","2490.03","2490.03","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","303.45","58.3","","750.00","750.00","750.00","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","275.87","53","","1192.50","120.84","4149.90","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","442.43","85","","750.00","75.00","750.00","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","520.50","100","","657.00","121.50","1971.00","14","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","520.50","100","","75.00","75.00","75.00","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","520.50","100","","366.00","144.00","1971.00","45","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","379.97","73","","667.50","667.50","667.50","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.36","44.45","","123.77","123.77","123.77","1 through 10","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.50","390.37","WELLPOINT [1015]","HB CH WELLPOINT","405.52","77.91","","483.51","229.32","1316.08","96","231.36","520.5","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.50","390.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","308.66","59.3","","439.50","225.34","1872.27","197","260.25","408.33","percent of total billed charges",""
"CABLE SLEEVE 2.0MM DALL MILES VITALLIUM COBALT CS/1BX/1EA","SUP-ITM-10003860","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.50","390.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","408.33","78.45","","385.32","55.36","1815.62","58","260.25","408.33","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","AETNA [1001]","HB CH AETNA HMO / PPO","1694.78","58.3","","554.95","91.85","1421.75","94","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2122.11","73","","2490.03","2490.03","2490.03","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1694.78","58.3","","750.00","750.00","750.00","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1540.71","53","","1192.50","120.84","4149.90","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2470.95","85","","750.00","75.00","750.00","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2907.00","100","","657.00","121.50","1971.00","14","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2907.00","100","","75.00","75.00","75.00","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2907.00","100","","366.00","144.00","1971.00","45","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2122.11","73","","667.50","667.50","667.50","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1292.16","44.45","","123.77","123.77","123.77","1 through 10","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","WELLPOINT [1015]","HB CH WELLPOINT","2264.84","77.91","","483.51","229.32","1316.08","96","1292.16","2907","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2907.00","2180.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1723.85","59.3","","439.50","225.34","1872.27","197","1453.5","2280.54","percent of total billed charges",""
"CADDY PROCEDURE STERILIZATION ACUTRAK 2 MINI SCREW","SUP-ITM-10044578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2907.00","2180.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2280.54","78.45","","385.32","55.36","1815.62","58","1453.5","2280.54","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","192.00","144.00","AETNA [1001]","HB CH AETNA HMO / PPO","111.94","58.3","","106.03","106.03","106.03","1 through 10","23.17","140.16","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","both","","","192.00","144.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","101.76","53","","99.11","99.11","99.11","1 through 10","23.17","140.16","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","192.00","144.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.86","59.3","","109.58","109.58","109.58","1 through 10","23.87","150.62","percent of total billed charges",""
"Cadmium","PX-30000333","CDM","82300","CPT","0301","RC","","","","outpatient","","","192.00","144.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","150.62","78.45","","138.77","138.77","138.77","1 through 10","23.87","150.62","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","AETNA [1001]","HB CH AETNA HMO / PPO","1011.62","58.3","","554.95","91.85","1421.75","94","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1266.70","73","","2490.03","2490.03","2490.03","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1011.62","58.3","","750.00","750.00","750.00","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","919.66","53","","1192.50","120.84","4149.90","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1474.92","85","","750.00","75.00","750.00","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1735.20","100","","657.00","121.50","1971.00","14","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1735.20","100","","75.00","75.00","75.00","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1735.20","100","","366.00","144.00","1971.00","45","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1266.70","73","","667.50","667.50","667.50","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","771.30","44.45","","123.77","123.77","123.77","1 through 10","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","both","","","1735.20","1301.40","WELLPOINT [1015]","HB CH WELLPOINT","1351.89","77.91","","483.51","229.32","1316.08","96","771.3","1735.2","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1735.20","1301.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","1028.97","59.3","","439.50","225.34","1872.27","197","867.6","1361.26","percent of total billed charges",""
"CALCANEAL PLATE LARGE BONE TIMAX LOWER EXTREMITY","SUP-ITM-10028073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1735.20","1301.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1361.26","78.45","","385.32","55.36","1815.62","58","867.6","1361.26","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","AETNA [1001]","HB CH AETNA HMO / PPO","1915.16","58.3","","554.95","91.85","1421.75","94","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","2490.03","2490.03","2490.03","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1915.16","58.3","","750.00","750.00","750.00","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1741.05","53","","1192.50","120.84","4149.90","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2792.25","85","","750.00","75.00","750.00","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3285.00","100","","657.00","121.50","1971.00","14","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3285.00","100","","75.00","75.00","75.00","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3285.00","100","","366.00","144.00","1971.00","45","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","667.50","667.50","667.50","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.18","44.45","","123.77","123.77","123.77","1 through 10","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","WELLPOINT [1015]","HB CH WELLPOINT","2559.34","77.91","","483.51","229.32","1316.08","96","1460.18","3285","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1948.01","59.3","","439.50","225.34","1872.27","197","1642.5","2577.08","percent of total billed charges",""
"CALCANEAL PLATE LONG BONE FRACTURE PERCUTANEOUS ANTERIOR PROCESS","SUP-ITM-10149124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2577.08","78.45","","385.32","55.36","1815.62","58","1642.5","2577.08","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","AETNA [1001]","HB CH AETNA HMO / PPO","727.58","58.3","","554.95","91.85","1421.75","94","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","911.04","73","","2490.03","2490.03","2490.03","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","727.58","58.3","","750.00","750.00","750.00","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","661.44","53","","1192.50","120.84","4149.90","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1060.80","85","","750.00","75.00","750.00","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1248.00","100","","657.00","121.50","1971.00","14","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1248.00","100","","75.00","75.00","75.00","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1248.00","100","","366.00","144.00","1971.00","45","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","911.04","73","","667.50","667.50","667.50","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","554.74","44.45","","123.77","123.77","123.77","1 through 10","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","both","","","1248.00","936.00","WELLPOINT [1015]","HB CH WELLPOINT","972.32","77.91","","483.51","229.32","1316.08","96","554.74","1248","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1248.00","936.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","740.06","59.3","","439.50","225.34","1872.27","197","624","979.06","percent of total billed charges",""
"CALCANEUS PLATE XL","SUP-ITM-10028739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1248.00","936.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","979.06","78.45","","385.32","55.36","1815.62","58","624","979.06","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","AETNA [1001]","HB CH AETNA HMO / PPO","948.66","58.3","","554.95","91.85","1421.75","94","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1187.86","73","","2490.03","2490.03","2490.03","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","948.66","58.3","","750.00","750.00","750.00","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","862.42","53","","1192.50","120.84","4149.90","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1383.12","85","","750.00","75.00","750.00","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1627.20","100","","657.00","121.50","1971.00","14","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1627.20","100","","75.00","75.00","75.00","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1627.20","100","","366.00","144.00","1971.00","45","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1187.86","73","","667.50","667.50","667.50","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","723.29","44.45","","123.77","123.77","123.77","1 through 10","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","both","","","1627.20","1220.40","WELLPOINT [1015]","HB CH WELLPOINT","1267.75","77.91","","483.51","229.32","1316.08","96","723.29","1627.2","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.20","1220.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","964.93","59.3","","439.50","225.34","1872.27","197","813.6","1276.54","percent of total billed charges",""
"CALCANEUS PLATE XS","SUP-ITM-10028071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1627.20","1220.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1276.54","78.45","","385.32","55.36","1815.62","58","813.6","1276.54","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.31","1 through 10","14.1","120.03","percent of total billed charges",""
"Calcium Ionized","PX-30000337","CDM","82330","CPT","0301","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","67.88","67.88","67.88","1 through 10","14.1","120.03","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","1 through 10","5.06","43.8","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","1 through 10","5.33","47.07","percent of total billed charges",""
"Calcium Total","PX-30000336","CDM","82310","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","26.42","44.59","1 through 10","5.33","47.07","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.78","82.78","82.78","1 through 10","12.64","109.5","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","85.56","85.56","85.56","1 through 10","13.29","117.68","percent of total billed charges",""
"Calculus Analysis Infrared","PX-30000342","CDM","82365","CPT","0301","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","112.24","112.24","112.24","1 through 10","13.29","117.68","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB CH AETNA HMO / PPO","132.34","58.3","","125.31","125.31","125.31","1 through 10","19.24","165.71","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","227.00","170.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.34","58.3","","125.31","125.31","125.31","1 through 10","19.24","165.71","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","both","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.90","44.45","","169.90","169.90","169.90","1 through 10","19.24","165.71","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","227.00","170.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.61","59.3","","129.51","129.51","129.51","1 through 10","20.24","178.08","percent of total billed charges",""
"Calprotectin","PX-30000606","CDM","83993","CPT","0301","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","169.90","169.90","169.90","1 through 10","20.24","178.08","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","AETNA [1001]","HB CH AETNA HMO / PPO","471.36","58.3","","554.95","91.85","1421.75","94","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","590.21","73","","2490.03","2490.03","2490.03","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","471.36","58.3","","750.00","750.00","750.00","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.51","53","","1192.50","120.84","4149.90","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","687.23","85","","750.00","75.00","750.00","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","808.50","100","","657.00","121.50","1971.00","14","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","808.50","100","","75.00","75.00","75.00","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","808.50","100","","366.00","144.00","1971.00","45","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","590.21","73","","667.50","667.50","667.50","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.38","44.45","","123.77","123.77","123.77","1 through 10","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","WELLPOINT [1015]","HB CH WELLPOINT","629.90","77.91","","483.51","229.32","1316.08","96","359.38","808.5","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","808.50","606.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.44","59.3","","439.50","225.34","1872.27","197","404.25","634.27","percent of total billed charges",""
"CAP END SHOULDERED PHANTOM HINDFOOT NAIL SHORT","SUP-ITM-10285945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","808.50","606.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.27","78.45","","385.32","55.36","1815.62","58","404.25","634.27","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","AETNA [1001]","HB CH AETNA HMO / PPO","631.39","58.3","","1634.24","1004.95","1718.99","42","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","790.59","73","","2123.89","1900.92","2123.89","1 through 10","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","631.39","58.3","","3729.00","1254.19","3729.00","1 through 10","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","573.99","53","","939.37","939.37","5593.65","1 through 10","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","920.55","85","","2323.25","1864.50","2882.25","16","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1083.00","100","","2909.44","1772.40","10952.08","45","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1083.00","100","","2323.25","2323.25","2323.25","1 through 10","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1083.00","100","","2882.25","1772.40","10169.17","187","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","790.59","73","","1659.41","1659.41","1659.41","1 through 10","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","both","","","1083.00","812.25","WELLPOINT [1015]","HB CH WELLPOINT","843.77","77.91","","2050.91","1468.48","2902.83","52","481.39","1083","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1083.00","812.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","642.22","59.3","","1548.60","1092.60","3613.79","82","541.5","849.61","percent of total billed charges",""
"CAP LOCKING HUMERAL NAILUALIS FLEX REVIVE","SUP-ITM-10269601","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1083.00","812.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.61","78.45","","2085.51","998.68","6202.11","56","541.5","849.61","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","68.56","1 through 10","15.03","94.14","percent of total billed charges",""
"Carbamazepine (Tegretol) Total","PX-30000180","CDM","80156","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","89.95","89.95","1 through 10","15.03","94.14","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","374.00","85","","110.12","110.12","110.12","1 through 10","195.58","440","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","440.00","100","","129.51","129.51","129.51","1 through 10","195.58","440","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","440.00","100","","141.53","137.38","141.53","11","195.58","440","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","440.00","330.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","260.92","59.3","","250.81","250.81","250.81","1 through 10","220","345.18","percent of total billed charges",""
"Carbon Monoxide Diff (Dlco)","PX-46000046","CDM","94729","CPT","0460","RC","","","","outpatient","","","440.00","330.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","345.18","78.45","","329.05","329.05","329.05","1 through 10","220","345.18","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","87.89","87.89","87.89","1 through 10","18.58","116.07","percent of total billed charges",""
"Carcinoembryonic Antigen (Cea)","PX-30000348","CDM","82378","CPT","0301","RC","","","","outpatient","","","159.00","119.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.29","59.3","","90.83","90.83","90.83","1 through 10","19.56","124.74","percent of total billed charges",""
"Cardiac Arrest And Shock,MODERATE","196","DRG","","","","","","","","inpatient","","","46890.22","","MASSHEALTH [3001]","HB BWF MEDICAID","6043.12","","Case rate ($6,681.70). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,111.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,478.25 and the sum of the standard inlier and any outlier amount.","6680.06","6680.06","6680.06","1 through 10","6043.12","51103.52","case rate",""
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7326.57","","Case rate ($7,113.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,253.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7204.28","7204.28","7204.28","1 through 10","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7760.82","","Case rate ($7,760.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,901.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7480.73","7480.73","7480.73","1 through 10","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6970.91","","Case rate ($7,113.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,253.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6832.54","6832.54","6832.54","1 through 10","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","HUMANA [1012]","HB BWF MEDICARE","7760.82","","Case rate ($7,760.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,901.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6825.48","6825.48","6825.48","1 through 10","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","MEDICARE [2001]","HB BWF MEDICARE","7760.82","","Case rate ($7,760.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,901.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7552.80","0.03","7602.37","39","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6970.91","","Case rate ($7,113.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,253.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6838.57","6838.57","6838.57","1 through 10","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With Cc","309","MS-DRG","","","","","","","","inpatient","","","24588.47","18441.35","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6970.91","","Case rate ($7,113.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,124.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,647.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,080.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,253.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,784.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $520.11. The transfer capital threshold is the transfer adjustment factor * $520.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6876.07","6876.07","6876.07","1 through 10","6970.91","7760.82","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","38221.05","28665.79","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","11767.79","","Case rate ($11,425.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,443.10, add-ons for qualifying new technology services are included. If operating cost exceeds $56,966.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,411.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,234.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,103.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.18. The transfer capital threshold is the transfer adjustment factor * $851.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","11549.23","11549.23","11549.23","1 through 10","11196.54","12359.06","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","38221.05","28665.79","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","11425.04","","Case rate ($11,425.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,443.10, add-ons for qualifying new technology services are included. If operating cost exceeds $56,966.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,411.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,234.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,103.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.18. The transfer capital threshold is the transfer adjustment factor * $851.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12046.12","12046.12","12046.12","1 through 10","11196.54","12359.06","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","38221.05","28665.79","MEDICARE [2001]","HB BWF MEDICARE","11425.04","","Case rate ($11,425.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,443.10, add-ons for qualifying new technology services are included. If operating cost exceeds $56,966.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,411.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,234.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,103.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.18. The transfer capital threshold is the transfer adjustment factor * $851.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12161.13","0.03","12241.99","12","11196.54","12359.06","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","38221.05","28665.79","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","11425.04","","Case rate ($11,425.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,443.10, add-ons for qualifying new technology services are included. If operating cost exceeds $56,966.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,411.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,234.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,103.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.18. The transfer capital threshold is the transfer adjustment factor * $851.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11008.27","11008.27","11008.27","1 through 10","11196.54","12359.06","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","38221.05","28665.79","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11196.54","","Case rate ($11,425.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,443.10, add-ons for qualifying new technology services are included. If operating cost exceeds $56,966.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,411.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,234.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,103.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.18. The transfer capital threshold is the transfer adjustment factor * $851.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10974.97","10974.97","10974.97","1 through 10","11196.54","12359.06","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders With McC","308","MS-DRG","","","","","","","","inpatient","","","38221.05","28665.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11196.54","","Case rate ($11,425.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,443.10, add-ons for qualifying new technology services are included. If operating cost exceeds $56,966.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,411.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,234.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,103.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $851.18. The transfer capital threshold is the transfer adjustment factor * $851.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11006.47","11006.47","11008.47","1 through 10","11196.54","12359.06","other","Inpatient DRG"
"Cardiac Arrhythmia And Conduction Disorders Without Cc/McC","310","MS-DRG","","","","","","","","inpatient","","","21974.74","16481.05","MEDICARE [2001]","HB BWF MEDICARE","5551.59","","Case rate ($5,551.59). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,560.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,083.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,960.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $4,812.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,220.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $400.21. The transfer capital threshold is the transfer adjustment factor * $400.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1055.62","1055.62","1360.45","1 through 10","5440.56","5718.14","other","Inpatient Replacement Plans DRG"
"Cardiac Arrhythmia And Conduction Disorders,EXTREME","201","DRG","","","","","","","","inpatient","","","43357.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36556.86","","Standard inlier is a Case rate ($36,556.86). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $46,562, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,189.09) for the length of stay and the standard reimbursement.","34899.63","34899.63","34899.63","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","20595.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13873.04","","Standard inlier is a Case rate ($13,873.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,969.33) for the length of stay and the standard reimbursement.","2396.98","2396.98","2396.98","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","20595.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14902.41","","Standard inlier is a Case rate ($14,902.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,879, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,115.33) for the length of stay and the standard reimbursement.","21247.70","21247.70","21247.70","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","20595.06","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8782.1748","","Fee schedule rate ($21,490.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8782.1748","21490.34","21490.34","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","20595.06","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","20087.33","","Fee schedule rate ($20,087.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20087.33","20087.33","20087.33","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MAJOR","201","DRG","","","","","","","","inpatient","","","20595.06","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9319.26","9319.26","9319.26","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","12564.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10700.80","","Standard inlier is a Case rate ($10,700.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,519.02) for the length of stay and the standard reimbursement.","1519.02","1519.02","1519.02","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","12564.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11494.79","","Standard inlier is a Case rate ($11,494.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,631.64) for the length of stay and the standard reimbursement.","10972.30","10972.30","10972.30","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MINOR","201","DRG","","","","","","","","inpatient","","","12564.86","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","3714.97","","Case rate ($4,107.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,537.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4106.53","4106.53","4106.53","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13873.04","","Standard inlier is a Case rate ($13,873.04). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,626, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,969.33) for the length of stay and the standard reimbursement.","13873.03","13873.03","13873.03","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14902.41","","Standard inlier is a Case rate ($14,902.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,879, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,115.33) for the length of stay and the standard reimbursement.","14225.02","14225.02","14902.41","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8782.1748","","Fee schedule rate ($21,490.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8782.1748","12749.20","12749.20","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","MASSHEALTH [3001]","HB BWF MEDICAID","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9319.26","9319.26","9319.26","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9424.25","","Fee schedule rate ($9,424.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6770.39","6770.39","6770.39","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","20087.33","","Fee schedule rate ($20,087.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14430.76","14430.76","14430.76","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Arrhythmia And Conduction Disorders,MODERATE","201","DRG","","","","","","","","inpatient","","","18054.41","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4905.32","","Case rate ($5,423.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,853.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5422.34","5422.34","5422.34","1 through 10","3714.97","77782.2","case rate",""
"Cardiac Catheterization For Other Non-Coronary Conditions,MAJOR","192","DRG","","","","","","","","inpatient","","","58287.62","","MASSHEALTH [3001]","HB BWF MEDICAID","18841.04","","Case rate ($20,832.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $63,262.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10598.45","10598.45","10598.45","1 through 10","10984.99","55333.93","case rate",""
"Cardiac Congenital And Valvular Disorders Without McC","307","MS-DRG","","","","","","","","inpatient","","","24906.05","18679.54","MEDICARE [2001]","HB BWF MEDICARE","9551.40","","Case rate ($9,551.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,761.20, add-ons for qualifying new technology services are included. If operating cost exceeds $54,284.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,206.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $8,566.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,421.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $645.60. The transfer capital threshold is the transfer adjustment factor * $645.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9400.69","9400.69","9400.69","1 through 10","8572.55","9551.4","other","Inpatient DRG"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","154.01","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","154.47","149.00","154.47","21","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","AETNA [1001]","HB CH AETNA HMO / PPO","324.15","58.3","","306.75","306.75","306.75","18","125.9","459.6","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.14","141.91","147.14","22","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.71","59.3","","317.03","317.03","317.03","21","125.9","459.6","percent of total billed charges",""
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","146.54","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.14","141.91","147.14","24","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","142.35","142.35","144.22","1 through 10","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","HUMANA [1012]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.74","147.74","147.74","1 through 10","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","MEDICARE [2001]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.53","149.53","149.53","507","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","146.54","146.54","146.54","15","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","146.54","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","141.34","147.14","61","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","both","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","146.54","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","146.54","94","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/Monitor per Session","PX-94000031","CDM","93798","CPT","0943","RC","","","","outpatient","","","556.00","417.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","436.18","78.45","","415.92","415.92","415.92","1 through 10","195.1","436.18","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","154.01","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","153.87","153.87","154.17","14","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","AETNA [1001]","HB CH AETNA HMO / PPO","216.29","58.3","","204.69","204.69","204.69","19","125.9","459.6","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","147.14","141.91","147.14","39","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","146.54","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","147.14","147.14","147.14","26","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","MEDICARE [2001]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","149.53","149.53","288.44","659","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","149.53","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","146.54","146.54","146.54","13","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","146.54","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","146.54","147.14","69","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","146.54","","APC Price ($149.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","146.54","141.34","146.79","131","125.9","459.6","other","OPPS APC"
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","outpatient","","","371.00","278.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","220.00","59.3","","211.55","206.49","211.55","18","164.91","341.55","percent of total billed charges",""
"Cardiac Rehab W/O Monitor Session","PX-48000032","CDM","93797","CPT","0943","RC","","","","outpatient","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","291.05","78.45","","277.54","277.54","277.54","1 through 10","164.91","341.55","percent of total billed charges",""
"Cardiac Structural And Valvular Disorders,MODERATE","200","DRG","","","","","","","","inpatient","","","23006.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16445.58","","Standard inlier is a Case rate ($16,445.58). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,354, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,334.38) for the length of stay and the standard reimbursement.","9337.52","9337.52","9337.52","1 through 10","6442.94","22374.11","case rate",""
"Cardiac Structural And Valvular Disorders,MODERATE","200","DRG","","","","","","","","inpatient","","","23006.14","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","17953.15","","Fee schedule rate ($17,953.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17953.15","17953.15","17953.15","1 through 10","6442.94","22374.11","case rate",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","131.00","98.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.68","59.3","","74.42","74.42","223.26","1 through 10","14.19","102.77","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","131.00","98.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","102.77","78.45","","93.27","93.27","93.27","1 through 10","14.19","102.77","percent of total billed charges",""
"Cardiolipin Antibody Ea Ig Class","PX-30000791","CDM","86147","CPT","0302","RC","","","","outpatient","","","131.00","98.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","102.77","78.45","","97.64","93.27","97.64","1 through 10","14.19","102.77","percent of total billed charges",""
"Cardiomyopathy,MINOR","205","DRG","","","","","","","","inpatient","","","38768.72","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6215.11","","Fee schedule rate ($6,215.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6215.11","6215.11","6215.11","1 through 10","5150.93","16731.41","case rate",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","AETNA [1001]","HB CH AETNA HMO / PPO","1154.34","58.3","","1091.48","1091.48","1091.48","1 through 10","738.26","2048.05","percent of total billed charges",""
"Cardioversion Elective External","PX-48000003","CDM","92960","CPT","0480","RC","","","","both","","","1980.00","1485.00","MEDICARE [2001]","HB BWF MEDICARE","777.12","","APC Price ($777.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","777.12","777.12","777.12","1 through 10","738.26","2048.05","other","OPPS APC"
"Carnitine Total and Free Qn","PX-30000349","CDM","82379","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","16.53","99.51","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","AETNA [1001]","HB CH AETNA HMO / PPO","4022.70","58.3","","1634.24","1004.95","1718.99","42","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5037.00","73","","2123.89","1900.92","2123.89","1 through 10","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4022.70","58.3","","3729.00","1254.19","3729.00","1 through 10","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3657.00","53","","939.37","939.37","5593.65","1 through 10","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5865.00","85","","2323.25","1864.50","2882.25","16","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6900.00","100","","2909.44","1772.40","10952.08","45","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6900.00","100","","2323.25","2323.25","2323.25","1 through 10","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6900.00","100","","2882.25","1772.40","10169.17","187","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5037.00","73","","1659.41","1659.41","1659.41","1 through 10","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","both","","","6900.00","5175.00","WELLPOINT [1015]","HB CH WELLPOINT","5375.79","77.91","","2050.91","1468.48","2902.83","52","3067.05","6900","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4091.70","59.3","","1548.60","1092.60","3613.79","82","3450","5413.05","percent of total billed charges",""
"CARTILAGE IMPLANT 10MM SYNTHETIC","SUP-ITM-10171206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6900.00","5175.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5413.05","78.45","","2085.51","998.68","6202.11","56","3450","5413.05","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","AETNA [1001]","HB CH AETNA HMO / PPO","598.65","58.3","","554.95","91.85","1421.75","94","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","749.59","73","","2490.03","2490.03","2490.03","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","598.65","58.3","","750.00","750.00","750.00","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","544.23","53","","1192.50","120.84","4149.90","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","872.81","85","","750.00","75.00","750.00","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1026.84","100","","657.00","121.50","1971.00","14","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1026.84","100","","75.00","75.00","75.00","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1026.84","100","","366.00","144.00","1971.00","45","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","749.59","73","","667.50","667.50","667.50","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","456.43","44.45","","123.77","123.77","123.77","1 through 10","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.84","770.13","WELLPOINT [1015]","HB CH WELLPOINT","800.01","77.91","","483.51","229.32","1316.08","96","456.43","1026.84","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.84","770.13","CIGNA [1006]","HB CH CIGNA HMO / PPO","608.92","59.3","","439.50","225.34","1872.27","197","513.42","805.56","percent of total billed charges",""
"CASE GRAPHIC INSTRUMENT BASE F/4.5MM VA LCP AND SCREW SET","SUP-ITM-10125904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.84","770.13","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","805.56","78.45","","385.32","55.36","1815.62","58","513.42","805.56","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","208.00","156.00","AETNA [1001]","HB CH AETNA HMO / PPO","121.26","58.3","","114.53","110.54","114.53","1 through 10","24.75","151.84","percent of total billed charges",""
"Catecholamines Fraction","PX-30000353","CDM","82384","CPT","0301","RC","","","","both","","","208.00","156.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.46","44.45","","90.70","90.70","90.70","1 through 10","24.75","151.84","percent of total billed charges",""
"Cath TPA Injection Into Hematoma/Seroma/Collection Subcutaneous","PX-76002452","CDM","17999","CPT","0761","RC","","","","outpatient","","","388.00","291.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","194.39","50.1","","285.72","285.72","285.72","1 through 10","190.39","567.68","percent of total billed charges",""
"Cath TPA Injection Into Hematoma/Seroma/Collection Subcutaneous","PX-76002452","CDM","17999","CPT","0761","RC","","","","outpatient","","","388.00","291.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","223.88","57.7","","8477.00","8477.00","8477.00","1 through 10","190.39","567.68","percent of total billed charges",""
"CATHETER ANGIOPLASTY 40X12MM 120CM XXL 0.035IN BALLOON","SUP-ITM-10007045","CDM","C1725","HCPCS","0272","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.40","53","","729.83","486.54","928.96","1 through 10","346.71","780","percent of total billed charges",""
"CATHETER ANGIOPLASTY 40X12MM 120CM XXL 0.035IN BALLOON","SUP-ITM-10007045","CDM","C1725","HCPCS","0272","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","663.00","85","","459.00","459.00","459.00","1 through 10","346.71","780","percent of total billed charges",""
"CATHETER ANGIOPLASTY 40X12MM 120CM XXL 0.035IN BALLOON","SUP-ITM-10007045","CDM","C1725","HCPCS","0272","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","780.00","100","","556.00","459.00","604.50","1 through 10","346.71","780","percent of total billed charges",""
"CATHETER ANGIOPLASTY 40X12MM 120CM XXL 0.035IN BALLOON","SUP-ITM-10007045","CDM","C1725","HCPCS","0272","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","780.00","100","","459.00","459.00","459.00","1 through 10","346.71","780","percent of total billed charges",""
"CATHETER ANGIOPLASTY 40X12MM 120CM XXL 0.035IN BALLOON","SUP-ITM-10007045","CDM","C1725","HCPCS","0272","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB CH WELLPOINT","607.70","77.91","","514.30","361.51","514.30","1 through 10","346.71","780","percent of total billed charges",""
"CATHETER ANGIOPLASTY 40X12MM 120CM XXL 0.035IN BALLOON","SUP-ITM-10007045","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","705.76","352.88","2982.17","1 through 10","390","611.91","percent of total billed charges",""
"CATHETER BALLOON 4MMX10CM 12FR 75 5.8 HIGH PRESSURE UROMAX ULTRA DILATATION","SUP-ITM-10041560","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","944.61","708.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.05","78.45","","2644.76","2644.76","2644.76","1 through 10","472.31","741.05","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM EMBOLECTOMY FOGARTY LATEX STAINLESS 11MM ARTERIAL TUBE STERILE","SUP-ITM-10003285","CDM","C1757","HCPCS","0272","RC","","","","both","","","110.31","82.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","93.76","85","","1621.37","1621.37","1621.37","1 through 10","49.03","110.31","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM EMBOLECTOMY FOGARTY LATEX STAINLESS 11MM ARTERIAL TUBE STERILE","SUP-ITM-10003285","CDM","C1757","HCPCS","0272","RC","","","","both","","","110.31","82.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","110.31","100","","2116.03","232.05","2316.03","1 through 10","49.03","110.31","percent of total billed charges",""
"CATHETER BALLOON 5FR 80CM EMBOLECTOMY FOGARTY LATEX STAINLESS 11MM ARTERIAL TUBE STERILE","SUP-ITM-10003285","CDM","C1757","HCPCS","0272","RC","","","","outpatient","","","110.31","82.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.54","78.45","","178.40","178.40","269.84","1 through 10","55.16","86.54","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T1","PX-27000038","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","625.16","468.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","490.44","78.45","","2644.76","2644.76","2644.76","1 through 10","312.58","490.44","percent of total billed charges",""
"Catheter Balloon Dilatation Non-Vascular T3","PX-27000039","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","5322.31","3991.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4175.35","78.45","","2644.76","2644.76","2644.76","1 through 10","2661.16","4175.35","percent of total billed charges",""
"Catheter Bladder Complicated","PX-76001259","CDM","51703","CPT","0761","RC","","","","both","","","591.00","443.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","191.36","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","191.20","191.20","191.20","1 through 10","176.52","528.85","other","OPPS APC"
"Catheter Bladder Complicated","PX-76001259","CDM","51703","CPT","0761","RC","","","","outpatient","","","591.00","443.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","155.47","","Case rate ($155.47). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","224.81","224.81","224.81","1 through 10","155.47","463.64","other","ASC "
"CATHETER CONQUEST 7FR 10MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10022692","CDM","C1725","HCPCS","0272","RC","","","","both","","","459.00","344.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","243.27","53","","729.83","486.54","928.96","1 through 10","204.03","459","percent of total billed charges",""
"CATHETER CONQUEST 7FR 10MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10022692","CDM","C1725","HCPCS","0272","RC","","","","both","","","459.00","344.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","390.15","85","","459.00","459.00","459.00","1 through 10","204.03","459","percent of total billed charges",""
"CATHETER CONQUEST 7FR 10MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10022692","CDM","C1725","HCPCS","0272","RC","","","","both","","","459.00","344.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","459.00","100","","556.00","459.00","604.50","1 through 10","204.03","459","percent of total billed charges",""
"CATHETER CONQUEST 7FR 10MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10022692","CDM","C1725","HCPCS","0272","RC","","","","both","","","459.00","344.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","459.00","100","","459.00","459.00","459.00","1 through 10","204.03","459","percent of total billed charges",""
"CATHETER CONQUEST 7FR 10MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10022692","CDM","C1725","HCPCS","0272","RC","","","","both","","","459.00","344.25","WELLPOINT [1015]","HB CH WELLPOINT","357.61","77.91","","514.30","361.51","514.30","1 through 10","204.03","459","percent of total billed charges",""
"CATHETER CONQUEST 7FR 10MM 2CM 75CM .035IN BALLOON DILATION PTA PERIPHERAL","SUP-ITM-10022692","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","459.00","344.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","360.09","78.45","","705.76","352.88","2982.17","1 through 10","229.5","360.09","percent of total billed charges",""
"CATHETER CRE PRO WIREGUIDED 7.5FR 6-8MM 5.5CM 240CM DILATION BILIARY BALLOON ESOPHAGEAL","SUP-ITM-10170125","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","579.27","434.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","454.44","78.45","","2644.76","2644.76","2644.76","1 through 10","289.64","454.44","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","AETNA [1001]","HB CH AETNA HMO / PPO","3302.70","58.3","","1830.28","315.58","1830.28","1 through 10","2518.09","5665","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4135.45","73","","4170.85","4170.85","4170.85","1 through 10","2518.09","5665","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2518.09","44.45","","649.55","649.55","649.55","1 through 10","2518.09","5665","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","both","","","5665.00","4248.75","WELLPOINT [1015]","HB CH WELLPOINT","4413.60","77.91","","8998.38","2542.37","8998.38","20","2518.09","5665","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5665.00","4248.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3359.35","59.3","","1891.61","1609.14","3664.18","25","2832.5","4444.19","percent of total billed charges",""
"CATHETER DIGITAL SPYGLASS DISCOVER","SUP-ITM-10282127","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","5665.00","4248.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4444.19","78.45","","1470.68","1310.06","2481.69","19","2832.5","4444.19","percent of total billed charges",""
"CATHETER DILATATION 18FR 4CM UROMAX ULTRA POLYMER HYDROPLUS COATED HIGH PRESSURE","SUP-ITM-10024783","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1010.91","758.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","793.06","78.45","","2644.76","2644.76","2644.76","1 through 10","505.46","793.06","percent of total billed charges",""
"CATHETER DILATATION 4MMCM 12FR 5.8 75 UROMAX ULTRA BALLOON HIGH PRESSURE","SUP-ITM-10027247","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","921.42","691.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","722.85","78.45","","2644.76","2644.76","2644.76","1 through 10","460.71","722.85","percent of total billed charges",""
"CATHETER DILATION 7.0FR 18X29CM URETHRAL OPEN TIP OVER THE WIRE","SUP-ITM-10078545","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","415.20","311.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","325.72","78.45","","2644.76","2644.76","2644.76","1 through 10","207.6","325.72","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.47","1.10","AETNA [1001]","HB CH AETNA HMO / PPO","0.86","58.3","","41.25","41.25","41.25","1 through 10","0.65","1.47","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.47","1.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1.47","100","","39.24","39.24","39.24","1 through 10","0.65","1.47","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.47","1.10","WELLPOINT [1015]","HB CH WELLPOINT","1.15","77.91","","157.50","30.92","221.94","11","0.65","1.47","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 12FR 16IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003304","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.47","1.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1.15","78.45","","32.43","30.18","307.47","11","0.74","1.15","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.29","0.97","AETNA [1001]","HB CH AETNA HMO / PPO","0.75","58.3","","41.25","41.25","41.25","1 through 10","0.57","1.29","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.29","0.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1.29","100","","39.24","39.24","39.24","1 through 10","0.57","1.29","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","both","","","1.29","0.97","WELLPOINT [1015]","HB CH WELLPOINT","1.01","77.91","","157.50","30.92","221.94","11","0.57","1.29","percent of total billed charges",""
"CATHETER DOVER ROB-NEL 16FR 14IN URETHRAL PVC ROUNDED TIP SMOOTH ROUNDED TIP 2 STAGGERED EYE CS/100EA","SUP-ITM-10003306","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","1.29","0.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1.01","78.45","","32.43","30.18","307.47","11","0.65","1.01","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","663.90","497.92","AETNA [1001]","HB CH AETNA HMO / PPO","387.05","58.3","","1830.28","315.58","1830.28","1 through 10","295.1","663.9","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","663.90","497.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","484.65","73","","4170.85","4170.85","4170.85","1 through 10","295.1","663.9","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","663.90","497.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","295.10","44.45","","649.55","649.55","649.55","1 through 10","295.1","663.9","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","both","","","663.90","497.92","WELLPOINT [1015]","HB CH WELLPOINT","517.24","77.91","","8998.38","2542.37","8998.38","20","295.1","663.9","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","663.90","497.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","393.69","59.3","","1891.61","1609.14","3664.18","25","331.95","520.83","percent of total billed charges",""
"CATHETER DRAINAGE 1.5 .7MM 80CM VENTRICULAR EXTERNAL LUMBAR HERMETIC CLOSED TIP LF","SUP-ITM-10007143","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","663.90","497.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","520.83","78.45","","1470.68","1310.06","2481.69","19","331.95","520.83","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","both","","","314.14","235.60","WELLPOINT [1015]","HB CH WELLPOINT","244.75","77.91","","60.00","47.26","60.00","1 through 10","139.64","314.14","percent of total billed charges",""
"Catheter Drainage T1","PX-27000044","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","314.14","235.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","246.44","78.45","","28.02","28.02","28.02","1 through 10","157.07","246.44","percent of total billed charges",""
"CATHETER GUIDING 6FRX100CM SHORT 4.0 SIDE HOLE LAUNCHER LT 4. CORONARY","SUP-ITM-10093135","CDM","C1887","HCPCS","0272","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","262.35","194.30","262.35","1 through 10","53.34","120","percent of total billed charges",""
"CATHETER GUIDING 6FRX100CM SHORT 4.0 SIDE HOLE LAUNCHER LT 4. CORONARY","SUP-ITM-10093135","CDM","C1887","HCPCS","0272","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","173.25","165.00","173.25","1 through 10","53.34","120","percent of total billed charges",""
"CATHETER GUIDING 6FRX100CM SHORT 4.0 SIDE HOLE LAUNCHER LT 4. CORONARY","SUP-ITM-10093135","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","513.75","29.41","761.11","1 through 10","60","94.14","percent of total billed charges",""
"CATHETER HURRICANE 5.8FR 4MM 4CM 180CM B2633 RX BILIARY BALLOON DILATION","SUP-ITM-10025628","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","739.80","554.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","580.37","78.45","","2644.76","2644.76","2644.76","1 through 10","369.9","580.37","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","177.00","132.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","93.81","53","","69.13","15.86","85.00","1 through 10","78.68","177","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","150.45","85","","29.94","29.94","29.94","1 through 10","78.68","177","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","177.00","100","","60.23","29.94","60.23","12","78.68","177","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","177.00","132.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","177.00","100","","65.22","29.94","360.69","1 through 10","78.68","177","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","both","","","177.00","132.75","WELLPOINT [1015]","HB CH WELLPOINT","137.90","77.91","","51.37","51.37","284.08","1 through 10","78.68","177","percent of total billed charges",""
"CATHETER KIT 5.0FRX50CM 0.035IN ENDOSCOPIC CHOLANGIOGRAPHY W/OUT BALLOON RADIOPAQUE MIXTER","SUP-ITM-10011757","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.86","78.45","","123.30","23.02","333.57","1 through 10","88.5","138.86","percent of total billed charges",""
"CATHETER MUSTANG 6FR 10MM 40MM 75CM .035IN 14ATM PERIPHERAL BALLOON","SUP-ITM-10091520","CDM","C1725","HCPCS","0272","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","729.83","486.54","928.96","1 through 10","333.38","750","percent of total billed charges",""
"CATHETER MUSTANG 6FR 10MM 40MM 75CM .035IN 14ATM PERIPHERAL BALLOON","SUP-ITM-10091520","CDM","C1725","HCPCS","0272","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","459.00","459.00","459.00","1 through 10","333.38","750","percent of total billed charges",""
"CATHETER MUSTANG 6FR 10MM 40MM 75CM .035IN 14ATM PERIPHERAL BALLOON","SUP-ITM-10091520","CDM","C1725","HCPCS","0272","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","556.00","459.00","604.50","1 through 10","333.38","750","percent of total billed charges",""
"CATHETER MUSTANG 6FR 10MM 40MM 75CM .035IN 14ATM PERIPHERAL BALLOON","SUP-ITM-10091520","CDM","C1725","HCPCS","0272","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","459.00","459.00","459.00","1 through 10","333.38","750","percent of total billed charges",""
"CATHETER MUSTANG 6FR 10MM 40MM 75CM .035IN 14ATM PERIPHERAL BALLOON","SUP-ITM-10091520","CDM","C1725","HCPCS","0272","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","514.30","361.51","514.30","1 through 10","333.38","750","percent of total billed charges",""
"CATHETER MUSTANG 6FR 10MM 40MM 75CM .035IN 14ATM PERIPHERAL BALLOON","SUP-ITM-10091520","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","705.76","352.88","2982.17","1 through 10","375","588.38","percent of total billed charges",""
"CATHETER OPTILUME 24FRX3CM 75CM SHAFT 0.038IN BASIC UROLOGICAL BALLOON","SUP-ITM-10339012","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","2644.76","2644.76","2644.76","1 through 10","472.5","741.35","percent of total billed charges",""
"CATHETER PRO RX 7-6FR 12-15MM 200CM .035IN RETRIEVAL EXTRACTOR TRIPLE LUMEN STONE DISTAL INJECTION","SUP-ITM-10138964","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","448.05","336.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.50","78.45","","2644.76","2644.76","2644.76","1 through 10","224.03","351.5","percent of total billed charges",""
"CATHETER RELIEVA SPINPLUS 6X16MM BALLOON SINUPLASTY SYSTEM W/ IRRIGATION BX/5EA","SUP-ITM-10159436","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","4095.00","3071.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3212.53","78.45","","2644.76","2644.76","2644.76","1 through 10","2047.5","3212.53","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.20","36.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","26.08","53","","262.35","194.30","262.35","1 through 10","21.87","49.2","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","both","","","49.20","36.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","49.20","100","","173.25","165.00","173.25","1 through 10","21.87","49.2","percent of total billed charges",""
"CATHETER SOFT VU 5FR 65CM .038IN ANGIOGRAPHY BERENSTEIN BRAIDED ULTRA TORQUE SHAFT ANGLED BX/5EA","SUP-ITM-10007115","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","49.20","36.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","38.60","78.45","","513.75","29.41","761.11","1 through 10","24.6","38.6","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T1","PX-27000065","CDM","C1757","HCPCS","0272","RC","","","","both","","","294.54","220.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","250.36","85","","1621.37","1621.37","1621.37","1 through 10","130.92","294.54","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T1","PX-27000065","CDM","C1757","HCPCS","0272","RC","","","","both","","","294.54","220.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","294.54","100","","2116.03","232.05","2316.03","1 through 10","130.92","294.54","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T1","PX-27000065","CDM","C1757","HCPCS","0272","RC","","","","outpatient","","","294.54","220.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.07","78.45","","178.40","178.40","269.84","1 through 10","147.27","231.07","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T2","PX-27000066","CDM","C1757","HCPCS","0272","RC","","","","both","","","3995.83","2996.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3396.46","85","","1621.37","1621.37","1621.37","1 through 10","1776.15","3995.83","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T2","PX-27000066","CDM","C1757","HCPCS","0272","RC","","","","both","","","3995.83","2996.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3995.83","100","","2116.03","232.05","2316.03","1 through 10","1776.15","3995.83","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T2","PX-27000066","CDM","C1757","HCPCS","0272","RC","","","","outpatient","","","3995.83","2996.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3134.73","78.45","","178.40","178.40","269.84","1 through 10","1997.92","3134.73","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T3","PX-27000067","CDM","C1757","HCPCS","0272","RC","","","","both","","","4521.94","3391.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3843.65","85","","1621.37","1621.37","1621.37","1 through 10","2010","4521.94","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T3","PX-27000067","CDM","C1757","HCPCS","0272","RC","","","","both","","","4521.94","3391.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4521.94","100","","2116.03","232.05","2316.03","1 through 10","2010","4521.94","percent of total billed charges",""
"Catheter Thrombectomy/Embolectomy T3","PX-27000067","CDM","C1757","HCPCS","0272","RC","","","","outpatient","","","4521.94","3391.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3547.46","78.45","","178.40","178.40","269.84","1 through 10","2260.97","3547.46","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","AETNA [1001]","HB CH AETNA HMO / PPO","96.89","58.3","","41.25","41.25","41.25","1 through 10","73.88","166.2","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","166.20","100","","39.24","39.24","39.24","1 through 10","73.88","166.2","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","both","","","166.20","124.65","WELLPOINT [1015]","HB CH WELLPOINT","129.49","77.91","","157.50","30.92","221.94","11","73.88","166.2","percent of total billed charges",""
"CATHETER URETERAL 10.0FR 50CM DUAL LUMEN FLEXIBLE TIP HYDROPHILIC COATED POLYURETHANE","SUP-ITM-10078530","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","166.20","124.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","130.38","78.45","","32.43","30.18","307.47","11","83.1","130.38","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","AETNA [1001]","HB CH AETNA HMO / PPO","161.78","58.3","","41.25","41.25","41.25","1 through 10","123.35","277.5","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","277.50","100","","39.24","39.24","39.24","1 through 10","123.35","277.5","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","both","","","277.50","208.12","WELLPOINT [1015]","HB CH WELLPOINT","216.20","77.91","","157.50","30.92","221.94","11","123.35","277.5","percent of total billed charges",""
"CATHETER URETERAL 10FR 50CM DUAL LUMEN 0.038IN ANGLED TIP C FLEX","SUP-ITM-10065088","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","277.50","208.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","217.70","78.45","","32.43","30.18","307.47","11","138.75","217.7","percent of total billed charges",""
"CATHETER URETERAL 4FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10078435","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.83","30.62","AETNA [1001]","HB CH AETNA HMO / PPO","23.80","58.3","","41.25","41.25","41.25","1 through 10","18.15","40.83","percent of total billed charges",""
"CATHETER URETERAL 4FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10078435","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.83","30.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","40.83","100","","39.24","39.24","39.24","1 through 10","18.15","40.83","percent of total billed charges",""
"CATHETER URETERAL 4FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10078435","CDM","C1758","HCPCS","0272","RC","","","","both","","","40.83","30.62","WELLPOINT [1015]","HB CH WELLPOINT","31.81","77.91","","157.50","30.92","221.94","11","18.15","40.83","percent of total billed charges",""
"CATHETER URETERAL 4FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10078435","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","40.83","30.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.03","78.45","","32.43","30.18","307.47","11","20.42","32.03","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.48","31.86","AETNA [1001]","HB CH AETNA HMO / PPO","24.77","58.3","","41.25","41.25","41.25","1 through 10","18.88","42.48","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.48","31.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","42.48","100","","39.24","39.24","39.24","1 through 10","18.88","42.48","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.48","31.86","WELLPOINT [1015]","HB CH WELLPOINT","33.10","77.91","","157.50","30.92","221.94","11","18.88","42.48","percent of total billed charges",""
"CATHETER URETERAL 5.0FR 70CM OPEN ENDED FLEXIBLE TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10020062","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","42.48","31.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.33","78.45","","32.43","30.18","307.47","11","21.24","33.33","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","39.71","29.78","AETNA [1001]","HB CH AETNA HMO / PPO","23.15","58.3","","41.25","41.25","41.25","1 through 10","17.65","39.71","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","39.71","29.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","39.71","100","","39.24","39.24","39.24","1 through 10","17.65","39.71","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","both","","","39.71","29.78","WELLPOINT [1015]","HB CH WELLPOINT","30.94","77.91","","157.50","30.92","221.94","11","17.65","39.71","percent of total billed charges",""
"CATHETER URETERAL 5FR 70CM OPEN ENDED TIP POLYURETHANE BX/20EA","SUP-ITM-10065089","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","39.71","29.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","31.15","78.45","","32.43","30.18","307.47","11","19.86","31.15","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","AETNA [1001]","HB CH AETNA HMO / PPO","12.73","58.3","","41.25","41.25","41.25","1 through 10","9.7","21.83","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","21.83","100","","39.24","39.24","39.24","1 through 10","9.7","21.83","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","both","","","21.83","16.37","WELLPOINT [1015]","HB CH WELLPOINT","17.01","77.91","","157.50","30.92","221.94","11","9.7","21.83","percent of total billed charges",""
"CATHETER URETERAL 5FRX115CM WHISTLE TIP 2 DRAINAGE EYES CS/10EA","SUP-ITM-10006095","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","21.83","16.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17.13","78.45","","32.43","30.18","307.47","11","10.92","17.13","percent of total billed charges",""
"CATHETER URETERAL 5FRX70CM OPEN ENDED TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10017393","CDM","C1758","HCPCS","0272","RC","","","","both","","","34.53","25.90","AETNA [1001]","HB CH AETNA HMO / PPO","20.13","58.3","","41.25","41.25","41.25","1 through 10","15.35","34.53","percent of total billed charges",""
"CATHETER URETERAL 5FRX70CM OPEN ENDED TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10017393","CDM","C1758","HCPCS","0272","RC","","","","both","","","34.53","25.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","34.53","100","","39.24","39.24","39.24","1 through 10","15.35","34.53","percent of total billed charges",""
"CATHETER URETERAL 5FRX70CM OPEN ENDED TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10017393","CDM","C1758","HCPCS","0272","RC","","","","both","","","34.53","25.90","WELLPOINT [1015]","HB CH WELLPOINT","26.90","77.91","","157.50","30.92","221.94","11","15.35","34.53","percent of total billed charges",""
"CATHETER URETERAL 5FRX70CM OPEN ENDED TIP POLYVINYLCHLORIDE BX/10EA","SUP-ITM-10017393","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","34.53","25.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","27.09","78.45","","32.43","30.18","307.47","11","17.27","27.09","percent of total billed charges",""
"CATHETER URETERAL 6.0FR 70CM OPEN ENDED FLEXIBLE TIP PVC STD BX/10EA","SUP-ITM-10078412","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.18","31.63","AETNA [1001]","HB CH AETNA HMO / PPO","24.59","58.3","","41.25","41.25","41.25","1 through 10","18.75","42.18","percent of total billed charges",""
"CATHETER URETERAL 6.0FR 70CM OPEN ENDED FLEXIBLE TIP PVC STD BX/10EA","SUP-ITM-10078412","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.18","31.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","42.18","100","","39.24","39.24","39.24","1 through 10","18.75","42.18","percent of total billed charges",""
"CATHETER URETERAL 6.0FR 70CM OPEN ENDED FLEXIBLE TIP PVC STD BX/10EA","SUP-ITM-10078412","CDM","C1758","HCPCS","0272","RC","","","","both","","","42.18","31.63","WELLPOINT [1015]","HB CH WELLPOINT","32.86","77.91","","157.50","30.92","221.94","11","18.75","42.18","percent of total billed charges",""
"CATHETER URETERAL 6.0FR 70CM OPEN ENDED FLEXIBLE TIP PVC STD BX/10EA","SUP-ITM-10078412","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","42.18","31.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.09","78.45","","32.43","30.18","307.47","11","21.09","33.09","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","AETNA [1001]","HB CH AETNA HMO / PPO","21.03","58.3","","41.25","41.25","41.25","1 through 10","16.04","36.08","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","36.08","100","","39.24","39.24","39.24","1 through 10","16.04","36.08","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","both","","","36.08","27.06","WELLPOINT [1015]","HB CH WELLPOINT","28.11","77.91","","157.50","30.92","221.94","11","16.04","36.08","percent of total billed charges",""
"CATHETER URETERAL 8FR CONE TIP 70CM 5FR SHAFT DIA PREATTACHED ADAPTER POLYURETHANE CS/10EA","SUP-ITM-10006208","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","36.08","27.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.30","78.45","","32.43","30.18","307.47","11","18.04","28.3","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","AETNA [1001]","HB CH AETNA HMO / PPO","162.47","58.3","","41.25","41.25","41.25","1 through 10","123.87","278.68","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","278.68","100","","39.24","39.24","39.24","1 through 10","123.87","278.68","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","both","","","278.68","209.01","WELLPOINT [1015]","HB CH WELLPOINT","217.12","77.91","","157.50","30.92","221.94","11","123.87","278.68","percent of total billed charges",""
"Catheter Ureteral T1","PX-27000068","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","278.68","209.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","218.62","78.45","","32.43","30.18","307.47","11","139.34","218.62","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","1 through 10","5.49","45.99","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","69.78","35.75","69.78","1 through 10","5.68","49.42","percent of total billed charges",""
"Cell Count Body Fluid W/Diff","PX-30000112","CDM","89051","CPT","0300","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","46.90","46.90","46.90","1 through 10","5.68","49.42","percent of total billed charges",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","30085.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21055.93","","Standard inlier is a Case rate ($21,055.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,249, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,988.97) for the length of stay and the standard reimbursement.","2435.84","2435.84","2435.84","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","30085.38","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23399.59","","Fee schedule rate ($23,399.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23399.59","23399.59","23399.59","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","30085.38","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8602.02","","Case rate ($9,511.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,941.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9508.67","9508.67","9508.67","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MAJOR","383","DRG","","","","","","","","inpatient","","","30085.38","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8602.02","","Case rate ($9,511.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,941.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9508.67","1052.93","12740.13","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","17666.67","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8436.73","","Fee schedule rate ($8,436.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9542.94","9542.94","9542.94","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","17666.67","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4470.08","","Case rate ($4,942.44). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,372.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4941.23","4941.23","4941.23","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","17666.67","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","4470.08","","Case rate ($4,942.44). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,372.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","60.90","60.90","60.90","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MINOR","383","DRG","","","","","","","","inpatient","","","17666.67","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4470.08","","Case rate ($4,942.44). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,372.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4941.23","4941.23","5339.44","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14152.51","","Standard inlier is a Case rate ($14,152.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,241, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,009.00) for the length of stay and the standard reimbursement.","10614.37","10614.37","14152.50","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15202.62","","Standard inlier is a Case rate ($15,202.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,157.95) for the length of stay and the standard reimbursement.","14512.51","14512.51","15202.61","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13941.26","","Fee schedule rate ($13,941.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13941.26","13941.26","13941.26","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","14638.25","","Fee schedule rate ($14,638.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18082.21","18082.21","18082.21","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","17426.22","","Fee schedule rate ($17,426.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17426.22","17426.22","17426.22","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","MASSHEALTH [3001]","HB BWF MEDICAID","5924.31","","Case rate ($6,550.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,980.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6548.73","6548.73","6548.73","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5924.31","","Case rate ($6,550.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,980.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6548.74","243.53","9660.58","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5924.31","","Case rate ($6,550.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,980.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1850.00","1850.00","1850.00","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis And Other Skin Infections,MODERATE","383","DRG","","","","","","","","inpatient","","","24755.14","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5924.31","","Case rate ($6,550.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,980.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6548.74","695.29","6548.74","1 through 10","3633.02","38608.97","case rate",""
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","30616.10","22962.07","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13828.59","","Case rate ($13,425.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,447.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,970.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,565.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,081.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,107.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.80. The transfer capital threshold is the transfer adjustment factor * $1,004.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","8505.35","8505.35","14061.92","1 through 10","13157.3","14589.64","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","30616.10","22962.07","MEDICARE [2001]","HB BWF MEDICARE","13425.82","","Case rate ($13,425.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,447.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,970.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,565.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,081.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,107.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.80. The transfer capital threshold is the transfer adjustment factor * $1,004.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14761.57","9714.87","14761.57","22","13157.3","14589.64","other","Inpatient Replacement Plans DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","30616.10","22962.07","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13157.30","","Case rate ($13,425.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,447.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,970.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,565.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,081.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,107.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.80. The transfer capital threshold is the transfer adjustment factor * $1,004.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13316.20","13316.20","13316.20","1 through 10","13157.3","14589.64","other","Inpatient DRG"
"Cellulitis With McC","602","MS-DRG","","","","","","","","inpatient","","","30616.10","22962.07","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13157.30","","Case rate ($13,425.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,447.14, add-ons for qualifying new technology services are included. If operating cost exceeds $58,970.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,565.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,081.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,107.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,004.80. The transfer capital threshold is the transfer adjustment factor * $1,004.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13310.21","13310.21","13347.16","1 through 10","13157.3","14589.64","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8608.76","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","8536.95","8536.95","8536.95","1 through 10","8190.86","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","8358.02","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8145.79","8145.79","8145.79","1 through 10","8190.86","8939.79","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8190.86","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8125.63","8100.34","8133.86","1 through 10","8190.86","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","HUMANA [1012]","HB BWF MEDICARE","8358.02","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8100.34","8100.34","8122.34","1 through 10","8190.86","8939.79","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","MEDICARE [2001]","HB BWF MEDICARE","8358.02","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8950.30","0.03","9009.38","59","8190.86","8939.79","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","8358.02","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8109.31","8109.31","8109.31","1 through 10","8190.86","8939.79","other","Inpatient Replacement Plans DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8190.86","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8118.19","8118.19","9651.53","1 through 10","8190.86","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8190.86","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8912.03","8912.03","8912.03","1 through 10","8190.86","8939.79","other","Inpatient DRG"
"Cellulitis Without McC","603","MS-DRG","","","","","","","","inpatient","","","23391.37","17543.53","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8190.86","","Case rate ($8,358.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,371.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,894.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,403.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,031.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $615.69. The transfer capital threshold is the transfer adjustment factor * $615.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8111.71","8100.34","49255.49","1 through 10","8190.86","8939.79","other","Inpatient DRG"
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","AETNA [1001]","HB CH AETNA HMO / PPO","169.65","58.3","","554.95","91.85","1421.75","94","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","212.43","73","","2490.03","2490.03","2490.03","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","169.65","58.3","","750.00","750.00","750.00","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.23","53","","1192.50","120.84","4149.90","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","247.35","85","","750.00","75.00","750.00","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","291.00","100","","657.00","121.50","1971.00","14","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","291.00","100","","75.00","75.00","75.00","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","291.00","100","","366.00","144.00","1971.00","45","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","212.43","73","","667.50","667.50","667.50","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.35","44.45","","123.77","123.77","123.77","1 through 10","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.00","218.25","WELLPOINT [1015]","HB CH WELLPOINT","226.72","77.91","","483.51","229.32","1316.08","96","129.35","291","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.00","218.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.56","59.3","","439.50","225.34","1872.27","197","145.5","228.29","percent of total billed charges",""
"CEMENT BONE 20G KYPHX HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY SINGLE DOSE","SUP-ITM-10016016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","228.29","78.45","","385.32","55.36","1815.62","58","145.5","228.29","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","554.95","91.85","1421.75","94","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","2490.03","2490.03","2490.03","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","750.00","750.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","1192.50","120.84","4149.90","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","750.00","75.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","657.00","121.50","1971.00","14","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","75.00","75.00","75.00","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","366.00","144.00","1971.00","45","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","667.50","667.50","667.50","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","123.77","123.77","123.77","1 through 10","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","483.51","229.32","1316.08","96","53.34","120","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","439.50","225.34","1872.27","197","60","94.14","percent of total billed charges",""
"CEMENT BONE 20GR SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER HALF DOSE SINGLE VIAL BX/10EA","SUP-ITM-10001471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","385.32","55.36","1815.62","58","60","94.14","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","AETNA [1001]","HB CH AETNA HMO / PPO","104.07","58.3","","554.95","91.85","1421.75","94","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","130.31","73","","2490.03","2490.03","2490.03","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.07","58.3","","750.00","750.00","750.00","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.61","53","","1192.50","120.84","4149.90","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","151.73","85","","750.00","75.00","750.00","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","178.50","100","","657.00","121.50","1971.00","14","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","178.50","100","","75.00","75.00","75.00","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","178.50","100","","366.00","144.00","1971.00","45","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","130.31","73","","667.50","667.50","667.50","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.34","44.45","","123.77","123.77","123.77","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB CH WELLPOINT","139.07","77.91","","483.51","229.32","1316.08","96","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.85","59.3","","439.50","225.34","1872.27","197","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE BX/10EA","SUP-ITM-10020933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.03","78.45","","385.32","55.36","1815.62","58","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","AETNA [1001]","HB CH AETNA HMO / PPO","104.07","58.3","","554.95","91.85","1421.75","94","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","130.31","73","","2490.03","2490.03","2490.03","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.07","58.3","","750.00","750.00","750.00","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.61","53","","1192.50","120.84","4149.90","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","151.73","85","","750.00","75.00","750.00","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","178.50","100","","657.00","121.50","1971.00","14","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","178.50","100","","75.00","75.00","75.00","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","178.50","100","","366.00","144.00","1971.00","45","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","130.31","73","","667.50","667.50","667.50","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.34","44.45","","123.77","123.77","123.77","1 through 10","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","both","","","178.50","133.87","WELLPOINT [1015]","HB CH WELLPOINT","139.07","77.91","","483.51","229.32","1316.08","96","79.34","178.5","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.85","59.3","","439.50","225.34","1872.27","197","89.25","140.03","percent of total billed charges",""
"CEMENT BONE 40G SIMPLEX P DEMINERALIZED MATRIX RADIOPAQUE VOID FILLER FULL DOSE SINGLE VIAL BX/10EA","SUP-ITM-10152757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","178.50","133.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.03","78.45","","385.32","55.36","1815.62","58","89.25","140.03","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","AETNA [1001]","HB CH AETNA HMO / PPO","383.03","58.3","","554.95","91.85","1421.75","94","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","479.61","73","","2490.03","2490.03","2490.03","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","383.03","58.3","","750.00","750.00","750.00","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","348.21","53","","1192.50","120.84","4149.90","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","558.45","85","","750.00","75.00","750.00","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","657.00","100","","657.00","121.50","1971.00","14","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","657.00","100","","75.00","75.00","75.00","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","657.00","100","","366.00","144.00","1971.00","45","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","479.61","73","","667.50","667.50","667.50","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","292.04","44.45","","123.77","123.77","123.77","1 through 10","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","both","","","657.00","492.75","WELLPOINT [1015]","HB CH WELLPOINT","511.87","77.91","","483.51","229.32","1316.08","96","292.04","657","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.00","492.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","389.60","59.3","","439.50","225.34","1872.27","197","328.5","515.42","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY NON-ANTIBIOTIC PALACOS MV PRO80","SUP-ITM-10306177","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","657.00","492.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","515.42","78.45","","385.32","55.36","1815.62","58","328.5","515.42","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","554.95","91.85","1421.75","94","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","122.64","73","","2490.03","2490.03","2490.03","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.94","58.3","","750.00","750.00","750.00","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.04","53","","1192.50","120.84","4149.90","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","142.80","85","","750.00","75.00","750.00","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","168.00","100","","657.00","121.50","1971.00","14","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","168.00","100","","75.00","75.00","75.00","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","168.00","100","","366.00","144.00","1971.00","45","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","122.64","73","","667.50","667.50","667.50","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.68","44.45","","123.77","123.77","123.77","1 through 10","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.00","126.00","WELLPOINT [1015]","HB CH WELLPOINT","130.89","77.91","","483.51","229.32","1316.08","96","74.68","168","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.62","59.3","","439.50","225.34","1872.27","197","84","131.8","percent of total billed charges",""
"CEMENT BONE MED VISCOSITY PALACOS","SUP-ITM-10258271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","385.32","55.36","1815.62","58","84","131.8","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","AETNA [1001]","HB CH AETNA HMO / PPO","342.80","58.3","","554.95","91.85","1421.75","94","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","429.24","73","","2490.03","2490.03","2490.03","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","342.80","58.3","","750.00","750.00","750.00","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","311.64","53","","1192.50","120.84","4149.90","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","499.80","85","","750.00","75.00","750.00","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","588.00","100","","657.00","121.50","1971.00","14","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","588.00","100","","75.00","75.00","75.00","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","588.00","100","","366.00","144.00","1971.00","45","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","429.24","73","","667.50","667.50","667.50","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","261.37","44.45","","123.77","123.77","123.77","1 through 10","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","both","","","588.00","441.00","WELLPOINT [1015]","HB CH WELLPOINT","458.11","77.91","","483.51","229.32","1316.08","96","261.37","588","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","588.00","441.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","348.68","59.3","","439.50","225.34","1872.27","197","294","461.29","percent of total billed charges",""
"CEMENT BONE PALACOS R HIGH VISCOSITY 1X40G PLUS GENTAMICIN","SUP-ITM-10241035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","588.00","441.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","461.29","78.45","","385.32","55.36","1815.62","58","294","461.29","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","554.95","91.85","1421.75","94","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2490.03","2490.03","2490.03","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","750.00","750.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","1192.50","120.84","4149.90","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","750.00","75.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","657.00","121.50","1971.00","14","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","75.00","75.00","75.00","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","366.00","144.00","1971.00","45","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","667.50","667.50","667.50","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","123.77","123.77","123.77","1 through 10","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","483.51","229.32","1316.08","96","333.38","750","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","439.50","225.34","1872.27","197","375","588.38","percent of total billed charges",""
"CEMENT BONE SIMPLEX P TOBRAMYCIN 41G POWDER AND 20ML AMPOULE ANTIBIOTIC IMPREGNATED FULL DOSE BX/10EA","SUP-ITM-10012104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","385.32","55.36","1815.62","58","375","588.38","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Certolizumab Abs","PX-31000870","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","both","","","355.00","266.25","AETNA [1001]","HB CH AETNA HMO / PPO","206.97","58.3","","121.91","121.91","121.91","1 through 10","18.27","259.15","percent of total billed charges",""
"Certolizumab Level","PX-31000869","CDM","80299","CPT","0301","RC","","","","outpatient","","","355.00","266.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.50","78.45","","165.29","165.29","165.29","1 through 10","14.12","278.5","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","both","","","93.00","69.75","AETNA [1001]","HB CH AETNA HMO / PPO","54.22","58.3","","51.03","51.03","51.03","1 through 10","10.53","67.89","percent of total billed charges",""
"Ceruloplasmin","PX-30000355","CDM","82390","CPT","0301","RC","","","","outpatient","","","93.00","69.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.15","59.3","","52.74","52.74","52.74","1 through 10","11.07","72.96","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","AETNA [1001]","HB CH AETNA HMO / PPO","5713.40","58.3","","1830.28","315.58","1830.28","1 through 10","4356.1","9800","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7154.00","73","","4170.85","4170.85","4170.85","1 through 10","4356.1","9800","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4356.10","44.45","","649.55","649.55","649.55","1 through 10","4356.1","9800","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","WELLPOINT [1015]","HB CH WELLPOINT","7635.18","77.91","","8998.38","2542.37","8998.38","20","4356.1","9800","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5811.40","59.3","","1891.61","1609.14","3664.18","25","4900","7688.1","percent of total billed charges",""
"CERVICAL DISC 15X15X5MM MOBI-C COBALT CHROME","SUP-ITM-10136261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7688.10","78.45","","1470.68","1310.06","2481.69","19","4900","7688.1","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","554.95","91.85","1421.75","94","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2490.03","2490.03","2490.03","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","750.00","750.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","1192.50","120.84","4149.90","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","750.00","75.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","657.00","121.50","1971.00","14","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","75.00","75.00","75.00","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","366.00","144.00","1971.00","45","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","667.50","667.50","667.50","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","123.77","123.77","123.77","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","483.51","229.32","1316.08","96","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","439.50","225.34","1872.27","197","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 14MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10115707","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","385.32","55.36","1815.62","58","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","554.95","91.85","1421.75","94","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2490.03","2490.03","2490.03","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","750.00","750.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","1192.50","120.84","4149.90","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","750.00","75.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","657.00","121.50","1971.00","14","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","75.00","75.00","75.00","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","366.00","144.00","1971.00","45","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","667.50","667.50","667.50","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","123.77","123.77","123.77","1 through 10","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","483.51","229.32","1316.08","96","666.75","1500","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","439.50","225.34","1872.27","197","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 18MM LEVEL 1 SKYLINE TITANIUM","SUP-ITM-10147015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","385.32","55.36","1815.62","58","750","1176.75","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","554.95","91.85","1421.75","94","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","2490.03","2490.03","2490.03","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.91","58.3","","750.00","750.00","750.00","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.10","53","","1192.50","120.84","4149.90","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1504.50","85","","750.00","75.00","750.00","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1770.00","100","","657.00","121.50","1971.00","14","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1770.00","100","","75.00","75.00","75.00","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1770.00","100","","366.00","144.00","1971.00","45","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","667.50","667.50","667.50","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","123.77","123.77","123.77","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","483.51","229.32","1316.08","96","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","439.50","225.34","1872.27","197","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 28MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10134607","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","385.32","55.36","1815.62","58","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","554.95","91.85","1421.75","94","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","2490.03","2490.03","2490.03","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.91","58.3","","750.00","750.00","750.00","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.10","53","","1192.50","120.84","4149.90","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1504.50","85","","750.00","75.00","750.00","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1770.00","100","","657.00","121.50","1971.00","14","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1770.00","100","","75.00","75.00","75.00","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1770.00","100","","366.00","144.00","1971.00","45","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","667.50","667.50","667.50","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","123.77","123.77","123.77","1 through 10","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","483.51","229.32","1316.08","96","786.77","1770","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","439.50","225.34","1872.27","197","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 30MM LEVEL 2 SKYLINE TITANIUM","SUP-ITM-10021486","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","385.32","55.36","1815.62","58","885","1388.57","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","554.95","91.85","1421.75","94","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","2490.03","2490.03","2490.03","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","750.00","750.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","1192.50","120.84","4149.90","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1721.25","85","","750.00","75.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2025.00","100","","657.00","121.50","1971.00","14","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2025.00","100","","75.00","75.00","75.00","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2025.00","100","","366.00","144.00","1971.00","45","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","667.50","667.50","667.50","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","123.77","123.77","123.77","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","483.51","229.32","1316.08","96","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","439.50","225.34","1872.27","197","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 45MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10124483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","385.32","55.36","1815.62","58","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","554.95","91.85","1421.75","94","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","2490.03","2490.03","2490.03","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","750.00","750.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","1192.50","120.84","4149.90","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1721.25","85","","750.00","75.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2025.00","100","","657.00","121.50","1971.00","14","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2025.00","100","","75.00","75.00","75.00","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2025.00","100","","366.00","144.00","1971.00","45","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","667.50","667.50","667.50","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","123.77","123.77","123.77","1 through 10","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","483.51","229.32","1316.08","96","900.11","2025","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","439.50","225.34","1872.27","197","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 51MM LEVEL 3 SKYLINE TITANIUM","SUP-ITM-10029556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","385.32","55.36","1815.62","58","1012.5","1588.61","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","AETNA [1001]","HB CH AETNA HMO / PPO","1294.26","58.3","","554.95","91.85","1421.75","94","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1620.60","73","","2490.03","2490.03","2490.03","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1294.26","58.3","","750.00","750.00","750.00","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1176.60","53","","1192.50","120.84","4149.90","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1887.00","85","","750.00","75.00","750.00","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2220.00","100","","657.00","121.50","1971.00","14","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2220.00","100","","75.00","75.00","75.00","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2220.00","100","","366.00","144.00","1971.00","45","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1620.60","73","","667.50","667.50","667.50","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","986.79","44.45","","123.77","123.77","123.77","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","WELLPOINT [1015]","HB CH WELLPOINT","1729.60","77.91","","483.51","229.32","1316.08","96","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1316.46","59.3","","439.50","225.34","1872.27","197","1110","1741.59","percent of total billed charges",""
"CERVICAL PLATE 60MM 4 LEVEL SPINE LOCKING TITANIUM","SUP-ITM-10011525","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1741.59","78.45","","385.32","55.36","1815.62","58","1110","1741.59","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","AETNA [1001]","HB CH AETNA HMO / PPO","1294.26","58.3","","554.95","91.85","1421.75","94","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1620.60","73","","2490.03","2490.03","2490.03","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1294.26","58.3","","750.00","750.00","750.00","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1176.60","53","","1192.50","120.84","4149.90","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1887.00","85","","750.00","75.00","750.00","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2220.00","100","","657.00","121.50","1971.00","14","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2220.00","100","","75.00","75.00","75.00","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2220.00","100","","366.00","144.00","1971.00","45","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1620.60","73","","667.50","667.50","667.50","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","986.79","44.45","","123.77","123.77","123.77","1 through 10","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","WELLPOINT [1015]","HB CH WELLPOINT","1729.60","77.91","","483.51","229.32","1316.08","96","986.79","2220","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1316.46","59.3","","439.50","225.34","1872.27","197","1110","1741.59","percent of total billed charges",""
"CERVICAL PLATE 72MM LEVEL 4 SKYLINE TITANIUM","SUP-ITM-10158112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1741.59","78.45","","385.32","55.36","1815.62","58","1110","1741.59","percent of total billed charges",""
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","57607.61","43205.71","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","26916.05","","Case rate ($27,465.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,509.57, add-ons for qualifying new technology services are included. If operating cost exceeds $73,033.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,643.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $25,043.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $27,170.33 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,082.77. The transfer capital threshold is the transfer adjustment factor * $2,082.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","26113.44","26113.44","26113.44","1 through 10","26916.05","28650.4108","other","Inpatient DRG"
"Cervical Spinal Fusion With Cc","472","MS-DRG","","","","","","","","inpatient","","","57607.61","43205.71","MEDICARE [2001]","HB BWF MEDICARE","27465.36","","Case rate ($27,465.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,509.57, add-ons for qualifying new technology services are included. If operating cost exceeds $73,033.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,643.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $25,043.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $27,170.33 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,082.77. The transfer capital threshold is the transfer adjustment factor * $2,082.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","28865.08","14646.28","29059.37","1 through 10","26916.05","28650.4108","other","Inpatient Replacement Plans DRG"
"Cervical Spinal Fusion With McC","471","MS-DRG","","","","","","","","inpatient","","","110891.45","83168.59","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","43903.34","","Case rate ($44,799.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $44,871.79, add-ons for qualifying new technology services are included. If operating cost exceeds $90,395.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,974.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $41,046.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $44,532.56 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,413.70. The transfer capital threshold is the transfer adjustment factor * $3,413.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","36889.54","36889.54","36889.54","1 through 10","43903.34","49566.61","other","Inpatient DRG"
"Cervical Spinal Fusion Without Cc/McC","473","MS-DRG","","","","","","","","inpatient","","","51574.08","38680.56","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","23501.95","","Case rate ($22,817.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,854.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,377.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,286.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $20,752.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,514.82 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,725.90. The transfer capital threshold is the transfer adjustment factor * $1,725.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","22361.83","22361.83","22361.83","1 through 10","22361.08","23501.95","other","Inpatient DRG"
"Cervical Spinal Fusion Without Cc/McC","473","MS-DRG","","","","","","","","inpatient","","","51574.08","38680.56","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","22817.43","","Case rate ($22,817.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,854.06, add-ons for qualifying new technology services are included. If operating cost exceeds $68,377.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,286.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $20,752.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,514.82 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,725.90. The transfer capital threshold is the transfer adjustment factor * $1,725.90. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21792.38","21792.38","21792.38","1 through 10","22361.08","23501.95","other","Inpatient Replacement Plans DRG"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","both","","","261.00","195.75","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","111.97","1146.7","other","OPPS APC"
"Change of Jejunostomy Tube W/O Fluoro","PX-75000456","CDM","44799","CPT","0361","RC","","","","outpatient","","","261.00","195.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","130.76","50.1","","6121.00","6121.00","6121.00","1 through 10","128.07","7178","percent of total billed charges",""
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","both","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","283.02","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","288.83","288.83","288.83","1 through 10","231.42","684.2","other","OPPS APC"
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","663.00","497.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","187.37","187.10","187.37","1 through 10","231.42","774.58","other","ASC "
"Change Tube Cystostomy Smp","PX-76001260","CDM","51705","CPT","0761","RC","","","","outpatient","","","663.00","497.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","191.34","187.37","191.34","1 through 10","231.42","774.58","other","ASC "
"CHARGER BATTERY","SUP-ITM-10269130","CDM","C1822","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","16922.90","16922.90","16922.90","1 through 10","2186.25","4125","percent of total billed charges",""
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","405.72","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","405.33","405.33","405.33","1 through 10","374.21","728.13","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","780.00","585.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","393.90","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","1 through 10","374.21","728.13","other","OPPS APC"
"Chem Ivp/ IV <16 Min Initial Single Drug -96409","PX-33000076","CDM","96409","CPT","0331","RC","","","","both","","","780.00","585.00","MEDICARE [2001]","HB BWF MEDICARE","393.90","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","369.63","739.26","1 through 10","374.21","728.13","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","361.07","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.53","360.73","361.63","15","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","374.79","59","247.48","731.58","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","28","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","227.65","344.95","37","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","727.59","727.59","727.59","1 through 10","247.48","731.58","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","640.97","616.23","640.97","15","247.48","731.58","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","496.40","73","","482.53","482.53","482.53","1 through 10","247.48","731.58","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","HUMANA [1012]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","345.65","345.65","345.65","1 through 10","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","348","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","316.79","343.55","1 through 10","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","MOLINA [1014]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","695.51","695.51","695.51","1 through 10","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","496.40","73","","374.79","374.79","374.79","1 through 10","247.48","731.58","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","TRICARE [160005]","HB BWF TRICARE","333.03","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","333.03","333.03","333.03","1 through 10","247.48","731.58","other","Tricare OPPS"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","316.79","343.55","11","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","350.56","323.26","350.56","52","247.48","731.58","other","OPPS APC"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","700.37","700.37","700.37","1 through 10","247.48","731.58","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","520.60","520.60","48","247.48","731.58","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","400.18","408.67","199","247.48","970.06","other","ASC "
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","400.74","409.23","363","247.48","970.06","other","ASC "
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.24","59.3","","387.35","387.35","387.35","48","247.48","970.06","percent of total billed charges",""
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","581.58","118","247.48","970.06","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","611.28","611.28","727.59","85","247.48","970.06","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","700.37","700.37","700.37","1 through 10","247.48","970.06","other","Multiple Surgery"
"Chemdnrvtn Mscl Facial Trige Cerv","PX-76001850","CDM","64615","CPT","0761","RC","","","","outpatient","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","533.46","78.45","","508.18","301.15","1927.65","48","247.48","970.06","percent of total billed charges",""
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","600.27","600.27","600.27","1 through 10","424.52","1804.32","other","ASC "
"Chemdnrvtn/Dest Nerve Neurlytic Fac|BILATERAL PROCEDURE","PX-76001571","CDM","64612","CPT","0761","RC","","","50","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","613.86","601.12","613.86","1 through 10","424.52","1804.32","other","ASC "
"Chemiluminescent Assay","PX-30000356","CDM","82397","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","89.95","89.95","1 through 10","11.02","94.14","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","405.72","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","406.23","405.33","406.23","12","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","393.90","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","387.60","387.60","387.60","1 through 10","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","790.59","73","","768.69","768.69","768.69","1 through 10","374.21","1121.8","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","MEDICARE [2001]","HB BWF MEDICARE","393.90","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","393.90","739.26","194","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","393.90","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","386.02","386.02","386.02","1 through 10","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","386.02","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","386.02","386.02","1158.06","34","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","386.02","","APC Price ($393.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","387.60","363.72","387.60","11","374.21","1121.8","other","OPPS APC"
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","both","","","1083.00","812.25","WELLPOINT [1015]","HB CH WELLPOINT","843.77","77.91","","829.34","829.34","829.34","1 through 10","374.21","1121.8","percent of total billed charges",""
"Chemo IV Infus Initial Up to 1 Hr - 96413","PX-33000078","CDM","96413","CPT","0335","RC","","","","outpatient","","","1083.00","812.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.61","78.45","","809.55","809.55","809.55","1 through 10","476.2","1250.1","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","86.97","86.97","86.97","12","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","1 through 10","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","231.41","73","","224.84","224.84","224.84","1 through 10","80.29","246.97","percent of total billed charges",""
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","MEDICARE [2001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","84.52","230.67","181","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","82.83","82.83","1 through 10","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","82.83","249.50","32","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","both","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","82.83","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","75.66","83.17","24","80.29","246.97","other","OPPS APC"
"Chemo IV Infus Same Drug Ea Add’L Hr > or = to 31 Min - 96415","PX-33000079","CDM","96415","CPT","0335","RC","","","","outpatient","","","317.00","237.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","248.69","78.45","","236.79","236.79","236.79","1 through 10","98.67","248.69","percent of total billed charges",""
"Chemodenerv 1 Extremity 1-4","PX-76001950","CDM","64642","CPT","0761","RC","","","","both","","","1877.00","1407.75","MEDICARE [2001]","HB BWF MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","598.81","1462.37","other","OPPS APC"
"Chemodenerv Trunk Musc 1-5","PX-76001952","CDM","64646","CPT","0761","RC","","","","outpatient","","","2682.00","2011.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.18","990.18","990.18","1 through 10","598.81","2104.03","other","ASC "
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","4775.00","3581.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2537.66","2537.66","2537.66","1 through 10","979.79","3720.2","other","Multiple Surgery"
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","4775.00","3581.25","MEDICARE [2001]","HB BWF MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","979.79","3720.2","other","OPPS APC"
"Chemodenervation Internal Anal Sph","PX-75000222","CDM","46505","CPT","0761","RC","","","","both","","","4775.00","3581.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","979.79","3720.2","per diem",""
"Chemodenervation Internal Anal Sph|BILATERAL PROCEDURE","PX-75000222","CDM","46505","CPT","0761","RC","","","50","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1680.68","","Case rate ($1,680.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1215.13","1215.13","1215.13","1 through 10","1680.68","8319.15","other","ASC "
"Chemodenervation of Trunk 6 or More Muscles","PX-76001969","CDM","64647","CPT","0761","RC","","","","both","","","2682.00","2011.50","MEDICARE [2001]","HB BWF MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1509.54","1509.54","1509.54","1 through 10","598.81","2089.55","other","OPPS APC"
"Chemodenervation of Trunk 6 or More Muscles","PX-76001969","CDM","64647","CPT","0761","RC","","","","both","","","2682.00","2011.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","598.81","2089.55","per diem",""
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","20117.19","15087.89","MEDICARE [2001]","HB BWF MEDICARE","7602.45","","Case rate ($7,602.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,979.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,503.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,069.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,754.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,640.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.01. The transfer capital threshold is the transfer adjustment factor * $509.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7296.99","0.03","7344.83","18","6829.25","7602.45","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","20117.19","15087.89","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6829.25","","Case rate ($6,968.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,979.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,503.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,069.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,120.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,640.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.01. The transfer capital threshold is the transfer adjustment factor * $509.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7353.91","7353.91","7353.91","1 through 10","6829.25","7602.45","other","Inpatient DRG"
"Chest Pain","313","MS-DRG","","","","","","","","inpatient","","","20117.19","15087.89","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6829.25","","Case rate ($6,968.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,979.43, add-ons for qualifying new technology services are included. If operating cost exceeds $52,503.16 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,069.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $6,120.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,640.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $509.01. The transfer capital threshold is the transfer adjustment factor * $509.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6589.67","6589.67","6589.67","1 through 10","6829.25","7602.45","other","Inpatient DRG"
"Chest Pain,MAJOR","203","DRG","","","","","","","","inpatient","","","9839.79","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6498.92","","Case rate ($7,185.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,615.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7183.91","7183.91","7183.91","1 through 10","3336.85","22980.3","case rate",""
"Chest Pain,MINOR","203","DRG","","","","","","","","inpatient","","","14472.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11438.70","","Standard inlier is a Case rate ($11,438.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,382, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,623.77) for the length of stay and the standard reimbursement.","11438.69","11438.69","11438.69","1 through 10","3336.85","22980.3","case rate",""
"Chest Pain,MODERATE","203","DRG","","","","","","","","inpatient","","","17365.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13529.83","","Standard inlier is a Case rate ($13,529.83). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,382, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,920.61) for the length of stay and the standard reimbursement.","13529.82","13529.82","13529.82","1 through 10","3336.85","22980.3","case rate",""
"Chest Pain,MODERATE","203","DRG","","","","","","","","inpatient","","","17365.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14533.73","","Standard inlier is a Case rate ($14,533.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,527, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,063.00) for the length of stay and the standard reimbursement.","14533.73","14533.73","14533.73","1 through 10","3336.85","22980.3","case rate",""
"Chest Pain,MODERATE","203","DRG","","","","","","","","inpatient","","","17365.67","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4371.83","","Case rate ($4,833.81). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,263.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7457.79","7457.79","7457.79","1 through 10","3336.85","22980.3","case rate",""
"Chest Physiotherapy Initial","PX-46000008","CDM","94667","CPT","0410","RC","","","","both","","","347.00","260.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","337.00","337.00","337.00","1 through 10","67.25","414.21","other","OPPS APC"
"CHIP BONE 1.7 10MM 5.0 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010580","CDM","C1889","HCPCS","0278","RC","","","","both","","","409.50","307.12","AETNA [1001]","HB CH AETNA HMO / PPO","238.74","58.3","","1830.28","315.58","1830.28","1 through 10","182.02","409.5","percent of total billed charges",""
"CHIP BONE 1.7 10MM 5.0 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010580","CDM","C1889","HCPCS","0278","RC","","","","both","","","409.50","307.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","298.94","73","","4170.85","4170.85","4170.85","1 through 10","182.02","409.5","percent of total billed charges",""
"CHIP BONE 1.7 10MM 5.0 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010580","CDM","C1889","HCPCS","0278","RC","","","","both","","","409.50","307.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.02","44.45","","649.55","649.55","649.55","1 through 10","182.02","409.5","percent of total billed charges",""
"CHIP BONE 1.7 10MM 5.0 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010580","CDM","C1889","HCPCS","0278","RC","","","","both","","","409.50","307.12","WELLPOINT [1015]","HB CH WELLPOINT","319.04","77.91","","8998.38","2542.37","8998.38","20","182.02","409.5","percent of total billed charges",""
"CHIP BONE 1.7 10MM 5.0 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","409.50","307.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","242.83","59.3","","1891.61","1609.14","3664.18","25","204.75","321.25","percent of total billed charges",""
"CHIP BONE 1.7 10MM 5.0 ASEP CANCELLOUS . 1.7 FREEZEDRIED","SUP-ITM-10010580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","409.50","307.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","321.25","78.45","","1470.68","1310.06","2481.69","19","204.75","321.25","percent of total billed charges",""
"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","415","MS-DRG","","","","","","","","inpatient","","","57021.77","42766.33","MEDICARE [2001]","HB BWF MEDICARE","19368.33","","Case rate ($19,368.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,399.33, add-ons for qualifying new technology services are included. If operating cost exceeds $64,923.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,021.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $17,568.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,060.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,461.07. The transfer capital threshold is the transfer adjustment factor * $1,461.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19920.33","19920.33","19920.33","1 through 10","18980.96","19949.38","other","Inpatient Replacement Plans DRG"
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","58619.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","44375.42","","Standard inlier is a Case rate ($44,375.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,028, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,298.90) for the length of stay and the standard reimbursement.","44375.42","44375.42","44375.42","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","58619.61","","MASSHEALTH [3001]","HB BWF MEDICAID","15164.91","","Case rate ($16,767.41). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,197.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16763.30","16763.30","16763.30","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MAJOR","263","DRG","","","","","","","","inpatient","","","58619.61","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","15164.91","","Case rate ($16,767.41). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,197.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16763.30","16763.30","16763.30","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","37992.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25689.27","","Standard inlier is a Case rate ($25,689.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,646.69) for the length of stay and the standard reimbursement.","25689.26","25689.26","25689.26","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","37992.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27595.40","","Standard inlier is a Case rate ($27,595.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,917.05) for the length of stay and the standard reimbursement.","27595.39","27595.39","27595.39","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","37992.34","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8498.06","","Case rate ($9,396.07). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,826.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9393.76","9393.76","9393.76","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MINOR","263","DRG","","","","","","","","inpatient","","","37992.34","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8498.06","","Case rate ($9,396.07). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,826.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9393.76","9393.76","9393.76","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32563.27","","Standard inlier is a Case rate ($32,563.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,003, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,622.48) for the length of stay and the standard reimbursement.","32563.27","32563.27","32563.27","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34979.45","","Standard inlier is a Case rate ($34,979.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $45,053, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,965.19) for the length of stay and the standard reimbursement.","34979.45","34979.45","34979.45","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","17650.3344","","Fee schedule rate ($17,650.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17650.3344","23852.96","23852.96","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","MASSHEALTH [3001]","HB BWF MEDICAID","10886.75","","Case rate ($12,037.17). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,467.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17026.16","17026.16","17026.16","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","33109.80","","Fee schedule rate ($33,109.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33109.80","33109.80","33109.80","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10886.75","","Case rate ($12,037.17). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,467.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12034.22","12034.22","12034.22","1 through 10","8498.06","56984.82","case rate",""
"Cholecystectomy,MODERATE","263","DRG","","","","","","","","inpatient","","","46885.07","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","10886.75","","Case rate ($12,037.17). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,467.17, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12034.22","12034.22","12034.22","1 through 10","8498.06","56984.82","case rate",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","72.00","54.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.70","59.3","","41.02","41.02","41.02","1 through 10","9.47","57.78","percent of total billed charges",""
"Cholesterol Ldl","PX-30000561","CDM","83721","CPT","0301","RC","","","","outpatient","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.48","78.45","","53.82","53.82","53.82","1 through 10","9.47","57.78","percent of total billed charges",""
"Cholesterol Total","PX-30000364","CDM","82465","CPT","0301","RC","","","","outpatient","","","36.00","27.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.35","59.3","","20.51","20.51","20.51","1 through 10","4.48","28.24","percent of total billed charges",""
"Chornc Gonad Stimj Pnl Total Estradiol Response","PX-30000047","CDM","80415","CPT","0300","RC","","","","outpatient","","","650.00","487.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","318.96","49.07","","169.59","169.59","169.59","1 through 10","260","509.93","percent of total billed charges",""
"Chronic Kidney Disease,MAJOR","470","DRG","","","","","","","","inpatient","","","40865.53","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11069.53","","Case rate ($12,239.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,669.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12236.26","12236.26","12236.26","1 through 10","9097.88","41261.81","case rate",""
"Chronic Kidney Disease,MAJOR","470","DRG","","","","","","","","inpatient","","","40865.53","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11069.53","","Case rate ($12,239.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,669.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12236.26","12236.26","12236.26","1 through 10","9097.88","41261.81","case rate",""
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","8843.23","","Case rate ($8,843.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,908.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6050.94","6050.94","6050.94","1 through 10","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7939.11","","Case rate ($8,101.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,165.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7918.76","7918.76","7918.76","1 through 10","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","HUMANA [1012]","HB BWF MEDICARE","8843.23","","Case rate ($8,843.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,908.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7922.00","7922.00","23645.91","1 through 10","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","MEDICARE [2001]","HB BWF MEDICARE","8843.23","","Case rate ($8,843.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,908.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8736.00","0.03","8793.61","24","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","MOLINA [1014]","HB BWF MEDICARE","8843.23","","Case rate ($8,843.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,908.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","29256.33","29256.33","29256.33","1 through 10","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7939.11","","Case rate ($8,101.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,165.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7940.36","7940.36","7940.36","1 through 10","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With Cc","191","MS-DRG","","","","","","","","inpatient","","","24337.40","18253.05","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7939.11","","Case rate ($8,101.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,113.78, add-ons for qualifying new technology services are included. If operating cost exceeds $53,637.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,156.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,165.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,774.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $595.97. The transfer capital threshold is the transfer adjustment factor * $595.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7885.24","7885.24","7885.24","1 through 10","7939.11","8843.23","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10854.49","","Case rate ($10,538.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,416.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","10822.56","10822.56","10822.56","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","11513.46","","Case rate ($11,513.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,391.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10317.71","10317.71","10317.71","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10327.57","","Case rate ($10,538.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,416.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","60282.71","60282.71","60282.71","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","HUMANA [1012]","HB BWF MEDICARE","11513.46","","Case rate ($11,513.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,391.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10260.06","10237.30","23894.21","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","MEDICARE [2001]","HB BWF MEDICARE","11513.46","","Case rate ($11,513.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,391.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11342.37","0.03","11417.66","38","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10327.57","","Case rate ($10,538.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,416.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10247.80","10247.80","10260.06","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","10327.57","","Case rate ($10,538.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,416.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10260.07","10254.30","10293.58","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease With McC","190","MS-DRG","","","","","","","","inpatient","","","27989.84","20992.38","WELLSENSE [1003]","HB BWF MEDICARE","11513.46","","Case rate ($11,513.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,554.97, add-ons for qualifying new technology services are included. If operating cost exceeds $56,078.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,343.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,391.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,215.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $783.10. The transfer capital threshold is the transfer adjustment factor * $783.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10293.58","10293.58","10293.58","1 through 10","10327.57","11513.46","other","Inpatient DRG"
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","17478.41","13108.81","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","6250.44","","Case rate ($6,250.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,260.07, add-ons for qualifying new technology services are included. If operating cost exceeds $51,783.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,014.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,457.33 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,920.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.87. The transfer capital threshold is the transfer adjustment factor * $453.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6050.94","6050.94","6050.94","1 through 10","6125.43","6437.95","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease Without Cc/McC","192","MS-DRG","","","","","","","","inpatient","","","17478.41","13108.81","MEDICARE [2001]","HB BWF MEDICARE","6250.44","","Case rate ($6,250.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,260.07, add-ons for qualifying new technology services are included. If operating cost exceeds $51,783.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,014.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,457.33 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,920.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $453.87. The transfer capital threshold is the transfer adjustment factor * $453.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6643.18","6643.18","6643.18","1 through 10","6125.43","6437.95","other","Inpatient Replacement Plans DRG"
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","49806.98","","MASSHEALTH [3001]","HB BWF MEDICAID","11198.61","","Case rate ($12,381.99). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,811.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22402.23","22402.23","22402.23","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","49806.98","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11198.61","","Case rate ($12,381.99). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,811.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12378.95","12378.95","12378.95","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,EXTREME","140","DRG","","","","","","","","inpatient","","","49806.98","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11198.61","","Case rate ($12,381.99). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,811.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12378.95","12378.95","12378.95","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","29786.21","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11518.0548","","Fee schedule rate ($35,019.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11518.0548","18135.89","18135.89","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","29786.21","","MASSHEALTH [3001]","HB BWF MEDICAID","6950.15","","Case rate ($7,684.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,114.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12378.95","12378.95","12378.95","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","29786.21","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10190.36","","Fee schedule rate ($10,190.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7950.64","7950.64","7950.64","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MAJOR","140","DRG","","","","","","","","inpatient","","","29786.21","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6950.15","","Case rate ($7,684.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,114.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7682.70","825.41","7682.70","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MINOR","140","DRG","","","","","","","","inpatient","","","19945.36","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4553.47","","Case rate ($5,034.64). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,464.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5033.41","3041.84","5033.41","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","21792.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12828.6995","","Standard inlier is a Case rate ($15,799.92). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,808, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,242.86) for the length of stay and the standard reimbursement.","12828.6995","15799.91","15799.91","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","21792.48","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11518.0548","","Fee schedule rate ($14,795.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11518.0548","20513.84","20513.84","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","21792.48","","MASSHEALTH [3001]","HB BWF MEDICAID","5706.12","","Case rate ($6,309.09). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,739.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6307.55","6307.55","6307.55","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","21792.48","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5706.12","","Case rate ($6,309.09). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,739.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6307.55","6307.55","6307.55","1 through 10","4504.98","67976.8","case rate",""
"Chronic Obstructive Pulmonary Disease,MODERATE","140","DRG","","","","","","","","inpatient","","","21792.48","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5706.12","","Case rate ($6,309.09). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,739.09, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6307.55","6307.55","6307.55","1 through 10","4504.98","67976.8","case rate",""
"Circulatory Disorders Except Ami, With Cardiac Catheterization With McC","286","MS-DRG","","","","","","","","inpatient","","","62684.51","47013.38","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","20299.25","","Case rate ($20,713.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,746.73, add-ons for qualifying new technology services are included. If operating cost exceeds $66,270.46 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,125.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $18,809.92 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $20,407.49 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,564.36. The transfer capital threshold is the transfer adjustment factor * $1,564.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11848.38","11848.38","11848.38","1 through 10","20299.25","22714.39","other","Inpatient DRG"
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without McC","287","MS-DRG","","","","","","","","inpatient","","","58287.62","43715.71","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9988.31","","Case rate ($10,192.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,208.21, add-ons for qualifying new technology services are included. If operating cost exceeds $55,731.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,317.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,096.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,868.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $756.52. The transfer capital threshold is the transfer adjustment factor * $756.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9969.25","9969.25","9969.25","1 through 10","9988.31","10776.0433","other","Inpatient DRG"
"Circumcision W/Clamp or Othr Device","PX-76001306","CDM","54150","CPT","0723","RC","","","","both","","","398.00","298.50","MEDICARE [2001]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","170.74","2505.46","other","OPPS APC"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","MEDICARE [2001]","HB BWF MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","1565.78","4578.34","other","OPPS APC"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","1565.78","4578.34","per diem",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1565.78","4578.34","per diem",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2393.81","2393.81","2393.81","1 through 10","1565.78","4578.34","other","OPPS APC"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2384.08","2384.08","2384.08","1 through 10","1565.78","4578.34","other","OPPS APC"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","both","","","5836.00","4377.00","WELLPOINT [1015]","HB CH WELLPOINT","4546.83","77.91","","17659.70","17659.70","17659.70","1 through 10","1565.78","4578.34","percent of total billed charges",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","AETNA [1001]","HB CH AETNA HMO / PPO","3402.39","58.3","","22405.58","10813.26","22405.58","1 through 10","1565.78","4472.66","percent of total billed charges",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2872.84","2872.84","2872.84","1 through 10","1565.78","4472.66","other","ASC "
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2817.13","2817.13","2876.82","1 through 10","1565.78","4472.66","other","ASC "
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3460.75","59.3","","12587.87","12587.87","12587.87","1 through 10","1565.78","4472.66","percent of total billed charges",""
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3679.58","3679.58","3679.58","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Circumcision W/O Clamp >28 Days Old","PX-76001308","CDM","54161","CPT","0761","RC","","","","outpatient","","","5836.00","4377.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","11602.44","11602.44","11602.44","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","35866.31","26899.73","MEDICARE [2001]","HB BWF MEDICARE","10064.17","","Case rate ($10,064.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,080.02, add-ons for qualifying new technology services are included. If operating cost exceeds $55,603.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,307.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,978.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,740.78 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.69. The transfer capital threshold is the transfer adjustment factor * $746.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10816.96","10816.96","10816.96","1 through 10","9862.89","10841.89","other","Inpatient Replacement Plans DRG"
"Cirrhosis And Alcoholic Hepatitis With Cc","433","MS-DRG","","","","","","","","inpatient","","","35866.31","26899.73","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9862.89","","Case rate ($10,064.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,080.02, add-ons for qualifying new technology services are included. If operating cost exceeds $55,603.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,307.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,978.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,740.78 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $746.69. The transfer capital threshold is the transfer adjustment factor * $746.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11162.56","11162.56","11162.56","1 through 10","9862.89","10841.89","other","Inpatient DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","56588.65","42441.49","MEDICARE [2001]","HB BWF MEDICARE","18461.38","","Case rate ($18,461.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,490.91, add-ons for qualifying new technology services are included. If operating cost exceeds $64,014.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,952.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,730.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,151.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.44. The transfer capital threshold is the transfer adjustment factor * $1,391.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19600.03","19600.03","19731.40","1 through 10","18092.15","20203.57","other","Inpatient Replacement Plans DRG"
"Cirrhosis And Alcoholic Hepatitis With McC","432","MS-DRG","","","","","","","","inpatient","","","56588.65","42441.49","MOLINA [1014]","HB BWF MEDICARE","18461.38","","Case rate ($18,461.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,490.91, add-ons for qualifying new technology services are included. If operating cost exceeds $64,014.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,952.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,730.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,151.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,391.44. The transfer capital threshold is the transfer adjustment factor * $1,391.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","56323.99","56323.99","56323.99","1 through 10","18092.15","20203.57","other","Inpatient Replacement Plans DRG"
"Cirrhosis And Alcoholic Hepatitis Without Cc/McC","434","MS-DRG","","","","","","","","inpatient","","","16689.61","12517.21","MEDICARE [2001]","HB BWF MEDICARE","6899.56","","Case rate ($6,899.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,910.24, add-ons for qualifying new technology services are included. If operating cost exceeds $52,433.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,064.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,056.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,571.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $503.71. The transfer capital threshold is the transfer adjustment factor * $503.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1415.84","1415.84","1415.84","1 through 10","6761.57","7106.55","other","Inpatient Replacement Plans DRG"
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","554.95","91.85","1421.75","94","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2490.03","2490.03","2490.03","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","750.00","750.00","750.00","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","1192.50","120.84","4149.90","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","750.00","75.00","750.00","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","657.00","121.50","1971.00","14","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","75.00","75.00","75.00","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","366.00","144.00","1971.00","45","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","667.50","667.50","667.50","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","123.77","123.77","123.77","1 through 10","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","483.51","229.32","1316.08","96","1466.85","3300","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","439.50","225.34","1872.27","197","1650","2588.85","percent of total billed charges",""
"CLAVICLE PLATE 101X11 14MM 16 HOLE BONE TITANIUM LOCKING DISTAL RIGHT","SUP-ITM-10050480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","385.32","55.36","1815.62","58","1650","2588.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","AETNA [1001]","HB CH AETNA HMO / PPO","1640.47","58.3","","554.95","91.85","1421.75","94","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2054.11","73","","2490.03","2490.03","2490.03","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1640.47","58.3","","750.00","750.00","750.00","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1491.34","53","","1192.50","120.84","4149.90","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2391.77","85","","750.00","75.00","750.00","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2813.85","100","","657.00","121.50","1971.00","14","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2813.85","100","","75.00","75.00","75.00","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2813.85","100","","366.00","144.00","1971.00","45","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2054.11","73","","667.50","667.50","667.50","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1250.76","44.45","","123.77","123.77","123.77","1 through 10","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","both","","","2813.85","2110.39","WELLPOINT [1015]","HB CH WELLPOINT","2192.27","77.91","","483.51","229.32","1316.08","96","1250.76","2813.85","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2813.85","2110.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","1668.61","59.3","","439.50","225.34","1872.27","197","1406.93","2207.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X12MM 5 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2813.85","2110.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2207.47","78.45","","385.32","55.36","1815.62","58","1406.93","2207.47","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","AETNA [1001]","HB CH AETNA HMO / PPO","1687.07","58.3","","554.95","91.85","1421.75","94","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2112.45","73","","2490.03","2490.03","2490.03","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1687.07","58.3","","750.00","750.00","750.00","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1533.70","53","","1192.50","120.84","4149.90","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2459.70","85","","750.00","75.00","750.00","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2893.77","100","","657.00","121.50","1971.00","14","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2893.77","100","","75.00","75.00","75.00","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2893.77","100","","366.00","144.00","1971.00","45","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2112.45","73","","667.50","667.50","667.50","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.28","44.45","","123.77","123.77","123.77","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","WELLPOINT [1015]","HB CH WELLPOINT","2254.54","77.91","","483.51","229.32","1316.08","96","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.77","2170.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1716.01","59.3","","439.50","225.34","1872.27","197","1446.89","2270.16","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.77","2170.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2270.16","78.45","","385.32","55.36","1815.62","58","1446.89","2270.16","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","AETNA [1001]","HB CH AETNA HMO / PPO","1687.07","58.3","","554.95","91.85","1421.75","94","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2112.45","73","","2490.03","2490.03","2490.03","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1687.07","58.3","","750.00","750.00","750.00","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1533.70","53","","1192.50","120.84","4149.90","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2459.70","85","","750.00","75.00","750.00","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2893.77","100","","657.00","121.50","1971.00","14","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2893.77","100","","75.00","75.00","75.00","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2893.77","100","","366.00","144.00","1971.00","45","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2112.45","73","","667.50","667.50","667.50","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.28","44.45","","123.77","123.77","123.77","1 through 10","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","both","","","2893.77","2170.33","WELLPOINT [1015]","HB CH WELLPOINT","2254.54","77.91","","483.51","229.32","1316.08","96","1286.28","2893.77","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.77","2170.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1716.01","59.3","","439.50","225.34","1872.27","197","1446.89","2270.16","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 6 HOLE LCP SS HOOK RIGHT","SUP-ITM-10037959","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2893.77","2170.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2270.16","78.45","","385.32","55.36","1815.62","58","1446.89","2270.16","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","AETNA [1001]","HB CH AETNA HMO / PPO","1758.90","58.3","","554.95","91.85","1421.75","94","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2202.40","73","","2490.03","2490.03","2490.03","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1758.90","58.3","","750.00","750.00","750.00","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1599.00","53","","1192.50","120.84","4149.90","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2564.43","85","","750.00","75.00","750.00","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3016.98","100","","657.00","121.50","1971.00","14","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3016.98","100","","75.00","75.00","75.00","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3016.98","100","","366.00","144.00","1971.00","45","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2202.40","73","","667.50","667.50","667.50","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1341.05","44.45","","123.77","123.77","123.77","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","WELLPOINT [1015]","HB CH WELLPOINT","2350.53","77.91","","483.51","229.32","1316.08","96","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3016.98","2262.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","1789.07","59.3","","439.50","225.34","1872.27","197","1508.49","2366.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP HOOK DEPTH LEFT","SUP-ITM-10037963","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3016.98","2262.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2366.82","78.45","","385.32","55.36","1815.62","58","1508.49","2366.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","AETNA [1001]","HB CH AETNA HMO / PPO","1758.90","58.3","","554.95","91.85","1421.75","94","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2202.40","73","","2490.03","2490.03","2490.03","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1758.90","58.3","","750.00","750.00","750.00","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1599.00","53","","1192.50","120.84","4149.90","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2564.43","85","","750.00","75.00","750.00","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3016.98","100","","657.00","121.50","1971.00","14","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3016.98","100","","75.00","75.00","75.00","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3016.98","100","","366.00","144.00","1971.00","45","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2202.40","73","","667.50","667.50","667.50","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1341.05","44.45","","123.77","123.77","123.77","1 through 10","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","both","","","3016.98","2262.73","WELLPOINT [1015]","HB CH WELLPOINT","2350.53","77.91","","483.51","229.32","1316.08","96","1341.05","3016.98","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3016.98","2262.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","1789.07","59.3","","439.50","225.34","1872.27","197","1508.49","2366.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X15MM 7 HOLE LCP SS RT HOOK","SUP-ITM-10037962","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3016.98","2262.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2366.82","78.45","","385.32","55.36","1815.62","58","1508.49","2366.82","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","AETNA [1001]","HB CH AETNA HMO / PPO","2100.55","58.3","","554.95","91.85","1421.75","94","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2630.19","73","","2490.03","2490.03","2490.03","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2100.55","58.3","","750.00","750.00","750.00","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1909.59","53","","1192.50","120.84","4149.90","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3062.55","85","","750.00","75.00","750.00","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3603.00","100","","657.00","121.50","1971.00","14","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3603.00","100","","75.00","75.00","75.00","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3603.00","100","","366.00","144.00","1971.00","45","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2630.19","73","","667.50","667.50","667.50","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1601.53","44.45","","123.77","123.77","123.77","1 through 10","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","both","","","3603.00","2702.25","WELLPOINT [1015]","HB CH WELLPOINT","2807.10","77.91","","483.51","229.32","1316.08","96","1601.53","3603","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3603.00","2702.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2136.58","59.3","","439.50","225.34","1872.27","197","1801.5","2826.55","percent of total billed charges",""
"CLAVICLE PLATE 3.5X68MM 9 HOLE BONE TITANIUM LOCKING DISTAL LEFT","SUP-ITM-10049186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3603.00","2702.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2826.55","78.45","","385.32","55.36","1815.62","58","1801.5","2826.55","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","554.95","91.85","1421.75","94","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2490.03","2490.03","2490.03","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","750.00","750.00","750.00","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","1192.50","120.84","4149.90","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","750.00","75.00","750.00","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","657.00","121.50","1971.00","14","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","75.00","75.00","75.00","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","366.00","144.00","1971.00","45","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","667.50","667.50","667.50","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","123.77","123.77","123.77","1 through 10","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","483.51","229.32","1316.08","96","733.43","1650","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","439.50","225.34","1872.27","197","825","1294.43","percent of total billed charges",""
"CLAVICLE PLATE FRACTURE CENTRAL THIRD RT SS","SUP-ITM-10169134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","385.32","55.36","1815.62","58","825","1294.43","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","AETNA [1001]","HB CH AETNA HMO / PPO","2258.10","58.3","","554.95","91.85","1421.75","94","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","2490.03","2490.03","2490.03","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2258.10","58.3","","750.00","750.00","750.00","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.82","53","","1192.50","120.84","4149.90","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3292.25","85","","750.00","75.00","750.00","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3873.24","100","","657.00","121.50","1971.00","14","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3873.24","100","","75.00","75.00","75.00","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3873.24","100","","366.00","144.00","1971.00","45","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","667.50","667.50","667.50","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","123.77","123.77","123.77","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","WELLPOINT [1015]","HB CH WELLPOINT","3017.64","77.91","","483.51","229.32","1316.08","96","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.83","59.3","","439.50","225.34","1872.27","197","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 10 XMM MIDFOOT OSTEOTOMY MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10051910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","385.32","55.36","1815.62","58","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","AETNA [1001]","HB CH AETNA HMO / PPO","2258.10","58.3","","554.95","91.85","1421.75","94","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","2490.03","2490.03","2490.03","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2258.10","58.3","","750.00","750.00","750.00","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.82","53","","1192.50","120.84","4149.90","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3292.25","85","","750.00","75.00","750.00","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3873.24","100","","657.00","121.50","1971.00","14","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3873.24","100","","75.00","75.00","75.00","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3873.24","100","","366.00","144.00","1971.00","45","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2827.47","73","","667.50","667.50","667.50","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.66","44.45","","123.77","123.77","123.77","1 through 10","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","both","","","3873.24","2904.93","WELLPOINT [1015]","HB CH WELLPOINT","3017.64","77.91","","483.51","229.32","1316.08","96","1721.66","3873.24","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","2296.83","59.3","","439.50","225.34","1872.27","197","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 12X10 10MM EASY SI NITINOL FIXATION NOTCH","SUP-ITM-10051911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3873.24","2904.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3038.56","78.45","","385.32","55.36","1815.62","58","1936.62","3038.56","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","AETNA [1001]","HB CH AETNA HMO / PPO","2547.62","58.3","","554.95","91.85","1421.75","94","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3189.99","73","","2490.03","2490.03","2490.03","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2547.62","58.3","","750.00","750.00","750.00","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2316.02","53","","1192.50","120.84","4149.90","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3714.37","85","","750.00","75.00","750.00","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4369.85","100","","657.00","121.50","1971.00","14","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4369.85","100","","75.00","75.00","75.00","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4369.85","100","","366.00","144.00","1971.00","45","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3189.99","73","","667.50","667.50","667.50","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.40","44.45","","123.77","123.77","123.77","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","WELLPOINT [1015]","HB CH WELLPOINT","3404.55","77.91","","483.51","229.32","1316.08","96","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2591.32","59.3","","439.50","225.34","1872.27","197","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 15X12MM EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10041871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3428.15","78.45","","385.32","55.36","1815.62","58","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","AETNA [1001]","HB CH AETNA HMO / PPO","2547.62","58.3","","554.95","91.85","1421.75","94","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3189.99","73","","2490.03","2490.03","2490.03","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2547.62","58.3","","750.00","750.00","750.00","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2316.02","53","","1192.50","120.84","4149.90","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3714.37","85","","750.00","75.00","750.00","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4369.85","100","","657.00","121.50","1971.00","14","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4369.85","100","","75.00","75.00","75.00","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4369.85","100","","366.00","144.00","1971.00","45","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3189.99","73","","667.50","667.50","667.50","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1942.40","44.45","","123.77","123.77","123.77","1 through 10","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","both","","","4369.85","3277.39","WELLPOINT [1015]","HB CH WELLPOINT","3404.55","77.91","","483.51","229.32","1316.08","96","1942.4","4369.85","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2591.32","59.3","","439.50","225.34","1872.27","197","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 18X17 5MM EASY BICORTICAL OSTEOTOMY FOOT HAND","SUP-ITM-10051904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4369.85","3277.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3428.15","78.45","","385.32","55.36","1815.62","58","2184.93","3428.15","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","AETNA [1001]","HB CH AETNA HMO / PPO","2574.50","58.3","","1634.24","1004.95","1718.99","42","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3223.65","73","","2123.89","1900.92","2123.89","1 through 10","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2574.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2340.46","53","","939.37","939.37","5593.65","1 through 10","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3753.57","85","","2323.25","1864.50","2882.25","16","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4415.96","100","","2909.44","1772.40","10952.08","45","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4415.96","100","","2323.25","2323.25","2323.25","1 through 10","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4415.96","100","","2882.25","1772.40","10169.17","187","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3223.65","73","","1659.41","1659.41","1659.41","1 through 10","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","WELLPOINT [1015]","HB CH WELLPOINT","3440.47","77.91","","2050.91","1468.48","2902.83","52","1962.89","4415.96","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4415.96","3311.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","2618.66","59.3","","1548.60","1092.60","3613.79","82","2207.98","3464.32","percent of total billed charges",""
"CLIP BONE 20X2.5 1.6MM SI REARFOOT MONOCORTICAL EASY FIXATION SYSTEM","SUP-ITM-10139609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4415.96","3311.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3464.32","78.45","","2085.51","998.68","6202.11","56","2207.98","3464.32","percent of total billed charges",""
"Closed Tx Nasal Bone Fx W/Mnpj W/O Stabilization","PX-76000325","CDM","21315","CPT","0761","RC","","","","outpatient","","","1832.00","1374.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1462.72","","Case rate ($1,462.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2115.09","2115.09","2115.09","1 through 10","916","1873.9","other","ASC "
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-76000326","CDM","21320","CPT","0761","RC","","","","both","","","4094.00","3070.50","AETNA [1001]","HB CH AETNA HMO / PPO","2386.80","58.3","","8410.88","8410.88","8410.88","1 through 10","98.5","3658.77","percent of total billed charges",""
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-76000326","CDM","21320","CPT","0761","RC","","","","outpatient","","","4094.00","3070.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2551.58","","Case rate ($2,551.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3689.58","3689.58","3689.58","1 through 10","2008.14","4472.66","other","ASC "
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-76000326","CDM","21320","CPT","0761","RC","","","","outpatient","","","4094.00","3070.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2008.14","","Case rate ($2,008.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4719.13","4719.13","4719.13","1 through 10","2008.14","4472.66","other","Multiple Surgery"
"Closed Tx Nasal Bone Fx W/Mnpj W/Stabilization","PX-76000326","CDM","21320","CPT","0761","RC","","","","outpatient","","","4094.00","3070.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3211.74","78.45","","2719.93","2719.93","2719.93","1 through 10","2008.14","4472.66","percent of total billed charges",""
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","4610.00","3457.50","MEDICARE [2001]","HB BWF MEDICARE","2326.32","","APC Price ($2,326.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1990.34","1990.34","1990.34","1 through 10","1548.96","3591.65","other","OPPS APC"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1548.96","3591.65","per diem",""
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","both","","","4610.00","3457.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2279.79","","APC Price ($2,326.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2129.08","2129.08","2129.08","1 through 10","1548.96","3591.65","other","OPPS APC"
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2557.79","2557.79","2557.79","1 through 10","1548.96","4472.66","other","ASC "
"Closure Wound Cplx Secondary","PX-76000153","CDM","13160","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1254.10","1254.10","1254.10","1 through 10","1548.96","4472.66","other","ASC "
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","37217.66","27913.24","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","14383.39","","Case rate ($14,383.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,406.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,930.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,639.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,965.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,067.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.33. The transfer capital threshold is the transfer adjustment factor * $1,078.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14089.86","14089.86","14089.86","1 through 10","14095.72","15426.84","other","Inpatient Replacement Plans DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","37217.66","27913.24","MEDICARE [2001]","HB BWF MEDICARE","14383.39","","Case rate ($14,383.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,406.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,930.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,639.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,965.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,067.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.33. The transfer capital threshold is the transfer adjustment factor * $1,078.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15539.84","0.03","15643.64","23","14095.72","15426.84","other","Inpatient Replacement Plans DRG"
"Coagulation Disorders","813","MS-DRG","","","","","","","","inpatient","","","37217.66","27913.24","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14095.72","","Case rate ($14,383.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,406.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,930.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,639.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,965.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,067.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,078.33. The transfer capital threshold is the transfer adjustment factor * $1,078.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14050.40","14050.40","14084.84","1 through 10","14095.72","15426.84","other","Inpatient DRG"
"Cocaine Abuse And Dependence,MAJOR","774","DRG","","","","","","","","inpatient","","","18030.42","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7831.31","","Fee schedule rate ($7,831.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7831.31","7831.31","7831.31","1 through 10","954.59","45854.63","case rate",""
"Cocaine Abuse And Dependence,MINOR","774","DRG","","","","","","","","inpatient","","","12445.75","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","3628.15","","Case rate ($4,011.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,441.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4010.56","4010.56","4010.56","1 through 10","954.59","45854.63","case rate",""
"Cocaine Abuse And Dependence,MODERATE","774","DRG","","","","","","","","inpatient","","","15199.21","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21854.59","","Standard inlier is a Case rate ($21,854.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,520, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,102.17) for the length of stay and the standard reimbursement.","3648.00","3648.00","3648.00","1 through 10","954.59","45854.63","case rate",""
"Cocaine Abuse And Dependence,MODERATE","774","DRG","","","","","","","","inpatient","","","15199.21","","MASSHEALTH [3001]","HB BWF MEDICAID","5397.68","","Case rate ($5,968.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,398.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5727.54","5727.54","5727.54","1 through 10","954.59","45854.63","case rate",""
"Cocaine Abuse And Dependence,MODERATE","774","DRG","","","","","","","","inpatient","","","15199.21","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","5397.68","","Case rate ($5,968.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,398.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7950.10","7950.10","7950.10","1 through 10","954.59","45854.63","case rate",""
"Cocaine Abuse And Dependence,MODERATE","774","DRG","","","","","","","","inpatient","","","15199.21","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5397.68","","Case rate ($5,968.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,398.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10136.72","10136.72","10136.72","1 through 10","954.59","45854.63","case rate",""
"Cocaine Abuse And Dependence,MODERATE","774","DRG","","","","","","","","inpatient","","","15199.21","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5397.68","","Case rate ($5,968.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,398.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","29121.92","29121.92","29121.92","1 through 10","954.59","45854.63","case rate",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","24","60.9","343.29","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","302.22","302.22","302.22","1 through 10","60.9","343.29","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","234.74","234.74","234.74","1 through 10","60.9","343.29","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","242.60","727.80","33","176.68","603.55","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.56","242.56","242.56","1 through 10","176.68","603.55","percent of total billed charges",""
"Cocaine Screen W/Conf Whole Blood","PX-31000872","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","16","176.68","603.55","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","AETNA [1001]","HB CH AETNA HMO / PPO","544.17","58.3","","1830.28","315.58","1830.28","1 through 10","414.9","933.4","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","681.38","73","","4170.85","4170.85","4170.85","1 through 10","414.9","933.4","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.90","44.45","","649.55","649.55","649.55","1 through 10","414.9","933.4","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","both","","","933.40","700.05","WELLPOINT [1015]","HB CH WELLPOINT","727.21","77.91","","8998.38","2542.37","8998.38","20","414.9","933.4","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","933.40","700.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","553.51","59.3","","1891.61","1609.14","3664.18","25","466.7","732.25","percent of total billed charges",""
"Coil Embolization T1","PX-27000678","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","933.40","700.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","732.25","78.45","","1470.68","1310.06","2481.69","19","466.7","732.25","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","AETNA [1001]","HB CH AETNA HMO / PPO","2255.50","58.3","","1830.28","315.58","1830.28","1 through 10","1719.68","3868.79","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2824.22","73","","4170.85","4170.85","4170.85","1 through 10","1719.68","3868.79","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1719.68","44.45","","649.55","649.55","649.55","1 through 10","1719.68","3868.79","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","both","","","3868.79","2901.59","WELLPOINT [1015]","HB CH WELLPOINT","3014.17","77.91","","8998.38","2542.37","8998.38","20","1719.68","3868.79","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3868.79","2901.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","2294.19","59.3","","1891.61","1609.14","3664.18","25","1934.4","3035.07","percent of total billed charges",""
"Coil Embolization T2","PX-27000679","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3868.79","2901.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3035.07","78.45","","1470.68","1310.06","2481.69","19","1934.4","3035.07","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","AETNA [1001]","HB CH AETNA HMO / PPO","2595.32","58.3","","1830.28","315.58","1830.28","1 through 10","1978.77","4451.67","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3249.72","73","","4170.85","4170.85","4170.85","1 through 10","1978.77","4451.67","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1978.77","44.45","","649.55","649.55","649.55","1 through 10","1978.77","4451.67","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","both","","","4451.67","3338.75","WELLPOINT [1015]","HB CH WELLPOINT","3468.30","77.91","","8998.38","2542.37","8998.38","20","1978.77","4451.67","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4451.67","3338.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2639.84","59.3","","1891.61","1609.14","3664.18","25","2225.84","3492.34","percent of total billed charges",""
"Coil Embolization T3","PX-27000680","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4451.67","3338.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3492.34","78.45","","1470.68","1310.06","2481.69","19","2225.84","3492.34","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1115.19","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","557.06","1114.11","18","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB CH AETNA HMO / PPO","1444.09","58.3","","1365.90","1365.90","1365.90","17","744.89","1808.21","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","981.55","1065.39","14","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","977.56","1061.06","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","HUMANA [1012]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","172","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1061.06","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.54","2409.00","43","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","615.02","1230.03","80","744.89","1943.21","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","615.87","1231.73","147","744.89","1943.21","other","ASC "
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1468.86","59.3","","1411.67","1411.67","1411.67","15","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1101.03","44.45","","1852.04","1852.04","1852.04","1 through 10","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Colonoscopy","PX-75000329","CDM","G0105","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1943.21","78.45","","1852.04","1852.04","1852.04","13","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1115.19","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1026.44","1114.11","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","AETNA [1001]","HB CH AETNA HMO / PPO","1444.09","58.3","","1365.90","1365.90","1365.90","14","744.89","1808.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","530.53","530.53","530.53","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","48","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","MOLINA [1014]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2143.77","1071.89","2143.77","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1061.06","1 through 10","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","both","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","530.53","1082.71","18","744.89","1808.21","other","OPPS APC"
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1204.47","1230.03","62","744.89","1943.21","other","ASC "
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","615.87","1231.73","82","744.89","1943.21","other","ASC "
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1468.86","59.3","","1411.67","1411.67","1411.67","17","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Non-Hr","PX-75000330","CDM","G0121","HCPCS","0750","RC","","","","outpatient","","","2477.00","1857.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1943.21","78.45","","1852.04","1097.54","1852.04","12","744.89","1943.21","percent of total billed charges",""
"Colon Cancer Scr Sigmoidoscopy","PX-75000328","CDM","G0104","HCPCS","0750","RC","","","","outpatient","","","1512.00","1134.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1750.49","1750.49","1 through 10","744.89","1873.9","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1442.24","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","720.42","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB CH AETNA HMO / PPO","1479.65","58.3","","1399.36","1399.36","1399.36","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","14","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.10","631.10","631.10","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","ELDER SERVICES [1037]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.83","263.83","263.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","686.11","686.11","686.11","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1837.66","1254.13","2439.68","13","979.79","1919.74","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MEDICARE [2001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","1400.23","105","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2554.14","1262.20","2556.14","13","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","2130.00","2130.00","2130.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","686.12","686.12","686.12","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","90","979.79","1919.74","other","OPPS APC"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1617.93","1584.32","1617.93","16","979.79","1991.06","other","ASC "
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","45","979.79","1991.06","other","ASC "
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1505.03","59.3","","1446.25","1445.89","1446.25","22","979.79","1991.06","percent of total billed charges",""
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2302.51","2302.51","11","979.79","1991.06","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2420.08","2125.11","3345.86","11","979.79","1991.06","other","Multiple Surgery"
"Colonoscopy Flex W/Rem Tumor Snare","PX-75000200","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1991.06","78.45","","1897.40","1124.42","1897.40","1 through 10","979.79","1991.06","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1115.19","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB CH AETNA HMO / PPO","2115.71","58.3","","2000.94","2000.94","3500.98","1 through 10","744.89","2649.17","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","981.55","981.55","981.55","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2189.98","729.43","2189.98","1 through 10","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1929.27","964.64","1929.27","15","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","997.51","1082.71","32","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1979.07","1977.57","1981.07","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","1968.00","2027.00","19","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","96","744.89","2649.17","per diem",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1065.39","977.56","1065.39","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","530.54","530.53","1061.06","11","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1854.78","1854.78","1854.78","1 through 10","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","1204.47","1230.03","19","744.89","2846.95","other","ASC "
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1206.18","1231.73","38","744.89","2846.95","other","ASC "
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2152.00","59.3","","2067.99","2067.99","2067.99","1 through 10","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1683.45","1750.49","83","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1839.88","1772.84","1929.27","39","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1182.59","1182.59","1182.59","1 through 10","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flexible","PX-75000193","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2846.95","78.45","","2713.10","2713.09","2967.31","1 through 10","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","both","","","2586.00","1939.50","MEDICARE [2001]","HB BWF MEDICARE","1499.49","","APC Price ($1,499.49). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","700.11","1 through 10","979.79","2014.75","other","OPPS APC"
"Colonoscopy Flx Ablation Tumor Polyp/Other Les","PX-75000420","CDM","45388","CPT","0750","RC","","","","both","","","2586.00","1939.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2151.00","2151.00","2151.00","1 through 10","979.79","2014.75","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1115.19","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","AETNA [1001]","HB CH AETNA HMO / PPO","2115.71","58.3","","2000.94","2000.94","3500.98","1 through 10","744.89","2649.17","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","981.55","981.55","981.55","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2189.98","729.43","2189.98","1 through 10","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1929.27","964.64","1929.27","15","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","997.51","1082.71","32","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1979.07","1977.57","1981.07","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","1968.00","2027.00","19","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","96","744.89","2649.17","per diem",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1065.39","977.56","1065.39","1 through 10","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","530.54","530.53","1061.06","11","744.89","2649.17","other","OPPS APC"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","both","","","3629.00","2721.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1854.78","1854.78","1854.78","1 through 10","744.89","2649.17","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","1204.47","1230.03","19","744.89","2846.95","other","ASC "
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1206.18","1231.73","38","744.89","2846.95","other","ASC "
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2152.00","59.3","","2067.99","2067.99","2067.99","1 through 10","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1683.45","1750.49","83","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1839.88","1772.84","1929.27","39","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1182.59","1182.59","1182.59","1 through 10","744.89","2846.95","other","Multiple Surgery"
"Colonoscopy Flx Dx W/Collj Spec When Pfrmd","PX-75000417","CDM","45378","CPT","0750","RC","","","","outpatient","","","3629.00","2721.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2846.95","78.45","","2713.10","2713.09","2967.31","1 through 10","744.89","2846.95","percent of total billed charges",""
"Colonoscopy Flx W/Endoscopic Mucosal Resection","PX-75000422","CDM","45390","CPT","0750","RC","","","","outpatient","","","2497.00","1872.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1620.17","1620.17","1 through 10","979.79","1958.9","other","ASC "
"Colonoscopy Flx W/Removal of Foreign Body(S)","PX-75000194","CDM","45379","CPT","0750","RC","","","","both","","","2476.00","1857.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1442.24","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1440.84","1440.84","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy Thru Stoma","PX-75000157","CDM","44388","CPT","0750","RC","","","","both","","","2476.00","1857.00","MEDICARE [2001]","HB BWF MEDICARE","1082.60","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","997.51","997.51","997.51","1 through 10","744.89","1807.48","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1442.24","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1440.84","720.42","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","AETNA [1001]","HB CH AETNA HMO / PPO","1371.80","58.3","","1297.30","1297.30","1297.30","20","979.79","1919.74","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1372.23","1372.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1407.59","1039.43","2119.05","1 through 10","979.79","1919.74","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","HUMANA [1012]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","1372.23","1372.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MEDICARE [2001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","97","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1378.23","1378.23","1378.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","16","979.79","1919.74","per diem",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","TRICARE [160005]","HB BWF TRICARE","1330.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1330.22","1330.22","1330.22","1 through 10","979.79","1919.74","other","Tricare OPPS"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1372.23","1372.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","1262.20","1372.23","77","979.79","1919.74","other","OPPS APC"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","both","","","2353.00","1764.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1045.91","44.45","","1042.41","1042.41","1042.41","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1617.93","1584.32","1617.93","35","979.79","1873.9","other","ASC "
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","810.09","1620.17","64","979.79","1873.9","other","ASC "
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1395.33","59.3","","1340.77","1340.38","2813.10","13","979.79","1873.9","percent of total billed charges",""
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2214.33","2302.51","11","979.79","1873.9","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2420.08","2331.90","7260.24","15","979.79","1873.9","other","Multiple Surgery"
"Colonoscopy W/Biopsy Single/Multiple","PX-75000195","CDM","45380","CPT","0750","RC","","","","outpatient","","","2353.00","1764.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1845.93","78.45","","1759.01","1042.41","1759.01","1 through 10","979.79","1873.9","percent of total billed charges",""
"Colporrhaphy Non-Obstetric","PX-76001355","CDM","57200","CPT","0761","RC","","","","outpatient","","","8481.00","6360.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4161.63","49.07","","3818.15","3818.15","3818.15","1 through 10","3392.4","6653.34","percent of total billed charges",""
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","441.44","441.44","441.44","1 through 10","273","972.78","other","ASC "
"Colposcopy W/Bx Cervix","PX-76001364","CDM","57455","CPT","0761","RC","","","","outpatient","","","1240.00","930.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","273.00","","Case rate ($273). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","962.34","641.55","962.34","1 through 10","273","972.78","other","Multiple Surgery"
"Colposcopy W/Bx Cervix & Curettage","PX-76001363","CDM","57454","CPT","0761","RC","","","","outpatient","","","651.00","488.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","312.19","","Case rate ($312.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","441.44","441.44","441.44","1 through 10","273","970.06","other","ASC "
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","both","","","4625.00","3468.75","MEDICARE [2001]","HB BWF MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1984.13","3888.77","other","OPPS APC"
"Colposcopy W/Bx Elect Loop Cervix","PX-76001366","CDM","57460","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3818.15","3818.15","3818.15","1 through 10","1873.9","3628.31","other","ASC "
"Colposcopy W/Bx Vagina/Cervix","PX-76001361","CDM","57421","CPT","0761","RC","","","","both","","","1240.00","930.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1013.27","","APC Price ($1,033.95). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1020.28","1020.28","1020.28","1 through 10","531.96","2108.81","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","1873.00","1404.75","FALLON HEALTH [1008]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1372.23","1372.23","1372.23","1 through 10","832.55","1919.74","other","OPPS APC"
"Colsc Flexible W/Control Bleeding Any Method","PX-75000197","CDM","45382","CPT","0750","RC","","","","both","","","1873.00","1404.75","MEDICARE [2001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","832.55","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1442.24","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","720.42","720.42","1440.84","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","AETNA [1001]","HB CH AETNA HMO / PPO","1479.65","58.3","","1399.36","1399.36","1399.36","1 through 10","979.79","1919.74","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1377.83","1377.83","1377.83","14","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.10","631.10","631.10","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","ELDER SERVICES [1037]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.83","263.83","263.83","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","686.11","686.11","686.11","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1837.66","1254.13","2439.68","13","979.79","1919.74","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MEDICARE [2001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","1400.23","105","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2554.14","1262.20","2556.14","13","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","979.79","1919.74","per diem",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","2130.00","2130.00","2130.00","1 through 10","979.79","1919.74","per diem",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","979.79","1919.74","per diem",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","686.12","686.12","686.12","1 through 10","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","both","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1372.23","686.12","1372.23","90","979.79","1919.74","other","OPPS APC"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1617.93","1584.32","1617.93","16","979.79","1991.06","other","ASC "
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1586.56","1620.17","45","979.79","1991.06","other","ASC "
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1505.03","59.3","","1446.25","1445.89","1446.25","22","979.79","1991.06","percent of total billed charges",""
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2302.51","2302.51","2302.51","11","979.79","1991.06","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2420.08","2125.11","3345.86","11","979.79","1991.06","other","Multiple Surgery"
"Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq","PX-75000418","CDM","45385","CPT","0750","RC","","","","outpatient","","","2538.00","1903.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1991.06","78.45","","1897.40","1124.42","1897.40","1 through 10","979.79","1991.06","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.82","78.82","78.82","30","11.76","104.39","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.79","53","","147.34","73.67","221.01","1 through 10","11.76","104.39","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.46","81.46","81.46","12","12.38","112.18","percent of total billed charges",""
"Complement Antigen Ea Component","PX-30000798","CDM","86160","CPT","0302","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.87","63.33","213.73","17","12.38","112.18","percent of total billed charges",""
"Complement Functional Activity","PX-30000799","CDM","86161","CPT","0302","RC","","","","outpatient","","","99.00","74.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.71","59.3","","56.26","56.26","56.26","1 through 10","12.38","77.67","percent of total billed charges",""
"Complement Functional Activity","PX-30000799","CDM","86161","CPT","0302","RC","","","","outpatient","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.67","78.45","","73.80","73.80","73.80","1 through 10","12.38","77.67","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","both","","","172.00","129.00","AETNA [1001]","HB CH AETNA HMO / PPO","100.28","58.3","","94.69","94.69","94.69","1 through 10","19.91","125.56","percent of total billed charges",""
"Complement Total (Ch50)","PX-30000800","CDM","86162","CPT","0302","RC","","","","outpatient","","","172.00","129.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.93","78.45","","128.39","128.39","128.39","1 through 10","20.95","134.93","percent of total billed charges",""
"Complete Tthrc Echo Congenital Cardiac Anomaly","PX-48000413","CDM","93303","CPT","0483","RC","","","","both","","","1858.00","1393.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","638.12","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","640.72","640.72","640.72","1 through 10","618.58","1935.24","other","OPPS APC"
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","17.62","106.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","both","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.34","44.45","","83.03","83.03","83.03","1 through 10","17.62","106.04","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","63.29","63.29","63.29","1 through 10","18.54","113.33","percent of total billed charges",""
"Complex Special Stain O/P Trich/Iro","PX-30001195","CDM","87209","CPT","0306","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","49.20","49.20","83.03","1 through 10","18.54","113.33","percent of total billed charges",""
"Complicated Peptic Ulcer With Cc","381","MS-DRG","","","","","","","","inpatient","","","30329.51","22747.13","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10625.00","","Case rate ($10,315.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,331.79, add-ons for qualifying new technology services are included. If operating cost exceeds $55,855.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,326.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,210.30 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,992.55 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.99. The transfer capital threshold is the transfer adjustment factor * $765.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","10463.56","10463.56","10463.56","1 through 10","10109.22","10770.1099","other","Inpatient DRG"
"Complicated Peptic Ulcer With McC","380","MS-DRG","","","","","","","","inpatient","","","42719.57","32039.68","MEDICARE [2001]","HB BWF MEDICARE","18406.13","","Case rate ($18,406.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,435.57, add-ons for qualifying new technology services are included. If operating cost exceeds $63,959.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,947.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $16,679.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,096.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,387.20. The transfer capital threshold is the transfer adjustment factor * $1,387.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11654.26","11654.26","15558.54","1 through 10","18038.01","19029.4027","other","Inpatient Replacement Plans DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","22655.58","16991.68","HUMANA [1012]","HB BWF MEDICARE","10450.23","","Case rate ($10,450.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,582.93, add-ons for qualifying new technology services are included. If operating cost exceeds $55,106.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,269.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,402.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,243.69 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.59. The transfer capital threshold is the transfer adjustment factor * $708.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6114.10","6114.10","6114.10","1 through 10","9376.53","10450.23","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","22655.58","16991.68","MEDICARE [2001]","HB BWF MEDICARE","10450.23","","Case rate ($10,450.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,582.93, add-ons for qualifying new technology services are included. If operating cost exceeds $55,106.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,269.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $9,402.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,243.69 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.59. The transfer capital threshold is the transfer adjustment factor * $708.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10352.74","10284.62","10352.74","1 through 10","9376.53","10450.23","other","Inpatient DRG"
"Complications Of Treatment With Cc","920","MS-DRG","","","","","","","","inpatient","","","22655.58","16991.68","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9376.53","","Case rate ($9,567.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,582.93, add-ons for qualifying new technology services are included. If operating cost exceeds $55,106.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,269.37, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,520.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,243.69 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $708.59. The transfer capital threshold is the transfer adjustment factor * $708.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9279.49","9279.49","9279.49","1 through 10","9376.53","10450.23","other","Inpatient DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","27829.02","20871.76","MEDICARE [2001]","HB BWF MEDICARE","17196.27","","Case rate ($17,196.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,223.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,747.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,855.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,562.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,884.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.30. The transfer capital threshold is the transfer adjustment factor * $1,294.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","18384.07","1 through 10","16852.34","18033.5804","other","Inpatient Replacement Plans DRG"
"Complications Of Treatment With McC","919","MS-DRG","","","","","","","","inpatient","","","27829.02","20871.76","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16852.34","","Case rate ($17,196.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,223.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,747.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,855.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $15,562.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,884.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.30. The transfer capital threshold is the transfer adjustment factor * $1,294.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16495.05","16461.53","16526.36","1 through 10","16852.34","18033.5804","other","Inpatient DRG"
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","AETNA [1001]","HB CH AETNA HMO / PPO","4919.24","58.3","","1634.24","1004.95","1718.99","42","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6159.59","73","","2123.89","1900.92","2123.89","1 through 10","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4919.24","58.3","","3729.00","1254.19","3729.00","1 through 10","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4472.03","53","","939.37","939.37","5593.65","1 through 10","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7172.13","85","","2323.25","1864.50","2882.25","16","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8437.80","100","","2909.44","1772.40","10952.08","45","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8437.80","100","","2323.25","2323.25","2323.25","1 through 10","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8437.80","100","","2882.25","1772.40","10169.17","187","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6159.59","73","","1659.41","1659.41","1659.41","1 through 10","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","both","","","8437.80","6328.35","WELLPOINT [1015]","HB CH WELLPOINT","6573.89","77.91","","2050.91","1468.48","2902.83","52","3750.6","8437.8","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8437.80","6328.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","5003.62","59.3","","1548.60","1092.60","3613.79","82","4218.9","6619.45","percent of total billed charges",""
"COMPONENT ANKLE SIZE 3 TRABECULAR METAL LEFT TALUS","SUP-ITM-10235655","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8437.80","6328.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6619.45","78.45","","2085.51","998.68","6202.11","56","4218.9","6619.45","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","AETNA [1001]","HB CH AETNA HMO / PPO","2477.75","58.3","","1634.24","1004.95","1718.99","42","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3102.50","73","","2123.89","1900.92","2123.89","1 through 10","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2477.75","58.3","","3729.00","1254.19","3729.00","1 through 10","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2252.50","53","","939.37","939.37","5593.65","1 through 10","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3612.50","85","","2323.25","1864.50","2882.25","16","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4250.00","100","","2909.44","1772.40","10952.08","45","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4250.00","100","","2323.25","2323.25","2323.25","1 through 10","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4250.00","100","","2882.25","1772.40","10169.17","187","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3102.50","73","","1659.41","1659.41","1659.41","1 through 10","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","WELLPOINT [1015]","HB CH WELLPOINT","3311.18","77.91","","2050.91","1468.48","2902.83","52","1889.13","4250","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4250.00","3187.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2520.25","59.3","","1548.60","1092.60","3613.79","82","2125","3334.13","percent of total billed charges",""
"COMPONENT FEMORAL EMPOWR 3D PRESS FIT 8 LEFT","SUP-ITM-10309402","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4250.00","3187.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3334.13","78.45","","2085.51","998.68","6202.11","56","2125","3334.13","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","257","10.35","87.6","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","85.41","85.41","85.41","1 through 10","10.35","87.6","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","62.01","66.34","1 through 10","10.35","87.6","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","62.01","62.01","62.01","1 through 10","10.35","87.6","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","89.95","53.31","89.95","1 through 10","10.35","87.6","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","68.56","68.56","68.56","230","10.89","94.14","percent of total billed charges",""
"Comprehensive Metabolic Panel","PX-30000172","CDM","80053","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","89.95","53.31","89.95","225","10.89","94.14","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","AETNA [1001]","HB CH AETNA HMO / PPO","414.34","58.3","","554.95","91.85","1421.75","94","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","518.81","73","","2490.03","2490.03","2490.03","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","414.34","58.3","","750.00","750.00","750.00","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","376.67","53","","1192.50","120.84","4149.90","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","604.10","85","","750.00","75.00","750.00","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","710.70","100","","657.00","121.50","1971.00","14","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","710.70","100","","75.00","75.00","75.00","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","710.70","100","","366.00","144.00","1971.00","45","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","518.81","73","","667.50","667.50","667.50","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.91","44.45","","123.77","123.77","123.77","1 through 10","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","both","","","710.70","533.02","WELLPOINT [1015]","HB CH WELLPOINT","553.71","77.91","","483.51","229.32","1316.08","96","315.91","710.7","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","710.70","533.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.45","59.3","","439.50","225.34","1872.27","197","355.35","557.54","percent of total billed charges",""
"COMPRESS PLATE 4.5MM 6 HOLE BONE LOCKING NARROW","SUP-ITM-10072315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","710.70","533.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.54","78.45","","385.32","55.36","1815.62","58","355.35","557.54","percent of total billed charges",""
"Concussion With Cc","089","MS-DRG","","","","","","","","inpatient","","","17818.36","13363.77","MEDICARE [2001]","HB BWF MEDICARE","11421.67","","Case rate ($11,421.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,471.05, add-ons for qualifying new technology services are included. If operating cost exceeds $55,994.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,337.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $10,305.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,131.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $776.67. The transfer capital threshold is the transfer adjustment factor * $776.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10911.56","10911.56","10911.56","1 through 10","10245.47","11421.67","other","Inpatient DRG"
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","AETNA [1001]","HB CH AETNA HMO / PPO","651.66","58.3","","554.95","91.85","1421.75","94","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","815.97","73","","2490.03","2490.03","2490.03","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","651.66","58.3","","750.00","750.00","750.00","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","592.42","53","","1192.50","120.84","4149.90","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","950.10","85","","750.00","75.00","750.00","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1117.77","100","","657.00","121.50","1971.00","14","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1117.77","100","","75.00","75.00","75.00","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1117.77","100","","366.00","144.00","1971.00","45","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","815.97","73","","667.50","667.50","667.50","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.85","44.45","","123.77","123.77","123.77","1 through 10","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","both","","","1117.77","838.33","WELLPOINT [1015]","HB CH WELLPOINT","870.85","77.91","","483.51","229.32","1316.08","96","496.85","1117.77","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1117.77","838.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.84","59.3","","439.50","225.34","1872.27","197","558.89","876.89","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE SS LEFT","SUP-ITM-10001620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1117.77","838.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","876.89","78.45","","385.32","55.36","1815.62","58","558.89","876.89","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","AETNA [1001]","HB CH AETNA HMO / PPO","718.96","58.3","","554.95","91.85","1421.75","94","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","900.24","73","","2490.03","2490.03","2490.03","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","718.96","58.3","","750.00","750.00","750.00","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","653.60","53","","1192.50","120.84","4149.90","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1048.23","85","","750.00","75.00","750.00","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1233.21","100","","657.00","121.50","1971.00","14","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1233.21","100","","75.00","75.00","75.00","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1233.21","100","","366.00","144.00","1971.00","45","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","900.24","73","","667.50","667.50","667.50","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","548.16","44.45","","123.77","123.77","123.77","1 through 10","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","both","","","1233.21","924.91","WELLPOINT [1015]","HB CH WELLPOINT","960.79","77.91","","483.51","229.32","1316.08","96","548.16","1233.21","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1233.21","924.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","731.29","59.3","","439.50","225.34","1872.27","197","616.61","967.45","percent of total billed charges",""
"CONDYLAR PLATE 1.5X36MM 7 HOLE TITANIUM LEFT","SUP-ITM-10002317","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1233.21","924.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","967.45","78.45","","385.32","55.36","1815.62","58","616.61","967.45","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","AETNA [1001]","HB CH AETNA HMO / PPO","897.57","58.3","","554.95","91.85","1421.75","94","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1123.89","73","","2490.03","2490.03","2490.03","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","897.57","58.3","","750.00","750.00","750.00","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","815.97","53","","1192.50","120.84","4149.90","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1308.63","85","","750.00","75.00","750.00","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1539.57","100","","657.00","121.50","1971.00","14","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1539.57","100","","75.00","75.00","75.00","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1539.57","100","","366.00","144.00","1971.00","45","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1123.89","73","","667.50","667.50","667.50","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","684.34","44.45","","123.77","123.77","123.77","1 through 10","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","both","","","1539.57","1154.68","WELLPOINT [1015]","HB CH WELLPOINT","1199.48","77.91","","483.51","229.32","1316.08","96","684.34","1539.57","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1539.57","1154.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","912.97","59.3","","439.50","225.34","1872.27","197","769.79","1207.79","percent of total billed charges",""
"CONDYLAR PLATE 2.4X57MM 8 HOLE SS RIGHT","SUP-ITM-10038158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1539.57","1154.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1207.79","78.45","","385.32","55.36","1815.62","58","769.79","1207.79","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","AETNA [1001]","HB CH AETNA HMO / PPO","1175.19","58.3","","554.95","91.85","1421.75","94","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1471.50","73","","2490.03","2490.03","2490.03","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1175.19","58.3","","750.00","750.00","750.00","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1068.35","53","","1192.50","120.84","4149.90","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1713.40","85","","750.00","75.00","750.00","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2015.76","100","","657.00","121.50","1971.00","14","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2015.76","100","","75.00","75.00","75.00","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2015.76","100","","366.00","144.00","1971.00","45","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1471.50","73","","667.50","667.50","667.50","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.01","44.45","","123.77","123.77","123.77","1 through 10","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","both","","","2015.76","1511.82","WELLPOINT [1015]","HB CH WELLPOINT","1570.48","77.91","","483.51","229.32","1316.08","96","896.01","2015.76","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.76","1511.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","1195.35","59.3","","439.50","225.34","1872.27","197","1007.88","1581.36","percent of total billed charges",""
"CONDYLAR PLATE 2X39MM 7HOLE DCP SS RIGHT","SUP-ITM-10006562","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2015.76","1511.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1581.36","78.45","","385.32","55.36","1815.62","58","1007.88","1581.36","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","AETNA [1001]","HB CH AETNA HMO / PPO","386.53","58.3","","554.95","91.85","1421.75","94","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","483.99","73","","2490.03","2490.03","2490.03","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","386.53","58.3","","750.00","750.00","750.00","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","351.39","53","","1192.50","120.84","4149.90","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","563.55","85","","750.00","75.00","750.00","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","663.00","100","","657.00","121.50","1971.00","14","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","663.00","100","","75.00","75.00","75.00","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","663.00","100","","366.00","144.00","1971.00","45","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","483.99","73","","667.50","667.50","667.50","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","294.70","44.45","","123.77","123.77","123.77","1 through 10","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","both","","","663.00","497.25","WELLPOINT [1015]","HB CH WELLPOINT","516.54","77.91","","483.51","229.32","1316.08","96","294.7","663","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","663.00","497.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","393.16","59.3","","439.50","225.34","1872.27","197","331.5","520.12","percent of total billed charges",""
"CONDYLE PLATE 1.5MM TITANIUM 5 HOLE LEFT","SUP-ITM-10072383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","663.00","497.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","520.12","78.45","","385.32","55.36","1815.62","58","331.5","520.12","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","AETNA [1001]","HB CH AETNA HMO / PPO","3539.98","58.3","","1634.24","1004.95","1718.99","42","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4432.56","73","","2123.89","1900.92","2123.89","1 through 10","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3539.98","58.3","","3729.00","1254.19","3729.00","1 through 10","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3218.16","53","","939.37","939.37","5593.65","1 through 10","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5161.20","85","","2323.25","1864.50","2882.25","16","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6072.00","100","","2909.44","1772.40","10952.08","45","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6072.00","100","","2323.25","2323.25","2323.25","1 through 10","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6072.00","100","","2882.25","1772.40","10169.17","187","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4432.56","73","","1659.41","1659.41","1659.41","1 through 10","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","WELLPOINT [1015]","HB CH WELLPOINT","4730.70","77.91","","2050.91","1468.48","2902.83","52","2699","6072","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3600.70","59.3","","1548.60","1092.60","3613.79","82","3036","4763.48","percent of total billed charges",""
"CONE SYM KNEE TRIATHLON AUGMENT SIZE A 20","SUP-ITM-10171337","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4763.48","78.45","","2085.51","998.68","6202.11","56","3036","4763.48","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","AETNA [1001]","HB CH AETNA HMO / PPO","2231.90","58.3","","1634.24","1004.95","1718.99","42","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2794.66","73","","2123.89","1900.92","2123.89","1 through 10","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2231.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2029.00","53","","939.37","939.37","5593.65","1 through 10","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3254.06","85","","2323.25","1864.50","2882.25","16","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3828.30","100","","2909.44","1772.40","10952.08","45","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3828.30","100","","2323.25","2323.25","2323.25","1 through 10","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3828.30","100","","2882.25","1772.40","10169.17","187","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2794.66","73","","1659.41","1659.41","1659.41","1 through 10","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","WELLPOINT [1015]","HB CH WELLPOINT","2982.63","77.91","","2050.91","1468.48","2902.83","52","1701.68","3828.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","2270.18","59.3","","1548.60","1092.60","3613.79","82","1914.15","3003.3","percent of total billed charges",""
"CONE TIB 15MM SM SIZE 52 KNEE TRABECULAR METAL FULL IMPLANT 19 NC","SUP-ITM-10049172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3003.30","78.45","","2085.51","998.68","6202.11","56","1914.15","3003.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","AETNA [1001]","HB CH AETNA HMO / PPO","3688.82","58.3","","1634.24","1004.95","1718.99","42","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4618.93","73","","2123.89","1900.92","2123.89","1 through 10","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3688.82","58.3","","3729.00","1254.19","3729.00","1 through 10","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3353.47","53","","939.37","939.37","5593.65","1 through 10","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5378.21","85","","2323.25","1864.50","2882.25","16","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6327.30","100","","2909.44","1772.40","10952.08","45","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6327.30","100","","2323.25","2323.25","2323.25","1 through 10","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6327.30","100","","2882.25","1772.40","10169.17","187","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4618.93","73","","1659.41","1659.41","1659.41","1 through 10","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","WELLPOINT [1015]","HB CH WELLPOINT","4929.60","77.91","","2050.91","1468.48","2902.83","52","2812.48","6327.3","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","3752.09","59.3","","1548.60","1092.60","3613.79","82","3163.65","4963.77","percent of total billed charges",""
"CONE WAGNER 36.7MM 20X126.8 125DEG STEM FEMORAL HIP MODULAR PROTASUL 64 TITANIUM ALLOY CORUNDUM BLASTED OFFSET","SUP-ITM-10022940","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4963.77","78.45","","2085.51","998.68","6202.11","56","3163.65","4963.77","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3357.59","3357.59","3357.59","1 through 10","1860.14","3888.77","other","OPPS APC"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","MEDICARE [2001]","HB BWF MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1860.14","3888.77","other","OPPS APC"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1860.14","3888.77","per diem",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","TRICARE [160005]","HB BWF TRICARE","3587.09","","APC Price ($3,775.88). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","3587.09","3587.09","3587.09","1 through 10","1860.14","3888.77","other","Tricare OPPS"
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","both","","","4336.00","3252.00","WELLPOINT [1015]","HB CH WELLPOINT","3378.18","77.91","","14779.88","14779.88","14779.88","1 through 10","1860.14","3888.77","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3904.56","3904.56","1 through 10","1873.9","3401.59","other","ASC "
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2571.25","59.3","","4457.60","4457.60","4457.60","1 through 10","1873.9","3401.59","percent of total billed charges",""
"Conization Cervix Loop Elect Exc","PX-76001374","CDM","57522","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","14408.46","4994.08","14982.24","1 through 10","1873.9","3401.59","other","Multiple Surgery"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","34947.05","26210.29","MEDICARE [2001]","HB BWF MEDICARE","11974.49","","Case rate ($11,974.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,976.44, add-ons for qualifying new technology services are included. If operating cost exceeds $56,500.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,819.84 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,637.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.41. The transfer capital threshold is the transfer adjustment factor * $815.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11685.10","0.03","11762.71","1 through 10","10739.96","11974.49","other","Inpatient DRG"
"Connective Tissue Disorders With Cc","546","MS-DRG","","","","","","","","inpatient","","","34947.05","26210.29","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10739.96","","Case rate ($10,959.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,976.44, add-ons for qualifying new technology services are included. If operating cost exceeds $56,500.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,376.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,804.48 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,637.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $815.41. The transfer capital threshold is the transfer adjustment factor * $815.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11367.49","11367.49","11367.49","1 through 10","10739.96","11974.49","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","54739.17","41054.38","MEDICARE [2001]","HB BWF MEDICARE","25374.08","","Case rate ($25,374.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,226.65, add-ons for qualifying new technology services are included. If operating cost exceeds $68,750.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,315.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $23,280.38 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,887.41 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,754.46. The transfer capital threshold is the transfer adjustment factor * $1,754.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","25207.86","25207.86","25377.29","1 through 10","22725.62","25374.08","other","Inpatient DRG"
"Connective Tissue Disorders With McC","545","MS-DRG","","","","","","","","inpatient","","","54739.17","41054.38","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","22725.62","","Case rate ($23,189.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,226.65, add-ons for qualifying new technology services are included. If operating cost exceeds $68,750.38 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,315.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $21,095.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,887.41 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,754.46. The transfer capital threshold is the transfer adjustment factor * $1,754.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","22742.73","22742.73","22742.73","1 through 10","22725.62","25374.08","other","Inpatient DRG"
"Connective Tissue Disorders Without Cc/McC","547","MS-DRG","","","","","","","","inpatient","","","28064.53","21048.40","MEDICARE [2001]","HB BWF MEDICARE","8038.53","","Case rate ($8,038.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,051.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,574.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,151.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $7,108.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,711.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.16. The transfer capital threshold is the transfer adjustment factor * $591.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7620.95","7620.95","7620.95","1 through 10","7379.1718","8279.69","other","Inpatient Replacement Plans DRG"
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","68214.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","29415.55","","Standard inlier is a Case rate ($29,415.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $41,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,175.65) for the length of stay and the standard reimbursement.","188294.62","188294.62","188294.62","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","68214.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","31598.17","","Standard inlier is a Case rate ($31,598.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $41,824, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,485.23) for the length of stay and the standard reimbursement.","31598.16","31598.16","31598.16","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","68214.22","","MASSHEALTH [3001]","HB BWF MEDICAID","14825.63","","Case rate ($16,392.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,822.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16388.26","16388.26","16388.26","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","68214.22","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","14825.63","","Case rate ($16,392.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,822.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16388.26","16388.26","16388.26","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MAJOR","346","DRG","","","","","","","","inpatient","","","68214.22","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","14825.63","","Case rate ($16,392.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,822.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17371.55","17371.55","17371.55","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MINOR","346","DRG","","","","","","","","inpatient","","","17107.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15547.59","","Standard inlier is a Case rate ($15,547.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,206.92) for the length of stay and the standard reimbursement.","15547.59","15547.59","15547.59","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MINOR","346","DRG","","","","","","","","inpatient","","","17107.04","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7112.37","","Case rate ($7,863.95). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,293.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2655.09","2655.09","2655.09","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","30827.57","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20703.79","","Standard inlier is a Case rate ($20,703.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,419, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,938.82) for the length of stay and the standard reimbursement.","20703.79","20703.79","20703.79","1 through 10","7112.37","51590.4","case rate",""
"Connective Tissue Disorders,MODERATE","346","DRG","","","","","","","","inpatient","","","30827.57","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8999.56","","Case rate ($9,950.56). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,380.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9948.12","209.20","9948.12","1 through 10","7112.37","51590.4","case rate",""
"CONNECTOR 5.0X15MM REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10173773","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3391.00","78.45","","555.84","555.84","555.84","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","AETNA [1001]","HB CH AETNA HMO / PPO","1377.34","58.3","","1634.24","1004.95","1718.99","42","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1724.63","73","","2123.89","1900.92","2123.89","1 through 10","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1377.34","58.3","","3729.00","1254.19","3729.00","1 through 10","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1252.13","53","","939.37","939.37","5593.65","1 through 10","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2008.13","85","","2323.25","1864.50","2882.25","16","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2362.50","100","","2909.44","1772.40","10952.08","45","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2362.50","100","","2323.25","2323.25","2323.25","1 through 10","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2362.50","100","","2882.25","1772.40","10169.17","187","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1724.63","73","","1659.41","1659.41","1659.41","1 through 10","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","both","","","2362.50","1771.87","WELLPOINT [1015]","HB CH WELLPOINT","1840.62","77.91","","2050.91","1468.48","2902.83","52","1050.13","2362.5","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","1400.96","59.3","","1548.60","1092.60","3613.79","82","1181.25","1853.38","percent of total billed charges",""
"CONNECTOR AC SHOULDER ASHCOM TITANIUM","SUP-ITM-10319625","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2362.50","1771.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1853.38","78.45","","2085.51","998.68","6202.11","56","1181.25","1853.38","percent of total billed charges",""
"CONNECTOR DIA 3MMX15 REPAIR NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10152892","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4322.50","3241.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3391.00","78.45","","555.84","555.84","555.84","1 through 10","2161.25","3391","percent of total billed charges",""
"CONNECTOR REPAIR 10X3.0MM NERVE AXOGUARD COAPTATION AID PERIPHERAL","SUP-ITM-10124173","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3513.00","2634.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2755.95","78.45","","555.84","555.84","555.84","1 through 10","1756.5","2755.95","percent of total billed charges",""
"Consult Path Surgery Cyto Ea Addl","PX-31000037","CDM","88334","CPT","0312","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","92.15","92.15","92.15","1 through 10","53.34","120","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","both","","","261.00","195.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","152.16","58.3","","381.00","381.00","381.00","1 through 10","116.01","2963.62","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","both","","","261.00","195.75","WELLPOINT [1015]","HB CH WELLPOINT","203.35","77.91","","1216.05","200.05","1216.05","20","116.01","2963.62","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","outpatient","","","261.00","195.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","154.77","59.3","","250.00","143.01","446.54","26","125.76","1886.45","percent of total billed charges",""
"Consult Path Surgery Cyto Initial","PX-31000036","CDM","88333","CPT","0312","RC","","","","outpatient","","","261.00","195.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","204.75","78.45","","195.28","115.72","195.28","12","125.76","1886.45","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","both","","","287.00","215.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","167.32","58.3","","279.00","279.00","279.00","1 through 10","127.57","768.52","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","287.00","215.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.19","59.3","","163.49","163.49","163.49","1 through 10","125.76","489.19","percent of total billed charges",""
"Consult Path Surgery W/Frozen","PX-31000157","CDM","88331","CPT","0312","RC","","","","outpatient","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.15","78.45","","214.50","214.50","214.50","1 through 10","125.76","489.19","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","both","","","17.20","12.90","AETNA [1001]","HB CH AETNA HMO / PPO","10.03","58.3","","2.21","2.21","2.21","7865","0.32","12.56","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","both","","","17.20","12.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","10.03","58.3","","2.21","0.35","2.21","227","0.32","12.56","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0255","RC","","","","both","","","17.20","12.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","9.12","53","","9.68","4.59","206.35","1 through 10","0.32","12.56","percent of total billed charges",""
"Contrast Low Osmolar 300-399mg 20ml","PX-25500014","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","17.20","12.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.98","52.2","","597.26","0.48","597.26","454","8.6","8.98","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","both","","","8.60","6.45","AETNA [1001]","HB CH AETNA HMO / PPO","5.01","58.3","","2.21","2.21","2.21","7865","0.32","6.28","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","both","","","8.60","6.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.01","58.3","","2.21","0.35","2.21","227","0.32","6.28","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0255","RC","","","","both","","","8.60","6.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4.56","53","","9.68","4.59","206.35","1 through 10","0.32","6.28","percent of total billed charges",""
"Contrast Lowosmolar 300-399mg 10ml","PX-25500015","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","8.60","6.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","4.49","52.2","","597.26","0.48","597.26","454","4.3","4.49","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","AETNA [1001]","HB CH AETNA HMO / PPO","664.62","58.3","","1634.24","1004.95","1718.99","42","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","832.20","73","","2123.89","1900.92","2123.89","1 through 10","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","664.62","58.3","","3729.00","1254.19","3729.00","1 through 10","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","604.20","53","","939.37","939.37","5593.65","1 through 10","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","969.00","85","","2323.25","1864.50","2882.25","16","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1140.00","100","","2909.44","1772.40","10952.08","45","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1140.00","100","","2323.25","2323.25","2323.25","1 through 10","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1140.00","100","","2882.25","1772.40","10169.17","187","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","832.20","73","","1659.41","1659.41","1659.41","1 through 10","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","both","","","1140.00","855.00","WELLPOINT [1015]","HB CH WELLPOINT","888.17","77.91","","2050.91","1468.48","2902.83","52","506.73","1140","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1140.00","855.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","676.02","59.3","","1548.60","1092.60","3613.79","82","570","894.33","percent of total billed charges",""
"CONTROL CABLE 1.8MMX25IN CABLE SLEEVE SS","SUP-ITM-10119539","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1140.00","855.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","894.33","78.45","","2085.51","998.68","6202.11","56","570","894.33","percent of total billed charges",""
"Control Nosebleed Posterior Initial","PX-76000750","CDM","30905","CPT","0761","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","121.77","","Case rate ($121.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","175.84","175.84","175.84","1 through 10","106.48","1873.9","other","ASC "
"Control Nosebleed Posterior Initial","PX-76000750","CDM","30905","CPT","0761","RC","","","","outpatient","","","478.00","358.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC PPO / PREFERRED A","106.48","","Case rate ($106.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","263.01","263.01","263.01","1 through 10","106.48","1873.9","other","Multiple Surgery"
"CONTROLLER PATIENT APPLE IPOD TOUCH MOBILE DEVICE PROCLAIM ELITE SYSTEM - DISCONTINUED PER SUPPLIER","SUP-ITM-10209190","CDM","C1787","HCPCS","0270","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2948.77","2948.77","2948.77","1 through 10","1590","3000","percent of total billed charges",""
"CONTROLLER PATIENT APPLE IPOD TOUCH MOBILE DEVICE PROCLAIM ELITE SYSTEM - DISCONTINUED PER SUPPLIER","SUP-ITM-10209190","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","4673.98","4673.98","4673.98","1 through 10","1333.5","2353.5","percent of total billed charges",""
"Contusion, Open Wound And Other Trauma To Skin And Subcutaneous Tissue,MODERATE","384","DRG","","","","","","","","inpatient","","","11244.74","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5477.64","","Case rate ($6,056.48). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,486.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6054.99","6054.99","6054.99","1 through 10","5477.64","18398.43","case rate",""
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","72.66","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","24.20","24.20","24.20","1 through 10","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.14","23.14","23.14","1 through 10","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","both","","","68.00","51.00","MEDICARE [2001]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.51","23.51","23.51","1 through 10","21.25","170.56","other","OPPS APC"
"Coombs Direct","PX-30000070","CDM","86880","CPT","0302","RC","","","","outpatient","","","68.00","51.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","40.32","59.3","","36.61","36.61","36.61","1 through 10","5.55","108.57","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","1 through 10","22.61","768.52","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.40","53","","248.04","248.04","248.04","1 through 10","22.61","768.52","percent of total billed charges",""
"Coombs Indirect Ql","PX-30000071","CDM","86885","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","43.47","43.47","43.47","1 through 10","5.9","489.19","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB CH AETNA HMO / PPO","60.05","58.3","","56.70","56.70","56.70","1 through 10","12.16","75.19","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","58.60","100.00","1 through 10","12.8","80.8","percent of total billed charges",""
"Copper","PX-30000380","CDM","82525","CPT","0301","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.80","78.45","","76.88","76.88","76.88","1 through 10","12.8","80.8","percent of total billed charges",""
"Cortical/Subcortical Mapping 1st Hr","PX-74000041","CDM","95961","CPT","0740","RC","","","","both","","","1818.00","1363.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","963.54","53","","937.04","937.04","937.04","1 through 10","808.1","3550.75","percent of total billed charges",""
"Cortisol Free","PX-30000382","CDM","82530","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","16.38","98.61","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","both","","","190.00","142.50","AETNA [1001]","HB CH AETNA HMO / PPO","110.77","58.3","","104.90","101.52","104.90","1 through 10","15.97","138.7","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","190.00","142.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.67","59.3","","108.41","108.41","108.41","1 through 10","16.81","149.06","percent of total billed charges",""
"Cortisol Total","PX-30000383","CDM","82533","CPT","0301","RC","","","","outpatient","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.06","78.45","","142.23","142.23","142.23","1 through 10","16.81","149.06","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","AETNA [1001]","HB CH AETNA HMO / PPO","298.20","58.3","","554.95","91.85","1421.75","94","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","373.40","73","","2490.03","2490.03","2490.03","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","298.20","58.3","","750.00","750.00","750.00","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","271.10","53","","1192.50","120.84","4149.90","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","434.78","85","","750.00","75.00","750.00","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","511.50","100","","657.00","121.50","1971.00","14","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","511.50","100","","75.00","75.00","75.00","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","511.50","100","","366.00","144.00","1971.00","45","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","373.40","73","","667.50","667.50","667.50","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.36","44.45","","123.77","123.77","123.77","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","WELLPOINT [1015]","HB CH WELLPOINT","398.51","77.91","","483.51","229.32","1316.08","96","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.50","383.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","303.32","59.3","","439.50","225.34","1872.27","197","255.75","401.27","percent of total billed charges",""
"COUNTERSINK HEADLESS 2.5MM","SUP-ITM-10242350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.50","383.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","401.27","78.45","","385.32","55.36","1815.62","58","255.75","401.27","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","AETNA [1001]","HB CH AETNA HMO / PPO","298.20","58.3","","554.95","91.85","1421.75","94","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","373.40","73","","2490.03","2490.03","2490.03","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","298.20","58.3","","750.00","750.00","750.00","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","271.10","53","","1192.50","120.84","4149.90","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","434.78","85","","750.00","75.00","750.00","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","511.50","100","","657.00","121.50","1971.00","14","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","511.50","100","","75.00","75.00","75.00","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","511.50","100","","366.00","144.00","1971.00","45","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","373.40","73","","667.50","667.50","667.50","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","227.36","44.45","","123.77","123.77","123.77","1 through 10","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","both","","","511.50","383.62","WELLPOINT [1015]","HB CH WELLPOINT","398.51","77.91","","483.51","229.32","1316.08","96","227.36","511.5","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.50","383.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","303.32","59.3","","439.50","225.34","1872.27","197","255.75","401.27","percent of total billed charges",""
"COUNTERSINK HEADLESS 4.0MM","SUP-ITM-10242347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","511.50","383.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","401.27","78.45","","385.32","55.36","1815.62","58","255.75","401.27","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","AETNA [1001]","HB CH AETNA HMO / PPO","457.26","58.3","","554.95","91.85","1421.75","94","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","572.55","73","","2490.03","2490.03","2490.03","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","457.26","58.3","","750.00","750.00","750.00","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","415.69","53","","1192.50","120.84","4149.90","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","666.67","85","","750.00","75.00","750.00","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","784.32","100","","657.00","121.50","1971.00","14","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","784.32","100","","75.00","75.00","75.00","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","784.32","100","","366.00","144.00","1971.00","45","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","572.55","73","","667.50","667.50","667.50","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","348.63","44.45","","123.77","123.77","123.77","1 through 10","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","both","","","784.32","588.24","WELLPOINT [1015]","HB CH WELLPOINT","611.06","77.91","","483.51","229.32","1316.08","96","348.63","784.32","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.32","588.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","465.10","59.3","","439.50","225.34","1872.27","197","392.16","615.3","percent of total billed charges",""
"COUNTERSINK SCREW 3.5 4MM BONE CANNULATED AND","SUP-ITM-10018540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","784.32","588.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","615.30","78.45","","385.32","55.36","1815.62","58","392.16","615.3","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","AETNA [1001]","HB CH AETNA HMO / PPO","379.97","58.3","","554.95","91.85","1421.75","94","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","475.78","73","","2490.03","2490.03","2490.03","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","379.97","58.3","","750.00","750.00","750.00","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.43","53","","1192.50","120.84","4149.90","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","553.99","85","","750.00","75.00","750.00","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.75","100","","657.00","121.50","1971.00","14","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","651.75","100","","75.00","75.00","75.00","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.75","100","","366.00","144.00","1971.00","45","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.78","73","","667.50","667.50","667.50","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.70","44.45","","123.77","123.77","123.77","1 through 10","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","WELLPOINT [1015]","HB CH WELLPOINT","507.78","77.91","","483.51","229.32","1316.08","96","289.7","651.75","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.49","59.3","","439.50","225.34","1872.27","197","325.88","511.3","percent of total billed charges",""
"COUNTERSINK SCREW 4 4.5MM SPINE HEADED","SUP-ITM-10242191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.30","78.45","","385.32","55.36","1815.62","58","325.88","511.3","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","AETNA [1001]","HB CH AETNA HMO / PPO","1364.22","58.3","","1634.24","1004.95","1718.99","42","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1708.20","73","","2123.89","1900.92","2123.89","1 through 10","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1364.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1240.20","53","","939.37","939.37","5593.65","1 through 10","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1989.00","85","","2323.25","1864.50","2882.25","16","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2340.00","100","","2909.44","1772.40","10952.08","45","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2340.00","100","","2323.25","2323.25","2323.25","1 through 10","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2340.00","100","","2882.25","1772.40","10169.17","187","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1708.20","73","","1659.41","1659.41","1659.41","1 through 10","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2340.00","1755.00","WELLPOINT [1015]","HB CH WELLPOINT","1823.09","77.91","","2050.91","1468.48","2902.83","52","1040.13","2340","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1387.62","59.3","","1548.60","1092.60","3613.79","82","1170","1835.73","percent of total billed charges",""
"COUPLER KNEE 4MM LEGION TITANIUM OFFSET PLUS","SUP-ITM-10018674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2340.00","1755.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1835.73","78.45","","2085.51","998.68","6202.11","56","1170","1835.73","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1634.24","1004.95","1718.99","42","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","2123.89","1900.92","2123.89","1 through 10","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2984.96","58.3","","3729.00","1254.19","3729.00","1 through 10","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","939.37","939.37","5593.65","1 through 10","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4352.00","85","","2323.25","1864.50","2882.25","16","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5120.00","100","","2909.44","1772.40","10952.08","45","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5120.00","100","","2323.25","2323.25","2323.25","1 through 10","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5120.00","100","","2882.25","1772.40","10169.17","187","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","1659.41","1659.41","1659.41","1 through 10","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","2050.91","1468.48","2902.83","52","2275.84","5120","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1548.60","1092.60","3613.79","82","2560","4016.64","percent of total billed charges",""
"COVER IMPLANT 4X150MM ELBOW HUMERAL COMPONENT DISY FLANGED RT 02","SUP-ITM-10019493","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","2085.51","998.68","6202.11","56","2560","4016.64","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","AETNA [1001]","HB CH AETNA HMO / PPO","232.62","58.3","","554.95","91.85","1421.75","94","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","291.27","73","","2490.03","2490.03","2490.03","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","232.62","58.3","","750.00","750.00","750.00","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","211.47","53","","1192.50","120.84","4149.90","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","339.15","85","","750.00","75.00","750.00","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","399.00","100","","657.00","121.50","1971.00","14","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","399.00","100","","75.00","75.00","75.00","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","399.00","100","","366.00","144.00","1971.00","45","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","291.27","73","","667.50","667.50","667.50","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.36","44.45","","123.77","123.77","123.77","1 through 10","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB CH WELLPOINT","310.86","77.91","","483.51","229.32","1316.08","96","177.36","399","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","236.61","59.3","","439.50","225.34","1872.27","197","199.5","313.02","percent of total billed charges",""
"COVER SCREW HUB CAP WRIST TITANIUM FUSION","SUP-ITM-10017364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","385.32","55.36","1815.62","58","199.5","313.02","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","498.00","373.50","AETNA [1001]","HB CH AETNA HMO / PPO","290.33","58.3","","274.43","274.43","274.43","1 through 10","221.36","745.32","percent of total billed charges",""
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","498.00","373.50","ELDER SERVICES [1037]","HB BWF MEDICARE","241.54","","APC Price ($241.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","27.04","27.04","27.04","1 through 10","221.36","745.32","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","both","","","498.00","373.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","236.71","","APC Price ($241.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","228.13","228.13","228.13","1 through 10","221.36","745.32","other","OPPS APC"
"Cpap Treatment","PX-46000005","CDM","94660","CPT","0410","RC","","","","outpatient","","","498.00","373.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","295.31","59.3","","283.62","276.85","283.62","1 through 10","249","473.25","percent of total billed charges",""
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","23587.35","17690.51","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14808.56","","Case rate ($15,110.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,134.86, add-ons for qualifying new technology services are included. If operating cost exceeds $60,658.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,637.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,795.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.18. The transfer capital threshold is the transfer adjustment factor * $1,134.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14097.44","14097.44","14097.44","1 through 10","14808.56","15564.1","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders With McC","073","MS-DRG","","","","","","","","inpatient","","","23587.35","17690.51","MEDICARE [2001]","HB BWF MEDICARE","15110.78","","Case rate ($15,110.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,134.86, add-ons for qualifying new technology services are included. If operating cost exceeds $60,658.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,694.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,637.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,795.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,134.18. The transfer capital threshold is the transfer adjustment factor * $1,134.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15516.15","15516.15","15619.79","1 through 10","14808.56","15564.1","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","30058.39","22543.79","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10125.20","","Case rate ($9,830.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,845.77, add-ons for qualifying new technology services are included. If operating cost exceeds $55,369.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,762.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,506.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.73. The transfer capital threshold is the transfer adjustment factor * $728.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","10018.41","10018.41","10018.41","1 through 10","9633.68","10308.2936","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","30058.39","22543.79","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9633.68","","Case rate ($9,830.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,845.77, add-ons for qualifying new technology services are included. If operating cost exceeds $55,369.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,762.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,506.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.73. The transfer capital threshold is the transfer adjustment factor * $728.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9548.65","9548.65","9548.65","1 through 10","9633.68","10308.2936","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","30058.39","22543.79","MEDICARE [2001]","HB BWF MEDICARE","9830.29","","Case rate ($9,830.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,845.77, add-ons for qualifying new technology services are included. If operating cost exceeds $55,369.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,762.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,506.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.73. The transfer capital threshold is the transfer adjustment factor * $728.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10546.33","0.03","10616.25","14","9633.68","10308.2936","other","Inpatient Replacement Plans DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","30058.39","22543.79","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9633.68","","Case rate ($9,830.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,845.77, add-ons for qualifying new technology services are included. If operating cost exceeds $55,369.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,762.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,506.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.73. The transfer capital threshold is the transfer adjustment factor * $728.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10494.85","10494.85","10494.85","1 through 10","9633.68","10308.2936","other","Inpatient DRG"
"Cranial And Peripheral Nerve Disorders Without McC","074","MS-DRG","","","","","","","","inpatient","","","30058.39","22543.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9633.68","","Case rate ($9,830.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,845.77, add-ons for qualifying new technology services are included. If operating cost exceeds $55,369.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,762.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,506.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.73. The transfer capital threshold is the transfer adjustment factor * $728.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9519.14","9519.14","9519.14","1 through 10","9633.68","10308.2936","other","Inpatient DRG"
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","AETNA [1001]","HB CH AETNA HMO / PPO","541.00","58.3","","554.95","91.85","1421.75","94","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","677.41","73","","2490.03","2490.03","2490.03","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","541.00","58.3","","750.00","750.00","750.00","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","491.82","53","","1192.50","120.84","4149.90","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","788.77","85","","750.00","75.00","750.00","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","927.96","100","","657.00","121.50","1971.00","14","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","927.96","100","","75.00","75.00","75.00","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","927.96","100","","366.00","144.00","1971.00","45","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","677.41","73","","667.50","667.50","667.50","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","412.48","44.45","","123.77","123.77","123.77","1 through 10","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","both","","","927.96","695.97","WELLPOINT [1015]","HB CH WELLPOINT","722.97","77.91","","483.51","229.32","1316.08","96","412.48","927.96","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.96","695.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","550.28","59.3","","439.50","225.34","1872.27","197","463.98","727.98","percent of total billed charges",""
"CRANIOMAXILLOFACIAL PLATE 1.3MM 8 HOLE BONE OBLIQUE STAINLESS LOCKING STRUT LEFT","SUP-ITM-10164646","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","927.96","695.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","727.98","78.45","","385.32","55.36","1815.62","58","463.98","727.98","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","65.78","18","6.38","43.8","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","30.74","30.74","30.74","1 through 10","6.38","43.8","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","11","6.71","47.07","percent of total billed charges",""
"Creatine Kinase (Cpk) Total","PX-30000389","CDM","82550","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","44.59","52.84","26","6.71","47.07","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","48.76","16","5.02","33.61","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","75.60","23","5.29","34.52","percent of total billed charges",""
"Creatinine Blood","PX-30000393","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","33.06","33.06","1 through 10","5.29","34.52","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","24.38","24.38","48.76","16","5.02","33.61","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.20","25.20","75.60","23","5.29","34.52","percent of total billed charges",""
"Creatinine Blood (Qw)","PX-30002775","CDM","82565","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","33.06","33.06","33.06","1 through 10","5.29","34.52","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.45","63","5.08","44.53","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","45.36","45.36","45.36","1 through 10","5.08","44.53","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","both","","","61.00","45.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.11","44.45","","26.88","26.88","26.88","1 through 10","5.08","44.53","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.57","103.71","55","5.34","47.85","percent of total billed charges",""
"Creatinine Other Source","PX-30000394","CDM","82570","CPT","0301","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","35","5.34","47.85","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","outpatient","","","3127.00","2345.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1534.42","49.07","","879.79","879.79","879.79","1 through 10","695.29","2453.13","percent of total billed charges",""
"Crisis Intervention Mental Health Services","PX-90000170","CDM","S9485","HCPCS","0900","RC","","","","outpatient","","","3127.00","2345.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1566.63","50.1","","881.04","881.04","881.04","1 through 10","695.29","2453.13","percent of total billed charges",""
"Critical Care; Ea Add 30 Minutes","PX-45000007","CDM","99292","CPT","0450","RC","","","","outpatient","","","1864.00","1398.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1105.35","59.3","","1062.42","1062.42","1062.42","1 through 10","932","1462.31","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","both","","","217.00","162.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","115.01","53","","223.66","223.66","223.66","1 through 10","96.46","768.52","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","both","","","217.00","162.75","WELLPOINT [1015]","HB CH WELLPOINT","169.06","77.91","","588.19","166.19","588.19","1 through 10","96.46","768.52","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","outpatient","","","217.00","162.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","128.68","59.3","","117.26","117.26","117.26","1 through 10","108.5","489.19","percent of total billed charges",""
"Crossmatch Antiglobulin (Ahg)","PX-30000086","CDM","86922","CPT","0302","RC","","","","outpatient","","","217.00","162.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","170.24","78.45","","162.22","162.22","162.22","1 through 10","108.5","489.19","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","AETNA [1001]","HB CH AETNA HMO / PPO","127.68","58.3","","120.77","120.77","120.77","1 through 10","97.35","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","116.07","53","","225.78","225.78","225.78","1 through 10","97.35","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","MEDICARE [2001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","203.50","203.50","1 through 10","97.35","768.52","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","99.72","99.72","99.72","1 through 10","97.35","768.52","other","OPPS APC"
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","both","","","219.00","164.25","WELLPOINT [1015]","HB CH WELLPOINT","170.62","77.91","","593.76","167.76","593.76","1 through 10","97.35","768.52","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","outpatient","","","219.00","164.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.87","59.3","","374.46","118.41","374.46","1 through 10","96.51","489.19","percent of total billed charges",""
"Crossmatch Immediate Spin","PX-30000084","CDM","86920","CPT","0302","RC","","","","outpatient","","","219.00","164.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.81","78.45","","163.76","163.76","163.76","1 through 10","96.51","489.19","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","58.00","43.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.39","59.3","","98.46","32.82","98.46","1 through 10","6.67","45.5","percent of total billed charges",""
"Cryoglobulin Ql or Sqn","PX-30000398","CDM","82595","CPT","0301","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.50","78.45","","43.05","43.05","43.05","1 through 10","6.67","45.5","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","AETNA [1001]","HB CH AETNA HMO / PPO","2147.77","58.3","","2030.99","2030.99","2030.99","1 through 10","265.02","2689.32","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","417.32","417.32","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","968.56","968.56","1 through 10","265.02","2689.32","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2147.77","58.3","","2030.99","2030.99","2030.99","1 through 10","265.02","2689.32","percent of total billed charges",""
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","424.11","47","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","415.63","414.54","415.63","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","847.27","847.27","847.27","1 through 10","265.02","2689.32","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","996.51","996.51","996.51","1 through 10","265.02","2689.32","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1089.00","1057.03","3267.00","1 through 10","265.02","2689.32","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","MOLINA [1014]","HB BWF MEDICARE","424.11","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","832.06","832.06","832.06","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","TRICARE [160005]","HB BWF TRICARE","402.91","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","265.02","2689.32","other","Tricare OPPS"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","402.91","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","424.11","419.73","424.11","1 through 10","265.02","2689.32","other","Tricare OPPS"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","both","","","3684.00","2763.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","415.63","2250.93","11","265.02","2689.32","other","OPPS APC"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","18","385.88","1842","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","41","385.88","1842","other","Multiple Imaging"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","12","385.88","1842","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","1842","other","Multiple Radiology"
"CT Abd/Pelvis W/Wocontrast Post","PX-35000074","CDM","74174","CPT","0352","RC","","","","outpatient","","","3684.00","2763.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1309.29","35.54","","1247.61","1247.61","1631.96","1 through 10","385.88","1842","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","263.16","282.47","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","263.16","282.47","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","1072.75","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","HUMANA [1012]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","283.04","283.04","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","775.92","53","","754.72","754.72","754.72","1 through 10","225.91","1072.75","percent of total billed charges",""
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","146","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","262.09","284.52","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","312.68","312.68","312.68","1 through 10","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","367.76","303.54","367.76","1 through 10","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","386.41","386.41","386.41","1 through 10","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","401.89","401.89","401.89","21","225.91","1072.75","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","281.32","284.12","1 through 10","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","both","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.25","263.16","286.32","27","225.91","1072.75","other","OPPS APC"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","38","230.56","1016.85","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","69","230.56","1016.85","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","1577.04","23","230.56","1016.85","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","530.29","578.71","1 through 10","230.56","1016.85","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","1016.85","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O Contrast","PX-35000076","CDM","74176","CPT","0352","RC","","","","outpatient","","","1464.00","1098.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","520.31","35.54","","495.98","495.98","1094.77","1 through 10","230.56","1016.85","percent of total billed charges",""
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","17","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","417.32","417.32","1 through 10","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","880.86","968.56","1 through 10","385.88","2201.68","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","213","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.63","414.54","418.83","1 through 10","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","752.28","752.28","752.28","1 through 10","385.88","2201.68","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","884.79","730.30","884.79","1 through 10","385.88","2201.68","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","966.92","966.92","966.92","22","385.88","2201.68","other","Multiple Imaging"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","417.13","420.63","1 through 10","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","415.63","420.63","39","385.88","2201.68","other","OPPS APC"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","both","","","3016.00","2262.00","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","929.97","929.97","929.97","1 through 10","385.88","2201.68","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","845.08","879.81","17","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","2766.75","12","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pelvis W/O&W Contras","PX-35000078","CDM","74178","CPT","0352","RC","","","","outpatient","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1071.89","35.54","","1021.56","1021.56","1336.27","1 through 10","385.88","1604.27","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","413.01","417.32","25","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","413.01","417.32","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","1450.91","1450.91","1450.91","1 through 10","265.02","1730.92","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","265.02","1730.92","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","826.97","1537.12","24","265.02","1730.92","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","HUMANA [1012]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","415.63","421.51","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","396","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","415.63","418.83","14","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","666.14","666.14","666.14","1 through 10","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","783.47","760.76","1521.52","44","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","823.22","823.22","823.22","1 through 10","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","856.20","856.20","856.20","86","265.02","1730.92","other","Multiple Imaging"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","TRICARE [160005]","HB BWF TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","265.02","1730.92","other","Tricare OPPS"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.63","415.63","499.96","13","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","424.11","415.63","839.46","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","831.28","35.54","","1036.03","792.03","1036.03","1 through 10","265.02","1730.92","percent of total billed charges",""
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","415.63","420.63","95","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","both","","","2339.00","1754.25","WELLSENSE [1003]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","413.01","413.01","413.01","1 through 10","265.02","1730.92","other","OPPS APC"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1289.36","1289.36","1289.36","1 through 10","385.88","1604.27","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","2639.43","145","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","968.56","23","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","1604.27","other","Multiple Radiology"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1289.36","1289.36","1289.36","1 through 10","385.88","1604.27","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Abdomen & Pevis With Contrast","PX-35000077","CDM","74177","CPT","0352","RC","","","","outpatient","","","2339.00","1754.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","831.28","35.54","","792.03","792.03","1036.03","37","385.88","1604.27","percent of total billed charges",""
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","981.35","23","200.84","2571.06","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.18","207.18","207.18","1 through 10","200.84","2571.06","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","770.37","770.37","770.37","1 through 10","200.84","2571.06","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","207.18","209.98","1 through 10","200.84","2571.06","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","both","","","3522.00","2641.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","207.19","211.41","1 through 10","200.84","2571.06","other","OPPS APC"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1761","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1761","other","Multiple Imaging"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1761","other","Multiple Radiology"
"CT Abdomen W&W/O Contrast","PX-35000073","CDM","74170","CPT","0352","RC","","","","outpatient","","","3522.00","2641.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","1761","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","1656.37","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.44","419.44","419.44","1 through 10","200.84","1656.37","other","OPPS APC"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","both","","","2269.00","1701.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","806.40","35.54","","447.18","447.18","447.18","1 through 10","200.84","1656.37","percent of total billed charges",""
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","255.50","511.00","1 through 10","201.74","1134.5","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","305.33","610.66","1 through 10","201.74","1134.5","other","Multiple Imaging"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","229.99","459.97","1 through 10","201.74","1134.5","other","Multiple Radiology"
"CT Abdomen W/Contrast","PX-35000072","CDM","74160","CPT","0352","RC","","","","outpatient","","","2269.00","1701.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","806.40","35.54","","768.35","768.35","768.35","1 through 10","201.74","1134.5","percent of total billed charges",""
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1347.58","other","Multiple Radiology"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","12","112.51","1347.58","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","291.86","291.86","291.86","1 through 10","112.51","1347.58","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","318.95","318.95","318.95","1 through 10","112.51","1347.58","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1347.58","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","both","","","1846.00","1384.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1347.58","other","OPPS APC"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","1 through 10","112.51","923","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","170.28","340.56","1 through 10","112.51","923","other","Multiple Imaging"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","923","other","Multiple Radiology"
"CT Abdomen W/O Contrast","PX-35000071","CDM","74150","CPT","0352","RC","","","","outpatient","","","1846.00","1384.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","656.07","35.54","","625.20","625.20","625.20","1 through 10","112.51","923","percent of total billed charges",""
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2310.00","1732.50","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","489.82","516.73","1 through 10","385.88","1686.3","other","OPPS APC"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","both","","","2310.00","1732.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1315.50","1315.50","1315.50","1 through 10","385.88","1686.3","other","Multiple Imaging"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2310.00","1732.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","488.72","488.72","488.72","1 through 10","385.88","1168.07","other","Multiple Imaging"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2310.00","1732.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","845.08","845.08","845.08","1 through 10","385.88","1168.07","other","Multiple Radiology"
"CT C-Spine W/Contrast","PX-35000035","CDM","72126","CPT","0352","RC","","","","outpatient","","","2310.00","1732.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","887.52","887.52","887.52","1 through 10","385.88","1168.07","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","262.40","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1420.58","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1420.58","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","266.67","26","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","255.02","255.02","255.02","1 through 10","112.51","1420.58","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","327.78","327.78","327.78","1 through 10","112.51","1420.58","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","126.29","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","both","","","1946.00","1459.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","112.51","1420.58","other","OPPS APC"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","1 through 10","112.51","973","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","142.49","340.56","1 through 10","112.51","973","other","Multiple Imaging"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","128.26","256.52","1 through 10","112.51","973","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","973","other","Multiple Radiology"
"CT C-Spine W/O Contrast","PX-35000034","CDM","72125","CPT","0352","RC","","","","outpatient","","","1946.00","1459.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.61","35.54","","862.00","862.00","862.00","1 through 10","112.51","973","percent of total billed charges",""
"CT Colonography Screen Postprocess","PX-35000003","CDM","74263","CPT","0350","RC","","","","both","","","5134.00","3850.50","MEDICARE [2001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","3999.9","other","OPPS APC"
"CT Colonography W/ Cntrst","PX-35000002","CDM","74262","CPT","0350","RC","","","","both","","","4930.00","3697.50","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","3598.9","other","OPPS APC"
"CT Colonography W/ Cntrst","PX-35000002","CDM","74262","CPT","0350","RC","","","","both","","","4930.00","3697.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.18","1 through 10","200.84","3598.9","other","OPPS APC"
"CT Colonography W/ Cntrst","PX-35000002","CDM","74262","CPT","0350","RC","","","","outpatient","","","4930.00","3697.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","2465","other","Multiple Radiology"
"CT GUIDE GASTROSTOMY/GJ/J TUBE Exchange/Replacement","PX-76002004","CDM","43999","CPT","0761","RC","","","","both","","","1283.00","962.25","WELLPOINT [1015]","HB CH WELLPOINT","999.59","77.91","","2383.28","2383.28","2383.28","1 through 10","550.41","1220.13","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","895.00","671.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","895.00","100","","605.43","605.43","605.43","1 through 10","318.08","1050.69","percent of total billed charges",""
"CT Guided Needle Placement","PX-35000084","CDM","77012","CPT","0352","RC","","","","both","","","895.00","671.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","895.00","100","","801.60","801.60","801.60","1 through 10","318.08","1050.69","percent of total billed charges",""
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2379.00","1784.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","1736.67","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2379.00","1784.25","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","1 through 10","200.84","1736.67","other","OPPS APC"
"CT Head W&W/O Contrast","PX-35000011","CDM","70470","CPT","0351","RC","","","","both","","","2379.00","1784.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","481.52","481.52","481.52","1 through 10","200.84","1736.67","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","1857.00","1392.75","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","13","200.84","1355.61","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","1857.00","1392.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","506.40","506.40","506.40","1 through 10","200.84","1355.61","other","OPPS APC"
"CT Head W/Contrast","PX-35000010","CDM","70460","CPT","0351","RC","","","","both","","","1857.00","1392.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","507.90","507.90","507.90","1 through 10","200.84","1355.61","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","FALLON HEALTH [1008]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","378.87","119.99","378.87","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1076.75","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","510.53","117.59","510.53","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","781.75","53","","760.02","760.02","760.02","1 through 10","112.51","1076.75","percent of total billed charges",""
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","266.67","150","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","202.98","202.98","202.98","1 through 10","112.51","1076.75","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","238.74","238.74","238.74","1 through 10","112.51","1076.75","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","260.90","260.90","260.90","13","112.51","1076.75","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","171.66","117.59","509.20","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","118.07","480.02","32","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","both","","","1475.00","1106.25","WELLSENSE [1003]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","112.51","1076.75","other","OPPS APC"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","142.49","340.56","28","112.51","737.5","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","35","112.51","737.5","other","Multiple Imaging"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","128.26","256.52","17","112.51","737.5","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","1971.80","258.77","1971.80","1 through 10","112.51","737.5","other","Multiple Radiology"
"CT Head W/O Contrast","PX-35000009","CDM","70450","CPT","0351","RC","","","","outpatient","","","1475.00","1106.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","524.22","35.54","","527.33","499.46","653.33","1 through 10","112.51","737.5","percent of total billed charges",""
"CT Head W/O Contrast|UNUSUAL SEPARATE SERVICE","PX-35000009","CDM","70450","CPT","0351","RC","","","XU","both","","","1475.00","1106.25","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","516.73","516.73","1 through 10","123.75","130.06","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","417.32","417.32","1 through 10","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","25","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","418.43","418.43","1 through 10","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","both","","","811.00","608.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","200.53","420.63","1 through 10","201.74","1052.31","other","OPPS APC"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","888.27","other","Multiple Imaging"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","610.66","1 through 10","201.74","888.27","other","Multiple Imaging"
"CT Hrt W/3d Image","PX-35000080","CDM","75572","CPT","0352","RC","","","","outpatient","","","811.00","608.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","888.27","other","Multiple Radiology"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","102.89","102.89","1 through 10","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","TRICARE [160005]","HB BWF TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","99.33","99.33","99.33","1 through 10","76.36","234.25","other","Tricare OPPS"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","1 through 10","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","both","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","97.59","104.56","14","76.36","234.25","other","OPPS APC"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","146.85","146.85","146.85","1 through 10","94.54","297.67","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","188.57","","Case rate ($188.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","188.57","157.80","188.57","38","94.54","297.67","other","Multiple Imaging"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","188.57","","Case rate ($188.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","157.80","157.80","188.57","81","94.54","297.67","other","Multiple Imaging"
"CT Hrt W/O Cntrst W/Ca Test","PX-35000079","CDM","75571","CPT","0352","RC","","","","outpatient","","","266.00","199.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.54","35.54","","90.21","90.21","90.21","1 through 10","94.54","297.67","percent of total billed charges",""
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2337.00","1752.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","385.88","1706.01","other","OPPS APC"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2337.00","1752.75","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","1706.01","other","OPPS APC"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","both","","","2337.00","1752.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1319.31","1319.31","1319.31","1 through 10","385.88","1706.01","other","Multiple Imaging"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2337.00","1752.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","977.44","977.44","1 through 10","385.88","1168.5","other","Multiple Imaging"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2337.00","1752.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","422.54","422.54","422.54","1 through 10","385.88","1168.5","other","Multiple Radiology"
"CT L-Spine W/Contrast","PX-35000041","CDM","72132","CPT","0352","RC","","","","outpatient","","","2337.00","1752.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","443.76","443.76","443.76","1 through 10","385.88","1168.5","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","262.40","1 through 10","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","56","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","252.07","252.07","252.07","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","296.47","296.47","296.47","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","323.98","323.98","323.98","1 through 10","112.51","1421.31","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","1421.31","other","Tricare OPPS"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","117.59","126.29","1 through 10","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","both","","","1947.00","1460.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.97","123.76","126.29","1 through 10","112.51","1421.31","other","OPPS APC"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","1 through 10","112.51","973.5","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","170.28","340.56","1 through 10","112.51","973.5","other","Multiple Imaging"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","973.5","other","Multiple Radiology"
"CT L-Spine W/O Contrast","PX-35000040","CDM","72131","CPT","0352","RC","","","","outpatient","","","1947.00","1460.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.96","35.54","","1893.00","1893.00","1893.00","1 through 10","112.51","973.5","percent of total billed charges",""
"CT Lwr Ext W/Contrast","PX-35000064","CDM","73701","CPT","0352","RC","","","","both","","","2304.00","1728.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.79","207.79","207.79","1 through 10","200.84","1681.92","other","OPPS APC"
"CT Lwr Ext W/Contrast Lt","PX-35000063","CDM","73701","CPT","0352","RC","","","","both","","","2192.00","1644.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.79","207.79","207.79","1 through 10","200.84","1600.16","other","OPPS APC"
"CT Lwr Ext W/Contrast Rt","PX-35000062","CDM","73701","CPT","0352","RC","","","","both","","","2192.00","1644.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.79","207.79","207.79","1 through 10","200.84","1600.16","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","1911.00","1433.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.05","282.40","1 through 10","112.51","1395.03","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","both","","","1911.00","1433.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.77","126.29","11","112.51","1395.03","other","OPPS APC"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","1911.00","1433.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1053.49","1053.49","1053.49","1 through 10","112.51","955.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","1911.00","1433.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","955.5","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast","PX-35000061","CDM","73700","CPT","0352","RC","","","","outpatient","","","1911.00","1433.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","679.17","35.54","","894.93","894.93","894.93","1 through 10","112.51","955.5","percent of total billed charges",""
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","both","","","1810.00","1357.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.05","282.40","1 through 10","112.51","1321.3","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","both","","","1810.00","1357.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.77","126.29","11","112.51","1321.3","other","OPPS APC"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","outpatient","","","1810.00","1357.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1053.49","1053.49","1053.49","1 through 10","112.51","905","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","outpatient","","","1810.00","1357.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","905","other","Multiple Radiology"
"CT Lwr Ext W/O Contrast Lt","PX-35000060","CDM","73700","CPT","0352","RC","","","","outpatient","","","1810.00","1357.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","643.27","35.54","","894.93","894.93","894.93","1 through 10","112.51","905","percent of total billed charges",""
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1807.48","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","1807.48","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","200.84","1807.48","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","516.73","1 through 10","200.84","1807.48","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","390.55","390.55","390.55","1 through 10","200.84","1807.48","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","both","","","2476.00","1857.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","207.18","211.41","1 through 10","200.84","1807.48","other","OPPS APC"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1238","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1238","other","Multiple Imaging"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","1 through 10","201.74","1238","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","1238","other","Multiple Radiology"
"CT Max/Facial W/Contrast","PX-35000022","CDM","70487","CPT","0351","RC","","","","outpatient","","","2476.00","1857.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","879.97","35.54","","838.71","838.71","838.71","1 through 10","201.74","1238","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","1481.17","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","1 through 10","112.51","1481.17","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","239.98","80","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.99","119.99","119.99","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","268.75","268.75","268.75","1 through 10","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","316.08","316.08","316.08","1 through 10","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","345.42","345.42","345.42","15","112.51","1481.17","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","119.99","123.76","1 through 10","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","721.11","35.54","","687.20","687.20","687.20","1 through 10","112.51","1481.17","percent of total billed charges",""
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","both","","","2029.00","1521.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","13","112.51","1481.17","other","OPPS APC"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1118.69","1118.69","1118.69","1 through 10","112.51","1014.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","39","112.51","1014.5","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","70","112.51","1014.5","other","Multiple Imaging"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","23","112.51","1014.5","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","129.38","282.40","1 through 10","112.51","1014.5","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","1014.5","other","Multiple Radiology"
"CT Max/Facial W/O Contrast","PX-35000021","CDM","70486","CPT","0351","RC","","","","outpatient","","","2029.00","1521.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","721.11","35.54","","687.20","687.20","898.90","16","112.51","1014.5","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","197.32","208.03","1 through 10","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","516.73","516.73","1 through 10","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","200.84","1500.88","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","441.83","253.19","506.37","1 through 10","200.84","1500.88","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1089.68","53","","1059.47","1059.47","1059.47","1 through 10","200.84","1500.88","percent of total billed charges",""
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","634.23","64","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.18","199.72","210.38","1 through 10","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","430.12","417.65","430.12","1 through 10","200.84","1500.88","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","470.05","470.05","470.05","11","200.84","1500.88","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","509.20","208.03","511.40","1 through 10","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","both","","","2056.00","1542.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","207.18","506.60","16","200.84","1500.88","other","OPPS APC"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","14","201.74","1028","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","305.33","610.66","34","201.74","1028","other","Multiple Imaging"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","883.62","1 through 10","201.74","1028","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","1028","other","Multiple Radiology"
"CT Neck W/Contrast","PX-35000025","CDM","70491","CPT","0351","RC","","","","outpatient","","","2056.00","1542.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","730.70","35.54","","696.25","696.25","910.74","1 through 10","201.74","1028","percent of total billed charges",""
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","1972.00","1479.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.67","126.29","516.73","1 through 10","112.51","1439.56","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","1972.00","1479.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","264.54","264.54","264.54","1 through 10","112.51","1439.56","other","OPPS APC"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","both","","","1972.00","1479.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","354.26","354.26","354.26","1 through 10","112.51","1439.56","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","284.98","284.98","1 through 10","112.51","986","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","1 through 10","112.51","986","other","Multiple Imaging"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","2186.90","2186.90","2186.90","1 through 10","112.51","986","other","Multiple Radiology"
"CT Neck W/O Contrast","PX-35000024","CDM","70490","CPT","0351","RC","","","","outpatient","","","1972.00","1479.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","700.85","35.54","","873.84","873.84","873.84","1 through 10","112.51","986","percent of total billed charges",""
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","ELDER SERVICES [1037]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1215.45","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","12","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","388.02","388.02","388.02","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","1215.45","other","Tricare OPPS"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","142.49","142.49","142.49","1 through 10","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","142.49","340.56","1 through 10","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000012","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","832.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","ELDER SERVICES [1037]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1215.45","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","12","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","388.02","388.02","388.02","1 through 10","112.51","1215.45","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","1215.45","other","Tricare OPPS"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","both","","","1665.00","1248.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","112.51","1215.45","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","142.49","142.49","142.49","1 through 10","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","142.49","340.56","1 through 10","112.51","832.5","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000013","CDM","70480","CPT","0351","RC","","","","outpatient","","","1665.00","1248.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","832.5","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","ELDER SERVICES [1037]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1287.72","other","Multiple Radiology"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","12","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","388.02","388.02","388.02","1 through 10","112.51","1287.72","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","1287.72","other","Tricare OPPS"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","both","","","1764.00","1323.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","112.51","1287.72","other","OPPS APC"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","142.49","142.49","142.49","1 through 10","112.51","882","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","142.49","340.56","1 through 10","112.51","882","other","Multiple Imaging"
"CT Orb/Fos/Sel/Ear W/O Contrast","PX-35000014","CDM","70480","CPT","0351","RC","","","","outpatient","","","1764.00","1323.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","1 through 10","112.51","882","other","Multiple Radiology"
"CT Pelvis W&W/O Contrast","PX-35000046","CDM","72194","CPT","0352","RC","","","","both","","","2955.00","2216.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","766.60","766.60","766.60","1 through 10","200.84","2157.15","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","758.54","758.54","758.54","1 through 10","200.84","1605.27","other","Multiple Radiology"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","HUMANA [1012]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.18","207.18","207.18","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","683.31","683.31","683.31","1 through 10","200.84","1605.27","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","both","","","2199.00","1649.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","197.32","208.03","1 through 10","200.84","1605.27","other","OPPS APC"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","610.66","610.66","1 through 10","201.74","1099.5","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","305.33","610.66","1 through 10","201.74","1099.5","other","Multiple Imaging"
"CT Pelvis W/Contrast","PX-35000045","CDM","72193","CPT","0352","RC","","","","outpatient","","","2199.00","1649.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","482.16","1 through 10","201.74","1099.5","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1333.71","other","Multiple Radiology"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","21","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","251.08","251.08","251.08","1 through 10","112.51","1333.71","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","262.40","262.40","262.40","1 through 10","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","both","","","1827.00","1370.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.76","126.29","1 through 10","112.51","1333.71","other","OPPS APC"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","284.98","142.49","284.98","1 through 10","112.51","913.5","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","170.28","340.56","1 through 10","112.51","913.5","other","Multiple Imaging"
"CT Pelvis W/O Contrast","PX-35000044","CDM","72192","CPT","0352","RC","","","","outpatient","","","1827.00","1370.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","913.5","other","Multiple Radiology"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","262.40","262.40","262.40","1 through 10","112.51","1435.91","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","266.67","126.29","519.25","16","112.51","1435.91","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","326.52","326.52","326.52","1 through 10","112.51","1435.91","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","both","","","1967.00","1475.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","266.34","123.76","266.34","1 through 10","112.51","1435.91","other","OPPS APC"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","1967.00","1475.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","340.56","340.56","1 through 10","112.51","983.5","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","1967.00","1475.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","340.56","340.56","1 through 10","112.51","983.5","other","Multiple Imaging"
"CT T-Spine W/O Contrast","PX-35000037","CDM","72128","CPT","0352","RC","","","","outpatient","","","1967.00","1475.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","128.26","128.26","128.26","1 through 10","112.51","983.5","other","Multiple Radiology"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","both","","","2300.00","1725.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1326.81","1326.81","1326.81","1 through 10","200.84","1679","other","Multiple Imaging"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2300.00","1725.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","255.50","255.50","255.50","1 through 10","201.74","1150","other","Multiple Imaging"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2300.00","1725.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","220.91","220.91","220.91","1 through 10","201.74","1150","other","Multiple Radiology"
"CT Thoracic Spine W/Contrast","PX-35000038","CDM","72129","CPT","0352","RC","","","","outpatient","","","2300.00","1725.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","232.00","232.00","232.00","1 through 10","201.74","1150","other","Multiple Radiology"
"CT Upper Extremity W Contrast Rt","PX-35000050","CDM","73201","CPT","0352","RC","","","","both","","","2156.00","1617.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","418.63","420.63","1 through 10","265.02","1573.88","other","OPPS APC"
"CT Upr Ext W Contrast","PX-35000052","CDM","73201","CPT","0352","RC","","","","both","","","2284.00","1713.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","418.63","420.63","1 through 10","265.02","1667.32","other","OPPS APC"
"CT Upr Ext W Contrast Lt","PX-35000051","CDM","73201","CPT","0352","RC","","","","both","","","2156.00","1617.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","418.63","420.63","1 through 10","265.02","1573.88","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","1922.00","1441.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.40","282.40","1 through 10","112.51","1403.06","other","Multiple Radiology"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","both","","","1922.00","1441.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.77","133.17","1 through 10","112.51","1403.06","other","OPPS APC"
"CT Upr Ext W/O Contrast","PX-35000049","CDM","73200","CPT","0352","RC","","","","outpatient","","","1922.00","1441.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1059.72","1059.72","1059.72","1 through 10","112.51","961","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.40","282.40","1 through 10","112.51","1326.41","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.77","133.17","1 through 10","112.51","1326.41","other","OPPS APC"
"CT Upr Ext W/O Contrast Lt","PX-35000048","CDM","73200","CPT","0352","RC","","","","outpatient","","","1817.00","1362.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1059.72","1059.72","1059.72","1 through 10","112.51","908.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","199.40","282.40","1 through 10","112.51","1326.41","other","Multiple Radiology"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","both","","","1817.00","1362.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.77","133.17","1 through 10","112.51","1326.41","other","OPPS APC"
"CT Upr Ext W/O Contrast Rt","PX-35000047","CDM","73200","CPT","0352","RC","","","","outpatient","","","1817.00","1362.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1059.72","1059.72","1059.72","1 through 10","112.51","908.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3872.00","2904.00","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2826.56","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","both","","","3872.00","2904.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","210.19","210.19","210.19","1 through 10","200.84","2826.56","other","OPPS APC"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3872.00","2904.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","357.59","","Case rate ($357.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","178.80","178.80","178.80","1 through 10","201.74","1936","other","Multiple Imaging"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3872.00","2904.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","357.59","","Case rate ($357.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","357.59","357.59","357.59","1 through 10","201.74","1936","other","Multiple Imaging"
"Cta Abd Aorta W/&W/O Runoff","PX-35000083","CDM","75635","CPT","0352","RC","","","","outpatient","","","3872.00","2904.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1376.11","35.54","","1311.35","1311.35","1311.35","1 through 10","201.74","1936","percent of total billed charges",""
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","1 through 10","200.84","2562.3","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","2562.3","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","865.95","865.95","865.95","1 through 10","200.84","2562.3","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","601.59","601.59","601.59","1 through 10","200.84","2562.3","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","both","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","211.41","211.41","211.41","1 through 10","200.84","2562.3","other","OPPS APC"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","511.00","1 through 10","201.74","1755","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","1 through 10","201.74","1755","other","Multiple Imaging"
"Cta Abdomen W&W/O Contrast","PX-35000075","CDM","74175","CPT","0352","RC","","","","outpatient","","","3510.00","2632.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","229.99","459.97","1 through 10","201.74","1755","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","481.98","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","ELDER SERVICES [1037]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","315.76","315.76","315.76","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","1776.60","506.37","1776.60","1 through 10","200.84","1957.13","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","92","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","397.85","397.85","397.85","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","209.98","208.03","506.40","1 through 10","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","both","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","207.18","1540.98","18","200.84","1957.13","other","OPPS APC"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","305.33","610.66","16","201.74","1340.5","other","Multiple Imaging"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","610.66","28","201.74","1340.5","other","Multiple Imaging"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","229.99","1379.91","19","201.74","1340.5","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","241.08","911.95","1 through 10","201.74","1340.5","other","Multiple Radiology"
"Cta Chest (Noncor) W&W/O Contrast","PX-35000033","CDM","71275","CPT","0352","RC","","","","outpatient","","","2681.00","2010.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","952.83","35.54","","908.02","753.98","908.02","1 through 10","201.74","1340.5","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0350","RC","","","","inpatient","","","4871.00","3653.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2727.76","56","","2708.99","2708.99","2708.99","1 through 10","2727.76","3438.93","percent of total billed charges",""
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","ELDER SERVICES [1037]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","516.73","516.73","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","508.46","508.46","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","200.84","3555.83","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","506.37","476.45","506.37","1 through 10","200.84","3555.83","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","71","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.20","507.93","509.60","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","696.56","677.56","696.56","1 through 10","200.84","3555.83","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","761.22","738.87","761.22","1 through 10","200.84","3555.83","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1024.91","516.73","1025.19","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","508.46","508.46","509.20","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","516.73","516.73","516.73","1 through 10","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","both","","","4871.00","3653.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","509.40","207.18","511.40","12","200.84","3555.83","other","OPPS APC"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","610.66","12","201.74","2435.5","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","610.66","27","201.74","2435.5","other","Multiple Imaging"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","459.97","459.97","459.97","11","201.74","2435.5","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","482.16","506.37","1 through 10","201.74","2435.5","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","201.74","2435.5","other","Multiple Radiology"
"Cta Head W&W/O Contrast","PX-35000027","CDM","70496","CPT","0351","RC","","","","outpatient","","","4871.00","3653.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1731.15","35.54","","2157.72","1649.55","4500.00","1 through 10","201.74","2435.5","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0350","RC","","","","inpatient","","","4894.00","3670.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2740.64","56","","2722.15","2722.15","2722.15","1 through 10","2740.64","3455.16","percent of total billed charges",""
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","481.98","508.46","1 through 10","200.84","3572.62","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","200.84","3572.62","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","516.73","1 through 10","200.84","3572.62","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.38","210.38","1 through 10","200.84","3572.62","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","695.40","676.44","695.40","1 through 10","200.84","3572.62","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","759.95","759.95","759.95","1 through 10","200.84","3572.62","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","both","","","4894.00","3670.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.18","207.18","207.18","1 through 10","200.84","3572.62","other","OPPS APC"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","610.66","511.00","610.66","12","201.74","2447","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","511.00","511.00","610.66","21","201.74","2447","other","Multiple Imaging"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","229.99","229.99","229.99","1 through 10","201.74","2447","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","241.08","241.08","482.16","1 through 10","201.74","2447","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","287.48","287.48","287.48","1 through 10","201.74","2447","other","Multiple Radiology"
"Cta Neck W&W/O Contrast","PX-35000028","CDM","70498","CPT","0351","RC","","","","outpatient","","","4894.00","3670.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1739.33","35.54","","2168.20","1657.56","4000.00","1 through 10","201.74","2447","percent of total billed charges",""
"Cta Upr Ext W&W/O Contrast","PX-35000058","CDM","73206","CPT","0352","RC","","","","both","","","3254.00","2440.50","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","489.82","489.82","489.82","1 through 10","200.84","2375.42","other","OPPS APC"
"Cta Upr Ext W&W/O Contrast Lt","PX-35000057","CDM","73206","CPT","0352","RC","","","","both","","","3072.00","2304.00","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","489.82","489.82","489.82","1 through 10","200.84","2242.56","other","OPPS APC"
"Cta Upr Ext W&W/O Contrast Rt","PX-35000056","CDM","73206","CPT","0352","RC","","","","both","","","3072.00","2304.00","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","489.82","489.82","489.82","1 through 10","200.84","2242.56","other","OPPS APC"
"CUBE 1 XCM GRAFT BONE READIGRAFT CANCELLOUS FREEZE DRIED VOID FILLER 8","SUP-ITM-10010239","CDM","C1889","HCPCS","0278","RC","","","","both","","","944.79","708.59","AETNA [1001]","HB CH AETNA HMO / PPO","550.81","58.3","","1830.28","315.58","1830.28","1 through 10","419.96","944.79","percent of total billed charges",""
"CUBE 1 XCM GRAFT BONE READIGRAFT CANCELLOUS FREEZE DRIED VOID FILLER 8","SUP-ITM-10010239","CDM","C1889","HCPCS","0278","RC","","","","both","","","944.79","708.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.70","73","","4170.85","4170.85","4170.85","1 through 10","419.96","944.79","percent of total billed charges",""
"CUBE 1 XCM GRAFT BONE READIGRAFT CANCELLOUS FREEZE DRIED VOID FILLER 8","SUP-ITM-10010239","CDM","C1889","HCPCS","0278","RC","","","","both","","","944.79","708.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","419.96","44.45","","649.55","649.55","649.55","1 through 10","419.96","944.79","percent of total billed charges",""
"CUBE 1 XCM GRAFT BONE READIGRAFT CANCELLOUS FREEZE DRIED VOID FILLER 8","SUP-ITM-10010239","CDM","C1889","HCPCS","0278","RC","","","","both","","","944.79","708.59","WELLPOINT [1015]","HB CH WELLPOINT","736.09","77.91","","8998.38","2542.37","8998.38","20","419.96","944.79","percent of total billed charges",""
"CUBE 1 XCM GRAFT BONE READIGRAFT CANCELLOUS FREEZE DRIED VOID FILLER 8","SUP-ITM-10010239","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","944.79","708.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.26","59.3","","1891.61","1609.14","3664.18","25","472.4","741.19","percent of total billed charges",""
"CUBE 1 XCM GRAFT BONE READIGRAFT CANCELLOUS FREEZE DRIED VOID FILLER 8","SUP-ITM-10010239","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","944.79","708.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.19","78.45","","1470.68","1310.06","2481.69","19","472.4","741.19","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","66.90","20","7.92","52.94","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.57","34.55","103.71","19","5.4","47.85","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","45.36","45.36","1 through 10","5.4","47.85","percent of total billed charges",""
"Culture Aerobic ID","PX-30001150","CDM","87077","CPT","0306","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","17","5.4","47.85","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","1 through 10","10.58","77.38","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","117.84","117.84","117.84","1 through 10","11.14","83.16","percent of total billed charges",""
"Culture Afb/TB/Mycobacteria","PX-30001166","CDM","87116","CPT","0306","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","46.93","46.93","46.93","1 through 10","11.14","83.16","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","95.00","71.25","AETNA [1001]","HB CH AETNA HMO / PPO","55.39","58.3","","52.16","52.16","52.16","1 through 10","9.28","69.35","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","both","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","50.35","53","","48.76","48.76","48.76","1 through 10","9.28","69.35","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","95.00","71.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.34","59.3","","161.73","53.91","161.73","15","9.76","74.53","percent of total billed charges",""
"Culture Anaerobic","PX-30001147","CDM","87075","CPT","0306","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","74.53","78.45","","70.73","41.92","70.73","1 through 10","9.76","74.53","percent of total billed charges",""
"Culture Anaerobic ID","PX-30001148","CDM","87076","CPT","0306","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","25.97","25.97","25.97","1 through 10","5.4","46.29","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","AETNA [1001]","HB CH AETNA HMO / PPO","58.30","58.3","","55.00","55.00","55.00","28","8.45","73","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","both","","","100.00","75.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","53.00","53","","51.41","51.41","51.41","1 through 10","8.45","73","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","100.00","75.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.30","59.3","","56.84","56.84","170.52","41","8.88","78.45","percent of total billed charges",""
"Culture Bacterial Other Source","PX-30001144","CDM","87070","CPT","0306","RC","","","","outpatient","","","100.00","75.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","78.45","78.45","","67.76","44.19","74.58","27","8.88","78.45","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","55.27","57.27","1 through 10","10.11","75.92","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","302.32","6.53","302.32","1 through 10","10.65","81.59","percent of total billed charges",""
"Culture Blood Aerobic","PX-30001140","CDM","87040","CPT","0306","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","46.02","155.30","1 through 10","10.65","81.59","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","8.24","70.08","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","both","","","96.00","72.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","50.88","53","","49.29","49.29","49.29","1 through 10","8.24","70.08","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","109.00","54.50","163.50","13","8.67","75.31","percent of total billed charges",""
"Culture Fungus Other","PX-30001157","CDM","87102","CPT","0306","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","42.37","71.50","1 through 10","8.67","75.31","percent of total billed charges",""
"Culture Screen Single Organism","PX-30001152","CDM","87081","CPT","0306","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","4.79","4.79","4.79","1 through 10","6.84","58.84","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","both","","","76.00","57.00","AETNA [1001]","HB CH AETNA HMO / PPO","44.31","58.3","","41.96","41.96","41.96","1 through 10","9.25","55.7","percent of total billed charges",""
"Culture Stool Other","PX-30001142","CDM","87046","CPT","0306","RC","","","","outpatient","","","76.00","57.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.07","59.3","","43.36","43.36","43.36","1 through 10","9.74","59.62","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","57.27","1 through 10","9.25","75.92","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.23","44.45","","77.65","77.65","77.65","1 through 10","9.25","75.92","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","59.19","59.19","59.19","1 through 10","9.74","81.59","percent of total billed charges",""
"Culture Stool Salmonella & Shigella","PX-30001141","CDM","87045","CPT","0306","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","46.02","46.02","46.02","1 through 10","9.74","81.59","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","AETNA [1001]","HB CH AETNA HMO / PPO","55.39","58.3","","52.16","52.16","52.16","50","7.91","69.35","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","both","","","95.00","71.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","69.35","73","","53.91","52.16","53.91","1 through 10","7.91","69.35","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.34","59.3","","53.91","53.91","53.91","45","8.33","74.53","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","74.53","78.45","","70.73","70.73","70.73","1 through 10","8.33","74.53","percent of total billed charges",""
"Culture Urine W/Colony Count","PX-30001154","CDM","87086","CPT","0306","RC","","","","outpatient","","","95.00","71.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","74.53","78.45","","70.73","41.92","70.73","38","8.33","74.53","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","1634.24","1004.95","1718.99","42","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","2123.89","1900.92","2123.89","1 through 10","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1661.55","58.3","","3729.00","1254.19","3729.00","1 through 10","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","939.37","939.37","5593.65","1 through 10","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2422.50","85","","2323.25","1864.50","2882.25","16","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2850.00","100","","2909.44","1772.40","10952.08","45","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2850.00","100","","2323.25","2323.25","2323.25","1 through 10","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2850.00","100","","2882.25","1772.40","10169.17","187","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","1659.41","1659.41","1659.41","1 through 10","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","2050.91","1468.48","2902.83","52","1266.83","2850","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","1548.60","1092.60","3613.79","82","1425","2235.83","percent of total billed charges",""
"CUP HIP PATIENT SPECIFIC","SUP-ITM-10215648","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","2085.51","998.68","6202.11","56","1425","2235.83","percent of total billed charges",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","both","","","4614.00","3460.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1979.41","3888.77","per diem",""
"Curettage Postpartum","PX-72000011","CDM","59160","CPT","0761","RC","","","","outpatient","","","4614.00","3460.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2736.10","59.3","","12309.51","12309.51","12309.51","1 through 10","2125.14","4472.66","percent of total billed charges",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","49073.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","46451.02","","Standard inlier is a Case rate ($46,451.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $59,300, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,593.90) for the length of stay and the standard reimbursement.","46451.02","46451.02","46451.02","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,EXTREME","045","DRG","","","","","","","","inpatient","","","49073.99","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","21308.55","","Case rate ($23,560.27). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,990.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26633.36","26633.36","26633.36","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","50475.17","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15913.0506","","Fee schedule rate ($34,735.91). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15913.0506","34735.90","34735.90","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","50475.17","","MASSHEALTH [3001]","HB BWF MEDICAID","11375.68","","Case rate ($12,577.77). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,007.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12574.68","922.59","12574.68","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MAJOR","045","DRG","","","","","","","","inpatient","","","50475.17","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11375.68","","Case rate ($12,577.77). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,007.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12574.68","12574.68","12574.68","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","33586.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18660.82","","Standard inlier is a Case rate ($18,660.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,648.98) for the length of stay and the standard reimbursement.","18660.81","18660.81","18660.81","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","33586.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20045.44","","Standard inlier is a Case rate ($20,045.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,845.37) for the length of stay and the standard reimbursement.","19134.28","19134.28","19134.28","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","33586.77","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15913.0506","","Fee schedule rate ($21,425.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15913.0506","15913.06","15913.06","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MINOR","045","DRG","","","","","","","","inpatient","","","33586.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","22305.13","","Fee schedule rate ($22,305.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18190.65","18190.65","18190.65","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","32963.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20045.44","","Standard inlier is a Case rate ($20,045.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,845.37) for the length of stay and the standard reimbursement.","23668.99","23668.99","24796.09","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","32963.77","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","15913.0506","","Fee schedule rate ($21,425.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15913.0506","21425.84","21425.84","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","32963.77","","MASSHEALTH [3001]","HB BWF MEDICAID","5115.51","","Case rate ($5,656.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,086.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7788.77","957.00","8866.55","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","32963.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10464.76","","Fee schedule rate ($10,464.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10464.76","10464.76","10464.76","1 through 10","5115.51","121095.57","case rate",""
"Cva And Precerebral Occlusion With Infarction,MODERATE","045","DRG","","","","","","","","inpatient","","","32963.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5115.51","","Case rate ($5,656.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,086.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7788.78","7788.78","7788.78","1 through 10","5115.51","121095.57","case rate",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","12","12.69","77.38","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","both","","","106.00","79.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","56.18","53","","54.59","54.59","54.59","1 through 10","12.69","77.38","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","59.31","60.36","12","13.35","83.16","percent of total billed charges",""
"Cyclic Citrulli Pept (CCP) Antibody","PX-30000804","CDM","86200","CPT","0302","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","46.93","79.19","1 through 10","13.35","83.16","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","18.15","98.34","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","1 through 10","11.72","75.31","percent of total billed charges",""
"Cystatin C","PX-30000402","CDM","82610","CPT","0301","RC","","","","outpatient","","","96.00","72.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.31","78.45","","71.50","42.37","71.50","1 through 10","11.72","75.31","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","both","","","7114.00","5335.50","AETNA [1001]","HB CH AETNA HMO / PPO","4147.46","58.3","","4687.96","4687.96","4687.96","1 through 10","3051.91","5542.52","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","both","","","7114.00","5335.50","WELLPOINT [1015]","HB CH WELLPOINT","5542.52","77.91","","11941.59","11941.59","11941.59","1 through 10","3051.91","5542.52","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3490.84","49.07","","2813.15","1406.58","2813.15","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Lesion Minor <.5cm","PX-76001279","CDM","52224","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3564.11","50.1","","2817.13","1408.57","2876.82","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","both","","","7114.00","5335.50","AETNA [1001]","HB CH AETNA HMO / PPO","4147.46","58.3","","2343.98","2343.98","2343.98","1 through 10","3051.91","5542.52","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","both","","","7114.00","5335.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","3051.91","5542.52","per diem",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","both","","","7114.00","5335.50","WELLPOINT [1015]","HB CH WELLPOINT","5542.52","77.91","","7389.94","7389.94","7389.94","1 through 10","3051.91","5542.52","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3490.84","49.07","","4732.70","4732.70","4732.70","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Fulg Tumor Small 0.5-2.0cm","PX-76001280","CDM","52234","CPT","0761","RC","","","","outpatient","","","7114.00","5335.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3564.11","50.1","","4839.81","4739.39","4839.81","1 through 10","2845.6","5580.93","percent of total billed charges",""
"Cysto Insertion Transprostatic Implant Single","PX-76002881","CDM","52441","CPT","0761","RC","","","","both","","","1193.00","894.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,615). Procedure 2, Per diem ($1,807.50). Procedures 3 - 9999, Per diem ($903.75).","3545.00","3545.00","3545.00","1 through 10","511.8","929.47","per diem",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4051.00","3038.25","AETNA [1001]","HB CH AETNA HMO / PPO","2361.73","58.3","","4687.96","4687.96","4687.96","1 through 10","1565.78","3156.13","percent of total billed charges",""
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4051.00","3038.25","HUMANA [1012]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2398.67","2398.67","2398.67","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","both","","","4051.00","3038.25","MEDICARE [2001]","HB BWF MEDICARE","2432.48","","APC Price ($2,432.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2182.05","2432.73","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2813.15","2813.15","2813.15","1 through 10","1565.78","4472.66","other","ASC "
"Cysto Rem FB Smp","PX-76001285","CDM","52310","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3867.48","3867.48","3867.48","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Cysto W/Catheterizat Ureteral","PX-76001277","CDM","52005","CPT","0761","RC","","","","outpatient","","","6749.00","5061.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3381.25","50.1","","2817.13","2817.13","2817.13","1 through 10","2699.6","5294.59","percent of total billed charges",""
"Cysto W/Dilat Bladder Anes Local","PX-76001281","CDM","52265","CPT","0761","RC","","","","both","","","1912.00","1434.00","MEDICARE [2001]","HB BWF MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","1 through 10","820.25","2683.34","other","OPPS APC"
"Cysto W/Dilat Rx Balo Cath Urtl Strix/Sten Male","PX-76002930","CDM","52284","CPT","0761","RC","","","","outpatient","","","921.00","690.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","461.42","50.1","","3784.98","3784.98","3784.98","1 through 10","368.4","722.52","percent of total billed charges",""
"Cysto W/Dilat Rx Balo Cath Urtl Strix/Sten Male","PX-76002930","CDM","52284","CPT","0761","RC","","","","outpatient","","","921.00","690.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","722.52","78.45","","4589.74","4589.74","4589.74","1 through 10","368.4","722.52","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","both","","","4051.00","3038.25","AETNA [1001]","HB CH AETNA HMO / PPO","2361.73","58.3","","3384.99","3384.99","3384.99","1 through 10","2147.03","3156.13","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2151.00","2151.00","2151.00","1 through 10","2147.03","3156.13","per diem",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1987.83","49.07","","2872.84","2872.84","2872.84","1 through 10","1620.4","3178.01","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2029.55","50.1","","2876.82","2817.13","2876.82","1 through 10","1620.4","3178.01","percent of total billed charges",""
"Cysto W/Dilat Stricture Urethral","PX-76001282","CDM","52281","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3178.01","78.45","","6356.44","6356.44","6356.44","1 through 10","1620.4","3178.01","percent of total billed charges",""
"Cysto/Pyeloscopy Diagnostic","PX-76001287","CDM","52351","CPT","0761","RC","","","","outpatient","","","3542.00","2656.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1738.06","49.07","","2817.13","2817.13","2817.13","1 through 10","1416.8","2778.7","percent of total billed charges",""
"Cysto/Pyeloscopy Diagnostic","PX-76001287","CDM","52351","CPT","0761","RC","","","","outpatient","","","3542.00","2656.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2778.70","78.45","","3896.20","3896.20","3896.20","1 through 10","1416.8","2778.7","percent of total billed charges",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt","PX-76002686","CDM","52356","CPT","0761","RC","","","","both","","","2104.00","1578.00","AETNA [1001]","HB CH AETNA HMO / PPO","1226.63","58.3","","5990.92","5990.92","5990.92","1 through 10","902.62","1639.23","percent of total billed charges",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE","PX-76002686","CDM","52356","CPT","0761","RC","","","50","both","","","2104.00","1578.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,215.50). Procedure 2, Per diem ($2,607.75). Procedures 3 - 9999, Per diem ($1,303.88).","5064.00","5064.00","5064.00","1 through 10","","","per diem",""
"Cysto/Uretero W/Lithotripsy &Indwell Stent Insrt|BILATERAL PROCEDURE","PX-76002686","CDM","52356","CPT","0761","RC","","","50","both","","","2104.00","1578.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($5,695.50). Procedure 2, Per diem ($2,847.75). Procedures 3 - 9999, Per diem ($1,423.88).","1422.83","1422.83","1422.83","1 through 10","","","per diem",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","FALLON HEALTH [1008]","HB BWF MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2330.43","2330.43","2330.43","1 through 10","562.25","1412.51","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","MEDICARE [2001]","HB BWF MEDICARE","792.58","","APC Price ($792.58). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","792.66","792.66","792.66","1 through 10","562.25","1412.51","other","OPPS APC"
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","both","","","1813.00","1359.75","WELLPOINT [1015]","HB CH WELLPOINT","1412.51","77.91","","4701.97","4701.97","4701.97","1 through 10","562.25","1412.51","percent of total billed charges",""
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1813.00","1359.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","642.96","","Case rate ($642.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","928.43","928.43","928.43","1 through 10","562.25","1873.9","other","ASC "
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1813.00","1359.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","642.96","","Case rate ($642.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","929.72","910.43","929.72","1 through 10","562.25","1873.9","other","ASC "
"Cystourethroscopy","PX-76001276","CDM","52000","CPT","0761","RC","","","","outpatient","","","1813.00","1359.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1075.11","59.3","","1033.12","1033.12","1033.12","1 through 10","562.25","1873.9","percent of total billed charges",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2683.34","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2512.18","2512.18","2512.18","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2393.81","2393.81","2393.81","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2393.81","2187.46","2393.81","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MEDICARE [2001]","HB BWF MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2432.73","2432.73","2432.73","38","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","2605.19","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2390.08","2388.08","2390.08","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","1565.78","3156.13","per diem",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1565.78","3156.13","per diem",""
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.88","2389.48","2393.81","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","both","","","4051.00","3038.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2553.09","","APC Price ($2,605.19). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2391.58","2391.08","2391.98","1 through 10","1565.78","3156.13","other","OPPS APC"
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2813.15","1406.58","2872.84","1 through 10","1565.78","4472.66","other","ASC "
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2817.13","2393.81","2876.82","1 through 10","1565.78","4472.66","other","ASC "
"Cystourethroscopy W Inj(S) Chemoden","PX-76001845","CDM","52287","CPT","0761","RC","","","","outpatient","","","4051.00","3038.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1565.78","","Case rate ($1,565.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3679.58","3679.58","3679.58","1 through 10","1565.78","4472.66","other","Multiple Surgery"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","AETNA [1001]","HB CH AETNA HMO / PPO","210.46","58.3","","199.02","199.02","199.02","1 through 10","60.28","281.26","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","29.10","62.43","15","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","HUMANA [1012]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","191.33","53","","186.03","186.03","186.03","1 through 10","60.28","281.26","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","MEDICARE [2001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","63.45","63.45","195","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","57.96","62.18","1 through 10","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","57.96","186.54","18","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.45","63.45","63.45","1 through 10","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","59.14","62.39","30","60.28","281.26","other","OPPS APC"
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","both","","","361.00","270.75","WELLPOINT [1015]","HB CH WELLPOINT","281.26","77.91","","276.45","276.45","627.45","15","60.28","281.26","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","361.00","270.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.07","59.3","","205.69","205.69","205.69","11","90.37","283.2","percent of total billed charges",""
"Cytopath Cellular Enhance Tech","PX-31000069","CDM","88112","CPT","0311","RC","","","","outpatient","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.20","78.45","","269.85","159.92","269.85","17","90.37","283.2","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-31000076","CDM","88142","CPT","0311","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","90.72","90.72","90.72","1 through 10","19.85","120.45","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","90.72","90.72","90.72","60","19.85","120.45","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","both","","","165.00","123.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","96.20","58.3","","90.72","90.72","90.72","1 through 10","19.85","120.45","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","165.00","123.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.85","59.3","","93.76","93.76","634.05","39","52.9","135.51","percent of total billed charges",""
"Cytopath Cerv/Vag Tlp Man Scrn","PX-92000084","CDM","G0123","HCPCS","0311","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","123.01","72.90","123.01","63","52.9","135.51","percent of total billed charges",""
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4875.00","3656.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1909.08","1909.08","1909.08","1 through 10","1873.9","3824.44","other","ASC "
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4875.00","3656.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3823.55","1911.77","3904.56","1 through 10","1873.9","3824.44","other","ASC "
"D & C Diagnostic/Therapeutic Non-OB","PX-76001379","CDM","58120","CPT","0761","RC","","","","outpatient","","","4875.00","3656.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2890.88","59.3","","2622.50","2622.50","2622.50","1 through 10","1873.9","3824.44","percent of total billed charges",""
"Debride Skin/Subq Tissu/Muscle/Bone","PX-76000024","CDM","11044","CPT","0761","RC","","","","both","","","2156.00","1617.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1741.20","1741.20","1741.20","1 through 10","1142.68","1981.66","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","both","","","1145.00","858.75","MEDICARE [2001]","HB BWF MEDICARE","726.87","","APC Price ($726.87). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","726.94","726.94","726.94","1 through 10","482.89","892.07","other","OPPS APC"
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","798.50","798.50","798.50","1 through 10","482.89","898.25","other","ASC "
"Debride Skin/Subq Tissue/Muscle","PX-76000023","CDM","11043","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","482.89","","Case rate ($482.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","596.37","596.37","596.37","1 through 10","482.89","898.25","other","Multiple Surgery"
"Debride/Rem Dev Tiss <20 Sq Cm","PX-76001692","CDM","97597","CPT","0761","RC","","","","both","","","860.00","645.00","MEDICARE [2001]","HB BWF MEDICARE","207.59","","APC Price ($207.59). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","218.50","218.50","218.50","1 through 10","164.98","627.8","other","OPPS APC"
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1057.95","49.07","","3845.67","1922.84","3845.67","1 through 10","862.4","1691.38","percent of total billed charges",""
"Debride/Remove FB Skin/Muscle/Bone","PX-76000021","CDM","11012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1080.16","50.1","","1925.56","1925.56","1925.56","1 through 10","862.4","1691.38","percent of total billed charges",""
"Debride/Remove FB Skin/Subq Open","PX-76000019","CDM","11010","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","680.73","680.73","680.73","1 through 10","579.34","1691.38","other","Multiple Surgery"
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","67.84","53","","65.72","65.72","65.72","1 through 10","56.9","128","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","both","","","128.00","96.00","WELLPOINT [1015]","HB CH WELLPOINT","99.72","77.91","","345.66","97.66","345.66","1 through 10","56.9","128","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","128.00","96.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","75.90","59.3","","360.00","72.67","360.00","15","64","100.42","percent of total billed charges",""
"Decalcification","PX-31000153","CDM","88311","CPT","0312","RC","","","","outpatient","","","128.00","96.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","100.42","78.45","","56.50","56.49","5926.36","1 through 10","64","100.42","percent of total billed charges",""
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","609.00","456.75","MEDICARE [2001]","HB BWF MEDICARE","393.90","","APC Price ($393.90). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","393.90","393.90","787.80","1 through 10","270.7","885.02","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","both","","","609.00","456.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","386.02","","APC Price ($393.90). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","772.04","772.04","772.04","1 through 10","270.7","885.02","other","OPPS APC"
"Declot Port Thrombolytic Agent","PX-76001110","CDM","36593","CPT","0761","RC","","","","outpatient","","","609.00","456.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","288.38","","Case rate ($288.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","677.69","677.69","677.69","1 through 10","288.38","884.1","other","Multiple Surgery"
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","140478.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26915.02","","Standard inlier is a Case rate ($26,915.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,259, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,820.69) for the length of stay and the standard reimbursement.","7088.00","7088.00","7088.00","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","140478.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28912.10","","Standard inlier is a Case rate ($28,912.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,259, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,103.95) for the length of stay and the standard reimbursement.","28912.09","28912.09","28912.09","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","140478.00","","MASSHEALTH [3001]","HB BWF MEDICAID","20246.15","","Case rate ($22,385.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,815.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,399.10 and the sum of the standard inlier and any outlier amount.","8886.13","5235.83","116331.56","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MAJOR","042","DRG","","","","","","","","inpatient","","","140478.00","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","20246.15","","Case rate ($22,385.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,815.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,399.10 and the sum of the standard inlier and any outlier amount.","39551.48","39551.48","39551.48","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","27981.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16930.13","","Standard inlier is a Case rate ($16,930.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,817, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,403.16) for the length of stay and the standard reimbursement.","2486.35","2486.35","2486.35","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","27981.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19207.56","","Fee schedule rate ($19,207.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19207.56","19207.56","19207.56","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders Except Multiple Sclerosis,MODERATE","042","DRG","","","","","","","","inpatient","","","27981.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12117.08","","Case rate ($13,397.51). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,827.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17772.25","17772.25","17772.25","1 through 10","7659.83","54482.69","case rate",""
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","39409.23","29556.92","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","202.80","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","23638.12","23638.12","23638.12","1 through 10","193.14","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","39409.23","29556.92","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","18959.47","18959.47","18959.47","1 through 10","193.14","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","39409.23","29556.92","MEDICARE [2001]","HB BWF MEDICARE","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","24982.68","1244.97","25150.58","27","193.14","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","39409.23","29556.92","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","22380.11","22380.11","22579.49","1 through 10","193.14","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders With McC","056","MS-DRG","","","","","","","","inpatient","","","39409.23","29556.92","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","22575.49","22512.49","22614.99","1 through 10","193.14","23846.62","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","30199.90","22649.92","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","200.98","","Case rate ($191.41) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12717.16","12717.16","12717.16","1 through 10","191.41","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","30199.90","22649.92","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","191.41","","Case rate ($191.41) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12178.66","12178.66","12178.66","1 through 10","191.41","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","30199.90","22649.92","MEDICARE [2001]","HB BWF MEDICARE","191.41","","Case rate ($191.41) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","13430.25","104.56","13519.73","30","191.41","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","30199.90","22649.92","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","191.41","","Case rate ($191.41) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12145.10","12145.10","12145.10","1 through 10","191.41","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","MS-DRG","","","","","","","","inpatient","","","30199.90","22649.92","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","191.41","","Case rate ($191.41) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12182.14","12182.14","12182.14","1 through 10","191.41","13299.33","other","Inpatient Psych"
"Degenerative Nervous System Disorders Without McC","057","TRIS-DRG","","","","","","","","inpatient","","","29806.57","","TRICARE [160005]","HB BWF TRICARE","11048.80","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($15,263.39). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,016.68, and the first day is paid a rate of $8,033.36. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,016.68, and the first day is paid a rate of $8,033.36. The transfer payment is capped at $13,968.51. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $59,084.84 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.79999995231628). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,923.68), capped at $13,968.51. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,016.68, and the first day is paid a rate of $8,033.36. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,016.68, and the first day is paid a rate of $8,033.36. The transfer payment is capped at $13,968.51. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $59,084.84 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.79999995231628). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","17321.73","17321.73","17321.73","1 through 10","11048.8","11048.8","other","Inpatient DRGs"
"Dental And Oral Diseases With McC","157","MS-DRG","","","","","","","","inpatient","","","32826.91","24620.18","MEDICARE [2001]","HB BWF MEDICARE","17657.92","","Case rate ($17,657.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,172.37, add-ons for qualifying new technology services are included. If operating cost exceeds $61,696.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,774.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $16,104.99 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,833.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,213.71. The transfer capital threshold is the transfer adjustment factor * $1,213.71. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","15823.67","17657.92","other","Inpatient DRG"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","29804.48","22353.36","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","191.93","","Case rate ($182.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12134.10","12134.10","12134.10","1 through 10","182.79","9658.34","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","29804.48","22353.36","HUMANA [1012]","HB BWF MEDICARE","182.79","","Case rate ($182.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","6836.47","6836.47","6836.47","1 through 10","182.79","9658.34","other","Inpatient Psych"
"Depressive Neuroses","881","MS-DRG","","","","","","","","inpatient","","","29804.48","22353.36","MEDICARE [2001]","HB BWF MEDICARE","182.79","","Case rate ($182.79) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16662.19","13758.35","56143.62","1 through 10","182.79","9658.34","other","Inpatient Psych"
"Dest Lesion Anus Any Method","PX-75000236","CDM","46924","CPT","0750","RC","","","","outpatient","","","5356.00","4017.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","13205.63","13205.63","13205.63","1 through 10","1873.9","4201.78","other","Multiple Surgery"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5441.90","5441.90","5441.90","1 through 10","2101.12","3958.61","other","Multiple Surgery"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","MEDICARE [2001]","HB BWF MEDICARE","2865.14","","APC Price ($2,865.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","2101.12","3958.61","other","OPPS APC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","2101.12","3958.61","per diem",""
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","both","","","5081.00","3810.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2807.84","","APC Price ($2,865.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3198.13","3198.13","3198.13","1 through 10","2101.12","3958.61","other","OPPS APC"
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","outpatient","","","5081.00","3810.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3855.09","3855.09","3855.09","1 through 10","1873.9","3986.04","other","ASC "
"Dest Lesion Anus Surgical Excision","PX-75000235","CDM","46922","CPT","0750","RC","","","","outpatient","","","5081.00","3810.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3860.43","1930.22","3860.43","1 through 10","1873.9","3986.04","other","ASC "
"Dest Nerve Cerv/Thor Sgl","PX-76001585","CDM","64633","CPT","0761","RC","","","","both","","","4417.00","3312.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2272.65","","APC Price ($2,319.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2279.65","2279.65","2279.65","1 through 10","1468.33","3441.28","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","3534.00","2650.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1468.33","","Case rate ($1,468.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5704.46","5704.46","5704.46","1 through 10","1468.33","2753.34","other","Multiple Surgery"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","both","","","3534.00","2650.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2272.65","","APC Price ($2,319.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.55","2280.15","2280.55","1 through 10","1468.33","2753.34","other","OPPS APC"
"Dest Nerve Lumbar/Sacral Sgl","PX-76001587","CDM","64635","CPT","0761","RC","","","","outpatient","","","3534.00","2650.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1468.33","","Case rate ($1,468.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3626.78","3626.78","3626.78","1 through 10","1468.33","2772.42","other","Multiple Surgery"
"DEVICE ABLATION 6MM ENDOMETRIAL NOVASURE BX/3EA","SUP-ITM-10277652","CDM","C1886","HCPCS","0272","RC","","","","both","","","3183.24","2387.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3183.24","100","","3670.50","3670.50","6900.00","1 through 10","1687.12","3183.24","percent of total billed charges",""
"DEVICE ABLATION 6MM ENDOMETRIAL NOVASURE BX/3EA","SUP-ITM-10277652","CDM","C1886","HCPCS","0272","RC","","","","both","","","3183.24","2387.43","WELLPOINT [1015]","HB CH WELLPOINT","2480.06","77.91","","3150.40","3150.40","3150.40","1 through 10","1687.12","3183.24","percent of total billed charges",""
"DEVICE ABLATION 6MM ENDOMETRIAL NOVASURE BX/3EA","SUP-ITM-10277652","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","3183.24","2387.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2497.25","78.45","","3075.20","1822.40","5304.72","1 through 10","1414.95","2497.25","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","AETNA [1001]","HB CH AETNA HMO / PPO","234.16","58.3","","554.95","91.85","1421.75","94","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","293.20","73","","2490.03","2490.03","2490.03","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","234.16","58.3","","750.00","750.00","750.00","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","212.87","53","","1192.50","120.84","4149.90","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","341.39","85","","750.00","75.00","750.00","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","401.64","100","","657.00","121.50","1971.00","14","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","401.64","100","","75.00","75.00","75.00","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","401.64","100","","366.00","144.00","1971.00","45","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","293.20","73","","667.50","667.50","667.50","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.53","44.45","","123.77","123.77","123.77","1 through 10","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","both","","","401.64","301.23","WELLPOINT [1015]","HB CH WELLPOINT","312.92","77.91","","483.51","229.32","1316.08","96","178.53","401.64","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.64","301.23","CIGNA [1006]","HB CH CIGNA HMO / PPO","238.17","59.3","","439.50","225.34","1872.27","197","200.82","315.09","percent of total billed charges",""
"DEVICE BONE 5.5X20MM FIXATION XTENDOBUTTON TITANIUM EXTERNAL PROFILE LOW","SUP-ITM-10029679","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","401.64","301.23","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","315.09","78.45","","385.32","55.36","1815.62","58","200.82","315.09","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","AETNA [1001]","HB CH AETNA HMO / PPO","2574.50","58.3","","554.95","91.85","1421.75","94","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3223.65","73","","2490.03","2490.03","2490.03","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2574.50","58.3","","750.00","750.00","750.00","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2340.46","53","","1192.50","120.84","4149.90","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3753.57","85","","750.00","75.00","750.00","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4415.96","100","","657.00","121.50","1971.00","14","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4415.96","100","","75.00","75.00","75.00","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4415.96","100","","366.00","144.00","1971.00","45","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3223.65","73","","667.50","667.50","667.50","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1962.89","44.45","","123.77","123.77","123.77","1 through 10","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","both","","","4415.96","3311.97","WELLPOINT [1015]","HB CH WELLPOINT","3440.47","77.91","","483.51","229.32","1316.08","96","1962.89","4415.96","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.96","3311.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","2618.66","59.3","","439.50","225.34","1872.27","197","2207.98","3464.32","percent of total billed charges",""
"DEVICE CLIP 25X22MM BONE EASY MONOCORTICAL FIXATION FOOT HAND","SUP-ITM-10145785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4415.96","3311.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3464.32","78.45","","385.32","55.36","1815.62","58","2207.98","3464.32","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","2915.10","2186.32","AETNA [1001]","HB CH AETNA HMO / PPO","1699.50","58.3","","1652.86","1565.83","3305.72","1 through 10","1020.29","3736.84","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","2915.10","2186.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1699.50","58.3","","1388.14","1388.14","1388.14","1 through 10","1020.29","3736.84","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","2915.10","2186.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1545.00","53","","1931.26","1931.26","1931.26","1 through 10","1020.29","3736.84","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","both","","","2915.10","2186.32","WELLPOINT [1015]","HB CH WELLPOINT","2271.15","77.91","","2186.60","2186.60","2186.60","1 through 10","1020.29","3736.84","percent of total billed charges",""
"DEVICE CONTRACEPTIVE 52MG IUD MIRENA - MUST ORDER IN MULTIPLES OF 5","SUP-ITM-10008696","CDM","J7298","HCPCS","0636","RC","","","","outpatient","","","2915.10","2186.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","1521.68","52.2","","1501.28","1429.79","1876.60","1 through 10","1400.52","3133.75","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","AETNA [1001]","HB CH AETNA HMO / PPO","332.31","58.3","","1634.24","1004.95","1718.99","42","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","2123.89","1900.92","2123.89","1 through 10","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","332.31","58.3","","3729.00","1254.19","3729.00","1 through 10","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.10","53","","939.37","939.37","5593.65","1 through 10","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","484.50","85","","2323.25","1864.50","2882.25","16","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","570.00","100","","2909.44","1772.40","10952.08","45","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","570.00","100","","2323.25","2323.25","2323.25","1 through 10","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","570.00","100","","2882.25","1772.40","10169.17","187","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","1659.41","1659.41","1659.41","1 through 10","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","both","","","570.00","427.50","WELLPOINT [1015]","HB CH WELLPOINT","444.09","77.91","","2050.91","1468.48","2902.83","52","253.37","570","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.01","59.3","","1548.60","1092.60","3613.79","82","285","447.17","percent of total billed charges",""
"DEVICE FIXATION 15MM 21MM DIA 10MM PEG XTENDO BUTTON ROUND MED","SUP-ITM-10217311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","2085.51","998.68","6202.11","56","285","447.17","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","554.95","91.85","1421.75","94","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","2490.03","2490.03","2490.03","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","750.00","750.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","1192.50","120.84","4149.90","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","573.75","85","","750.00","75.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","675.00","100","","657.00","121.50","1971.00","14","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","675.00","100","","75.00","75.00","75.00","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","675.00","100","","366.00","144.00","1971.00","45","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","667.50","667.50","667.50","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","123.77","123.77","123.77","1 through 10","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","483.51","229.32","1316.08","96","300.04","675","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","439.50","225.34","1872.27","197","337.5","529.54","percent of total billed charges",""
"DEVICE FIXATION 15MM FEMORAL ENDOBUTTON CL ULTRA POLYESTER BRAID SUTURE CONTINUOUS LOOP","SUP-ITM-10026699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","385.32","55.36","1815.62","58","337.5","529.54","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB CH AETNA HMO / PPO","454.74","58.3","","554.95","91.85","1421.75","94","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","569.40","73","","2490.03","2490.03","2490.03","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","454.74","58.3","","750.00","750.00","750.00","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.40","53","","1192.50","120.84","4149.90","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","663.00","85","","750.00","75.00","750.00","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","780.00","100","","657.00","121.50","1971.00","14","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","780.00","100","","75.00","75.00","75.00","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","780.00","100","","366.00","144.00","1971.00","45","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","569.40","73","","667.50","667.50","667.50","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.71","44.45","","123.77","123.77","123.77","1 through 10","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB CH WELLPOINT","607.70","77.91","","483.51","229.32","1316.08","96","346.71","780","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.54","59.3","","439.50","225.34","1872.27","197","390","611.91","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON ADJUSTABLE","SUP-ITM-10168305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","385.32","55.36","1815.62","58","390","611.91","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","AETNA [1001]","HB CH AETNA HMO / PPO","848.27","58.3","","554.95","91.85","1421.75","94","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1062.15","73","","2490.03","2490.03","2490.03","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","848.27","58.3","","750.00","750.00","750.00","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","771.15","53","","1192.50","120.84","4149.90","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1236.75","85","","750.00","75.00","750.00","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1455.00","100","","657.00","121.50","1971.00","14","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1455.00","100","","75.00","75.00","75.00","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1455.00","100","","366.00","144.00","1971.00","45","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.15","73","","667.50","667.50","667.50","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.75","44.45","","123.77","123.77","123.77","1 through 10","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","WELLPOINT [1015]","HB CH WELLPOINT","1133.59","77.91","","483.51","229.32","1316.08","96","646.75","1455","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.82","59.3","","439.50","225.34","1872.27","197","727.5","1141.45","percent of total billed charges",""
"DEVICE FIXATION ULTRABUTTON BB","SUP-ITM-10320480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","385.32","55.36","1815.62","58","727.5","1141.45","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","AETNA [1001]","HB CH AETNA HMO / PPO","2072.57","58.3","","554.95","91.85","1421.75","94","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2595.15","73","","2490.03","2490.03","2490.03","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2072.57","58.3","","750.00","750.00","750.00","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1884.15","53","","1192.50","120.84","4149.90","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3021.75","85","","750.00","75.00","750.00","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3555.00","100","","657.00","121.50","1971.00","14","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3555.00","100","","75.00","75.00","75.00","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3555.00","100","","366.00","144.00","1971.00","45","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2595.15","73","","667.50","667.50","667.50","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1580.20","44.45","","123.77","123.77","123.77","1 through 10","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","WELLPOINT [1015]","HB CH WELLPOINT","2769.70","77.91","","483.51","229.32","1316.08","96","1580.2","3555","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2108.12","59.3","","439.50","225.34","1872.27","197","1777.5","2788.9","percent of total billed charges",""
"DEVICE INSERTER 2.8MM SUTURE MAGNUM2 KNOTLESS HANDLE ORDERIN MULTIPLES OF 6 CS/6EA","SUP-ITM-10022099","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","385.32","55.36","1815.62","58","1777.5","2788.9","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","AETNA [1001]","HB CH AETNA HMO / PPO","2086.56","58.3","","554.95","91.85","1421.75","94","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2612.67","73","","2490.03","2490.03","2490.03","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2086.56","58.3","","750.00","750.00","750.00","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.87","53","","1192.50","120.84","4149.90","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3042.15","85","","750.00","75.00","750.00","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3579.00","100","","657.00","121.50","1971.00","14","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3579.00","100","","75.00","75.00","75.00","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3579.00","100","","366.00","144.00","1971.00","45","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2612.67","73","","667.50","667.50","667.50","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1590.87","44.45","","123.77","123.77","123.77","1 through 10","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","both","","","3579.00","2684.25","WELLPOINT [1015]","HB CH WELLPOINT","2788.40","77.91","","483.51","229.32","1316.08","96","1590.87","3579","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2122.35","59.3","","439.50","225.34","1872.27","197","1789.5","2807.73","percent of total billed charges",""
"DEVICE INSERTER 5.5MM SUTURE SPEEDSCREW PEEK OPTIMA POLYMER KNOTLESS FULLY THREADED RADIOLUCENT HANDLE CS/6EA","SUP-ITM-10056432","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3579.00","2684.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2807.73","78.45","","385.32","55.36","1815.62","58","1789.5","2807.73","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1830.28","315.58","1830.28","1 through 10","1778","4000","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","4170.85","4170.85","4170.85","1 through 10","1778","4000","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","649.55","649.55","649.55","1 through 10","1778","4000","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","8998.38","2542.37","8998.38","20","1778","4000","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1891.61","1609.14","3664.18","25","2000","3138","percent of total billed charges",""
"DEVICE SPINE 9X10 23.0MM 5DEG FUSION INTERBODY CONCORDE CARBON FIBER REINFORCED POLYMER BULLET LORDOTIC LUMBAR","SUP-ITM-10111727","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1470.68","1310.06","2481.69","19","2000","3138","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","2832.20","2124.15","AETNA [1001]","HB CH AETNA HMO / PPO","1651.17","58.3","","1952.48","1952.48","1952.48","1 through 10","1258.91","2832.2","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","2832.20","2124.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1501.07","53","","1825.07","1825.07","1825.07","1 through 10","1258.91","2832.2","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","both","","","2832.20","2124.15","WELLPOINT [1015]","HB CH WELLPOINT","2206.57","77.91","","2712.12","2712.12","2712.12","1 through 10","1258.91","2832.2","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T1","PX-27000087","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2832.20","2124.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","1679.49","59.3","","2017.91","2017.91","2017.91","1 through 10","1416.1","2221.86","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","3945.36","2959.02","AETNA [1001]","HB CH AETNA HMO / PPO","2300.14","58.3","","1952.48","1952.48","1952.48","1 through 10","1753.71","3945.36","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","3945.36","2959.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2091.04","53","","1825.07","1825.07","1825.07","1 through 10","1753.71","3945.36","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","both","","","3945.36","2959.02","WELLPOINT [1015]","HB CH WELLPOINT","3073.83","77.91","","2712.12","2712.12","2712.12","1 through 10","1753.71","3945.36","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T2","PX-27000088","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3945.36","2959.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","2339.60","59.3","","2017.91","2017.91","2017.91","1 through 10","1972.68","3095.13","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","5652.70","4239.52","AETNA [1001]","HB CH AETNA HMO / PPO","3295.52","58.3","","1952.48","1952.48","1952.48","1 through 10","2512.63","5652.7","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","5652.70","4239.52","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2995.93","53","","1825.07","1825.07","1825.07","1 through 10","2512.63","5652.7","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","both","","","5652.70","4239.52","WELLPOINT [1015]","HB CH WELLPOINT","4404.02","77.91","","2712.12","2712.12","2712.12","1 through 10","2512.63","5652.7","percent of total billed charges",""
"Device Urinary Repair W/Sling Graft T3","PX-27000089","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","5652.70","4239.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","3352.05","59.3","","2017.91","2017.91","2017.91","1 through 10","2826.35","4434.54","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","AETNA [1001]","HB CH AETNA HMO / PPO","0.45","58.3","","0.27","0.27","0.75","243","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","0.56","73","","0.34","0.34","0.34","1 through 10","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","0.45","58.3","","0.27","0.26","0.27","57","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","0.41","53","","1.97","0.25","2.98","33","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","both","","","0.77","0.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","0.56","73","","0.41","0.41","1.06","14","0.31","0.56","percent of total billed charges",""
"Dexameth Na Phos Inj 1mg","PX-63600103","CDM","J1100","HCPCS","0636","RC","","","","outpatient","","","0.77","0.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.40","52.2","","0.49","0.24","1.23","1167","0.26","0.4","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","158.76","158.76","158.76","39","128.02","288","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","152.64","53","","148.40","148.40","148.40","1 through 10","128.02","288","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","288.00","100","","81.98","81.98","81.98","18","128.02","288","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","288.00","100","","250.88","250.88","250.88","51","128.02","288","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","288.00","100","","89.59","89.59","89.59","63","128.02","288","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","5320.00","5037.42","5320.00","1 through 10","128.02","288","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","492.24","164.08","492.24","144","144","225.94","percent of total billed charges",""
"Dfci Flow Cytometry/Tc Add-On","PX-31001077","CDM","88185","CPT","0310","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","127.57","127.57","215.26","53","144","225.94","percent of total billed charges",""
"Dfci Idh1 and Idh2 Mutation Analysis","PX-30002756","CDM","81403","CPT","0300","RC","","","","outpatient","","","1294.00","970.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1015.14","78.45","","562.39","562.39","562.39","1 through 10","456.38","1015.14","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","100.36","100.36","100.36","1 through 10","21.79","132.86","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","182.00","136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","107.93","59.3","","103.72","103.72","103.72","1 through 10","22.93","142.78","percent of total billed charges",""
"Dhea-S","PX-30000405","CDM","82627","CPT","0301","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","142.78","78.45","","80.64","80.64","80.64","1 through 10","22.93","142.78","percent of total billed charges",""
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","26108.24","19581.18","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","9379.91","","Case rate ($9,379.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,604.42, add-ons for qualifying new technology services are included. If operating cost exceeds $54,128.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,194.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,407.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,265.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.58. The transfer capital threshold is the transfer adjustment factor * $633.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8603.43","8603.43","8603.43","1 through 10","8419.15","9379.91","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","26108.24","19581.18","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8419.15","","Case rate ($8,590.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,604.42, add-ons for qualifying new technology services are included. If operating cost exceeds $54,128.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,194.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,618.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,265.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.58. The transfer capital threshold is the transfer adjustment factor * $633.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8458.43","8458.43","8458.43","1 through 10","8419.15","9379.91","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","26108.24","19581.18","MEDICARE [2001]","HB BWF MEDICARE","9379.91","","Case rate ($9,379.91). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,604.42, add-ons for qualifying new technology services are included. If operating cost exceeds $54,128.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,194.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,407.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,265.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.58. The transfer capital threshold is the transfer adjustment factor * $633.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9309.80","0.03","9371.31","42","8419.15","9379.91","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","26108.24","19581.18","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8419.15","","Case rate ($8,590.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,604.42, add-ons for qualifying new technology services are included. If operating cost exceeds $54,128.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,194.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,618.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,265.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.58. The transfer capital threshold is the transfer adjustment factor * $633.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8435.36","8435.36","8435.36","1 through 10","8419.15","9379.91","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","26108.24","19581.18","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8419.15","","Case rate ($8,590.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,604.42, add-ons for qualifying new technology services are included. If operating cost exceeds $54,128.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,194.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,618.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,265.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.58. The transfer capital threshold is the transfer adjustment factor * $633.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9655.40","9655.40","9820.36","1 through 10","8419.15","9379.91","other","Inpatient DRG"
"Diabetes With Cc","638","MS-DRG","","","","","","","","inpatient","","","26108.24","19581.18","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8419.15","","Case rate ($8,590.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,604.42, add-ons for qualifying new technology services are included. If operating cost exceeds $54,128.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,194.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,618.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,265.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.58. The transfer capital threshold is the transfer adjustment factor * $633.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8435.36","8401.84","8573.31","1 through 10","8419.15","9379.91","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","36982.77","27737.08","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13296.26","","Case rate ($13,567.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,589.17, add-ons for qualifying new technology services are included. If operating cost exceeds $59,112.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,576.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,212.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,249.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.69. The transfer capital threshold is the transfer adjustment factor * $1,015.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9985.66","9985.66","9985.66","1 through 10","13296.26","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","36982.77","27737.08","MEDICARE [2001]","HB BWF MEDICARE","13567.61","","Case rate ($13,567.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,589.17, add-ons for qualifying new technology services are included. If operating cost exceeds $59,112.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,576.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,212.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,249.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.69. The transfer capital threshold is the transfer adjustment factor * $1,015.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14634.19","7442.68","14731.84","21","13296.26","14747.73","other","Inpatient Replacement Plans DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","36982.77","27737.08","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13296.26","","Case rate ($13,567.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,589.17, add-ons for qualifying new technology services are included. If operating cost exceeds $59,112.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,576.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,212.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,249.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.69. The transfer capital threshold is the transfer adjustment factor * $1,015.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15194.22","15194.22","15194.22","1 through 10","13296.26","14747.73","other","Inpatient DRG"
"Diabetes With McC","637","MS-DRG","","","","","","","","inpatient","","","36982.77","27737.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13296.26","","Case rate ($13,567.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,589.17, add-ons for qualifying new technology services are included. If operating cost exceeds $59,112.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,576.47, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,212.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,249.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,015.69. The transfer capital threshold is the transfer adjustment factor * $1,015.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13269.15","13269.15","13271.65","1 through 10","13296.26","14747.73","other","Inpatient DRG"
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","18974.52","14230.89","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6240.69","","Case rate ($6,058.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,068.24, add-ons for qualifying new technology services are included. If operating cost exceeds $51,591.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,999.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,280.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,729.00 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.16. The transfer capital threshold is the transfer adjustment factor * $439.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","6138.44","6138.44","6138.44","1 through 10","5937.74","6605.77","other","Inpatient DRG"
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","18974.52","14230.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","5937.74","","Case rate ($6,058.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,068.24, add-ons for qualifying new technology services are included. If operating cost exceeds $51,591.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,999.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,280.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,729.00 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.16. The transfer capital threshold is the transfer adjustment factor * $439.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","5851.37","5851.37","5851.37","1 through 10","5937.74","6605.77","other","Inpatient DRG"
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","18974.52","14230.89","MEDICARE [2001]","HB BWF MEDICARE","6605.77","","Case rate ($6,605.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,068.24, add-ons for qualifying new technology services are included. If operating cost exceeds $51,591.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,999.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,827.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,729.00 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.16. The transfer capital threshold is the transfer adjustment factor * $439.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","6439.73","1 through 10","5937.74","6605.77","other","Inpatient DRG"
"Diabetes Without Cc/McC","639","MS-DRG","","","","","","","","inpatient","","","18974.52","14230.89","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","5937.74","","Case rate ($6,058.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,068.24, add-ons for qualifying new technology services are included. If operating cost exceeds $51,591.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,999.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $5,280.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,729.00 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.16. The transfer capital threshold is the transfer adjustment factor * $439.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","5856.12","5856.12","5856.12","1 through 10","5937.74","6605.77","other","Inpatient DRG"
"Diabetes,EXTREME","420","DRG","","","","","","","","inpatient","","","36982.77","","MASSHEALTH [3001]","HB BWF MEDICAID","17988.84","","Case rate ($19,889.75). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,319.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $5,152.78 and the sum of the standard inlier and any outlier amount.","19884.88","19884.88","19884.88","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,EXTREME","420","DRG","","","","","","","","inpatient","","","36982.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","40432.22","","Fee schedule rate ($40,432.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","40432.22","40432.22","40432.22","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21188.34","","Standard inlier is a Case rate ($21,188.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,883, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,007.59) for the length of stay and the standard reimbursement.","21188.33","21188.33","21188.33","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8627.793","","Fee schedule rate ($18,762.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8627.793","18762.28","18762.28","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","MASSHEALTH [3001]","HB BWF MEDICAID","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","9439.22","9439.22","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19020.24","","Fee schedule rate ($19,020.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19020.24","19020.24","19020.24","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","695.29","9439.22","14","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","9439.22","9439.22","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MAJOR","420","DRG","","","","","","","","inpatient","","","26797.68","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8539.19","","Case rate ($9,441.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,871.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9439.22","9439.22","9439.22","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","29044.76","","MASSHEALTH [3001]","HB BWF MEDICAID","5033.26","","Case rate ($5,565.14). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,995.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4324.18","4324.18","4324.18","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","29044.76","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4538.27","","Fee schedule rate ($4,538.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5339.10","5339.10","5339.10","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","29044.76","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5033.26","","Case rate ($5,565.14). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,995.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5563.77","5563.77","5563.77","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MINOR","420","DRG","","","","","","","","inpatient","","","29044.76","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5033.26","","Case rate ($5,565.14). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,995.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5563.77","838.96","12338.78","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","20408.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13341.06","","Standard inlier is a Case rate ($13,341.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,299, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,893.82) for the length of stay and the standard reimbursement.","13341.06","13341.06","13341.06","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","20408.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14330.96","","Standard inlier is a Case rate ($14,330.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,334, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,034.22) for the length of stay and the standard reimbursement.","14330.96","8225.18","14330.96","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","20408.44","","FALLON HEALTH [1008]","HB BWF MEDICAID","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11472.84","11472.84","11472.84","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","20408.44","","MASSHEALTH [3001]","HB BWF MEDICAID","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4225.21","1621.65","6259.56","1 through 10","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","20408.44","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6259.56","536.82","6259.56","12","3857.53","78888.17","case rate",""
"Diabetes,MODERATE","420","DRG","","","","","","","","inpatient","","","20408.44","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5662.71","","Case rate ($6,261.10). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,691.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6259.56","1678.37","10166.00","1 through 10","3857.53","78888.17","case rate",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","19","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","208.03","508.46","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","379.27","379.27","379.27","1 through 10","200.84","1727.91","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","200.84","1727.91","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","253.19","243.10","506.37","14","200.84","1727.91","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HEALTH NEW ENGLAND [1034]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","511.40","511.40","511.40","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","HUMANA [1012]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","512.90","208.45","512.90","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1254.51","53","","1220.06","1220.06","1220.06","1 through 10","200.84","1727.91","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","332","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.18","509.60","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","343.14","343.14","343.14","1 through 10","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","403.58","391.88","403.58","15","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","441.04","428.09","441.04","30","200.84","1727.91","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.44","397.85","1025.19","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","516.73","516.73","516.73","1 through 10","200.84","1727.91","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","207.18","508.46","13","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","489.82","489.82","489.82","1 through 10","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","841.23","35.54","","1048.79","1048.79","1048.79","1 through 10","200.84","1727.91","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","207.18","511.40","66","200.84","1727.91","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","610.66","56","201.74","1183.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","610.66","135","201.74","1183.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","229.99","229.99","1379.91","43","201.74","1183.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","241.08","964.32","1 through 10","201.74","1183.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","241.08","241.08","241.08","1 through 10","201.74","1183.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000031","CDM","71260","CPT","0352","RC","","","","outpatient","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","841.23","35.54","","801.79","801.79","1048.79","12","201.74","1183.5","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","508.46","208.03","508.46","19","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","208.03","508.46","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 376%, 188 procedures at 0%.","379.27","379.27","379.27","1 through 10","200.84","1635.93","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","574.96","574.96","574.96","1 through 10","200.84","1635.93","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","253.19","243.10","506.37","14","200.84","1635.93","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HEALTH NEW ENGLAND [1034]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","511.40","511.40","511.40","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","HUMANA [1012]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","512.90","208.45","512.90","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1187.73","53","","1220.06","1220.06","1220.06","1 through 10","200.84","1635.93","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","516.73","211.41","516.73","332","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","210.38","210.18","509.60","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","343.14","343.14","343.14","1 through 10","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","403.58","391.88","403.58","15","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","441.04","428.09","441.04","30","200.84","1635.93","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.44","397.85","1025.19","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","200.84","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","516.73","516.73","516.73","1 through 10","200.84","1635.93","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","207.18","508.46","13","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","489.82","489.82","489.82","1 through 10","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","796.45","35.54","","1048.79","1048.79","1048.79","1 through 10","200.84","1635.93","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","both","","","2241.00","1680.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","506.40","207.18","511.40","66","200.84","1635.93","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","610.66","56","201.74","1120.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","610.66","","Case rate ($610.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","305.33","255.50","610.66","135","201.74","1120.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","229.99","229.99","1379.91","43","201.74","1120.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","482.16","241.08","964.32","1 through 10","201.74","1120.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","201.74","","Case rate ($201.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","241.08","241.08","241.08","1 through 10","201.74","1120.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/Contrast","PX-35000091","CDM","71260","CPT","0352","RC","","","","outpatient","","","2241.00","1680.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","796.45","35.54","","801.79","801.79","1048.79","12","201.74","1120.5","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","45","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","118.55","481.98","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","ELDER SERVICES [1037]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","117.59","124.27","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","1425.69","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","635","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","16","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","252.07","252.07","252.07","1 through 10","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","296.47","287.87","296.47","14","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","302.40","302.40","302.40","1 through 10","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.73","","Case rate ($112.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","323.98","323.98","323.98","51","112.51","1425.69","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","2225.85","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","1425.69","other","Tricare OPPS"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","118.07","126.29","17","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","694.10","35.54","","865.18","865.18","865.18","1 through 10","112.51","1425.69","percent of total billed charges",""
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","both","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.76","126.29","96","112.51","1425.69","other","OPPS APC"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","1076.73","1076.73","1076.73","1 through 10","112.51","976.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","91","112.51","976.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","340.56","","Case rate ($340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","340.56","284.98","340.56","164","112.51","976.5","other","Multiple Imaging"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","55","112.51","976.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","282.40","13","112.51","976.5","other","Multiple Radiology"
"Diagnostic Computed Tomography Thorax W/O Cntrst","PX-35000030","CDM","71250","CPT","0352","RC","","","","outpatient","","","1953.00","1464.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.10","35.54","","661.42","661.42","865.18","16","112.51","976.5","percent of total billed charges",""
"Diagnostic Digital Breast Tomosynthesis, Unilateral or Bilateral","PX-40000129","CDM","G0279","HCPCS","0401","RC","","","","both","","","267.00","200.25","CHAMPVA [160001]","HB BWF TRICARE","253.65","95","","23.11","23.11","23.11","1 through 10","17.84","253.65","percent of total billed charges",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1227.00","920.25","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","545.4","955.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1227.00","920.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","1527.00","1527.00","1527.00","1 through 10","545.4","955.96","per diem",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","both","","","1227.00","920.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.26","747.08","809.26","1 through 10","545.4","955.96","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1227.00","920.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","685.02","","Case rate ($685.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","968.62","968.62","968.62","1 through 10","598.81","1873.9","other","ASC "
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1227.00","920.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","685.02","","Case rate ($685.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.54","969.99","990.54","1 through 10","598.81","1873.9","other","ASC "
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1227.00","920.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1353.31","1353.31","1353.31","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-76002661","CDM","62328","CPT","0761","RC","","","","outpatient","","","1227.00","920.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1479.06","1479.06","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","207.58","847.08","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","1527.00","1527.00","1527.00","1 through 10","207.58","847.08","per diem",""
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","both","","","467.00","350.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.26","747.08","809.26","1 through 10","207.58","847.08","other","OPPS APC"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1353.31","1353.31","1353.31","1 through 10","215.62","1873.9","other","Multiple Surgery"
"Diagnostic Lumbar Spinal Puncture W/Fluor or CT","PX-98301897","CDM","62328","CPT","0983","RC","","","","outpatient","","","467.00","350.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1479.06","1479.06","1 through 10","215.62","1873.9","other","Multiple Surgery"
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","678.00","508.50","AETNA [1001]","HB CH AETNA HMO / PPO","395.27","58.3","","373.65","373.65","373.65","1 through 10","126.92","644.1","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","678.00","508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","494.94","73","","481.07","481.07","481.07","1 through 10","126.92","644.1","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","both","","","678.00","508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","359.34","53","","349.27","349.27","349.27","1 through 10","126.92","644.1","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","402.05","59.3","","386.17","386.17","4008.20","29","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","301.37","44.45","","506.64","228.03","506.64","1 through 10","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammo Bilat 2d Digital (Incl. Cad)","PX-40000009","CDM","77066","HCPCS","0401","RC","","","","outpatient","","","678.00","508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","531.89","78.45","","506.64","382.14","506.64","11","274.44","581.21","percent of total billed charges",""
"Diagnostic Mammography 2d Digital (Incl. Cad)","PX-40000013","CDM","77065","HCPCS","0401","RC","","","","both","","","550.00","412.50","AETNA [1001]","HB CH AETNA HMO / PPO","320.65","58.3","","303.35","303.35","303.35","1 through 10","99.6","522.5","percent of total billed charges",""
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","47007.98","35255.98","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","11820.90","","Case rate ($11,476.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,494.75, add-ons for qualifying new technology services are included. If operating cost exceeds $57,018.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,415.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,282.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,155.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.14. The transfer capital threshold is the transfer adjustment factor * $855.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","11794.31","11794.31","11794.31","1 through 10","11247.07","12150.6143","other","Inpatient DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","47007.98","35255.98","MEDICARE [2001]","HB BWF MEDICARE","11476.60","","Case rate ($11,476.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,494.75, add-ons for qualifying new technology services are included. If operating cost exceeds $57,018.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,415.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,282.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,155.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.14. The transfer capital threshold is the transfer adjustment factor * $855.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12386.30","12386.30","12468.69","1 through 10","11247.07","12150.6143","other","Inpatient Replacement Plans DRG"
"Digestive Malignancy With Cc","375","MS-DRG","","","","","","","","inpatient","","","47007.98","35255.98","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11247.07","","Case rate ($11,476.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,494.75, add-ons for qualifying new technology services are included. If operating cost exceeds $57,018.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,415.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,282.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,155.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $855.14. The transfer capital threshold is the transfer adjustment factor * $855.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11171.69","11171.69","11171.69","1 through 10","11247.07","12150.6143","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","47103.93","35327.95","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","19630.63","","Case rate ($20,031.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,063.35, add-ons for qualifying new technology services are included. If operating cost exceeds $65,587.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,072.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $18,180.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,724.10 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.98. The transfer capital threshold is the transfer adjustment factor * $1,511.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","19054.14","19054.14","19054.14","1 through 10","19630.63","21953.76","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","47103.93","35327.95","MEDICARE [2001]","HB BWF MEDICARE","21913.99","","Case rate ($21,913.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,063.35, add-ons for qualifying new technology services are included. If operating cost exceeds $65,587.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,072.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $20,062.76 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,724.10 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.98. The transfer capital threshold is the transfer adjustment factor * $1,511.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21104.21","21104.21","21245.80","1 through 10","19630.63","21953.76","other","Inpatient DRG"
"Digestive Malignancy With McC","374","MS-DRG","","","","","","","","inpatient","","","47103.93","35327.95","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","19630.63","","Case rate ($20,031.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,063.35, add-ons for qualifying new technology services are included. If operating cost exceeds $65,587.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,072.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $18,180.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,724.10 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,511.98. The transfer capital threshold is the transfer adjustment factor * $1,511.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","19107.25","19107.25","19107.25","1 through 10","19630.63","21953.76","other","Inpatient DRG"
"Digestive Malignancy Without Cc/McC","376","MS-DRG","","","","","","","","inpatient","","","25671.28","19253.46","MEDICARE [2001]","HB BWF MEDICARE","9663.37","","Case rate ($9,663.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,863.57, add-ons for qualifying new technology services are included. If operating cost exceeds $54,387.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,214.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $8,670.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,524.33 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $653.44. The transfer capital threshold is the transfer adjustment factor * $653.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8972.04","8972.04","8972.04","1 through 10","8672.71","9663.37","other","Inpatient DRG"
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","19158.74","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","16316.7088","","Per diem ($8,561). If length of stay < 8, first 1 days paid at a per diem of $17,122 instead.","16316.7088","68484.20","68484.20","1 through 10","2244","53808.79","per diem","Estimated amount calculated based on 1 day length of stay."
"Digestive Malignancy,EXTREME","240","DRG","","","","","","","","inpatient","","","19158.74","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","10002.43","10002.43","10002.43","1 through 10","2244","53808.79","percent of total billed charges",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","42284.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28980.57","","Standard inlier is a Case rate ($28,980.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,325, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,113.67) for the length of stay and the standard reimbursement.","28980.56","28980.56","28980.56","1 through 10","2244","53808.79","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","42284.05","","MASSHEALTH [3001]","HB BWF MEDICAID","12873.32","","Case rate ($14,233.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,663.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2210.25","2210.25","2210.25","1 through 10","2244","53808.79","case rate",""
"Digestive Malignancy,MAJOR","240","DRG","","","","","","","","inpatient","","","42284.05","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","12873.32","","Case rate ($14,233.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,663.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14230.18","14230.18","14230.18","1 through 10","2244","53808.79","case rate",""
"Digestive Malignancy,MODERATE","240","DRG","","","","","","","","inpatient","","","49114.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21251.54","","Standard inlier is a Case rate ($21,251.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,943, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,016.57) for the length of stay and the standard reimbursement.","21251.53","21251.53","21251.53","1 through 10","2244","53808.79","case rate",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","AETNA [1001]","HB CH AETNA HMO / PPO","172.57","58.3","","163.30","163.30","163.30","1 through 10","17.84","615.63","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","216.08","73","","210.24","210.24","210.24","1 through 10","17.84","615.63","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","156.88","53","","152.64","152.64","152.64","1 through 10","17.84","615.63","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","both","","","296.00","222.00","WELLPOINT [1015]","HB CH WELLPOINT","230.61","77.91","","226.83","226.83","514.83","17","17.84","615.63","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","296.00","222.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","175.53","59.3","","168.77","168.77","506.31","21","69.66","287.68","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","131.57","44.45","","221.41","99.66","221.41","1 through 10","69.66","287.68","percent of total billed charges",""
"Digital Breast Tomosynthesis Bilateral","PX-32000400","CDM","77062","CPT","0401","RC","","","","outpatient","","","296.00","222.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","232.21","78.45","","221.41","167.00","221.41","11","69.66","287.68","percent of total billed charges",""
"Digital Breast Tomosynthesis Unilateral","PX-32000399","CDM","77061","CPT","0401","RC","","","","both","","","232.00","174.00","AETNA [1001]","HB CH AETNA HMO / PPO","135.26","58.3","","128.14","128.14","128.14","1 through 10","17.84","484.74","percent of total billed charges",""
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","both","","","2253.00","1689.75","MEDICARE [2001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","1 through 10","761.55","1755.31","other","OPPS APC"
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","both","","","2253.00","1689.75","WELLPOINT [1015]","HB CH WELLPOINT","1755.31","77.91","","1725.63","1725.63","1725.63","1 through 10","761.55","1755.31","percent of total billed charges",""
"Dilate Esophagus Sound or Bougie","PX-75000121","CDM","43450","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1336.03","59.3","","1283.93","1283.93","1283.93","1 through 10","761.55","1873.9","percent of total billed charges",""
"DILATOR BALLOON CRE 6FR 15-18MM 8CM 180CM .035IN FIXED WIRE","SUP-ITM-10005180","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","513.45","385.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","402.80","78.45","","2644.76","2644.76","2644.76","1 through 10","256.73","402.8","percent of total billed charges",""
"DILATOR CRE 6FR 18-19-20MM 8CM 180CM ESOPHAGEAL BALLOON FIXED WIRE SHAFT BX/5EA","SUP-ITM-10082686","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","418.06","313.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","327.97","78.45","","2644.76","2644.76","2644.76","1 through 10","209.03","327.97","percent of total billed charges",""
"DILATOR RIGIFLEX II 14FR 4.6MM 120FR 40MM 10CM .038IN BALLOON SINGLE-USE ACHALASIA STERILE","SUP-ITM-10138951","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","1251.45","938.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","981.76","78.45","","2644.76","2644.76","2644.76","1 through 10","625.73","981.76","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","225.09","168.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.30","53","","69.13","15.86","85.00","1 through 10","100.05","225.09","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","225.09","168.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","191.33","85","","29.94","29.94","29.94","1 through 10","100.05","225.09","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","225.09","168.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.09","100","","60.23","29.94","60.23","12","100.05","225.09","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","225.09","168.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.09","100","","65.22","29.94","360.69","1 through 10","100.05","225.09","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","both","","","225.09","168.82","WELLPOINT [1015]","HB CH WELLPOINT","175.37","77.91","","51.37","51.37","284.08","1 through 10","100.05","225.09","percent of total billed charges",""
"DILATOR SHEATH 8 TO 10FR 20CM RENAL","SUP-ITM-10072436","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","225.09","168.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.58","78.45","","123.30","23.02","333.57","1 through 10","112.55","176.58","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","AETNA [1001]","HB CH AETNA HMO / PPO","566.68","58.3","","554.95","91.85","1421.75","94","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","709.56","73","","2490.03","2490.03","2490.03","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","566.68","58.3","","750.00","750.00","750.00","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","515.16","53","","1192.50","120.84","4149.90","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","826.20","85","","750.00","75.00","750.00","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","972.00","100","","657.00","121.50","1971.00","14","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","972.00","100","","75.00","75.00","75.00","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","972.00","100","","366.00","144.00","1971.00","45","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","709.56","73","","667.50","667.50","667.50","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","432.05","44.45","","123.77","123.77","123.77","1 through 10","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","both","","","972.00","729.00","WELLPOINT [1015]","HB CH WELLPOINT","757.29","77.91","","483.51","229.32","1316.08","96","432.05","972","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","972.00","729.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","576.40","59.3","","439.50","225.34","1872.27","197","486","762.53","percent of total billed charges",""
"DILATOR THREADED 4.75MM HEALICOIL REGENESORB","SUP-ITM-10191939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","972.00","729.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","762.53","78.45","","385.32","55.36","1815.62","58","486","762.53","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","89.59","89.59","89.59","1 through 10","13.27","118.26","percent of total billed charges",""
"Dipropylacetic Acid (Valproic)","PX-30000182","CDM","80164","CPT","0301","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","92.59","92.59","92.59","1 through 10","13.98","127.09","percent of total billed charges",""
"Direct Admission of Patient for Hospital Observation Care","PX-76200007","CDM","G0379","HCPCS","0762","RC","","","","both","","","110.00","82.50","MEDICARE [2001]","HB BWF MEDICARE","728.09","","APC Price ($728.09). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","2987.45","3144.34","1 through 10","58.3","6281","other","OPPS APC"
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","AETNA [1001]","HB CH AETNA HMO / PPO","5713.40","58.3","","1830.28","315.58","1830.28","1 through 10","4356.1","9800","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7154.00","73","","4170.85","4170.85","4170.85","1 through 10","4356.1","9800","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4356.10","44.45","","649.55","649.55","649.55","1 through 10","4356.1","9800","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","both","","","9800.00","7350.00","WELLPOINT [1015]","HB CH WELLPOINT","7635.18","77.91","","8998.38","2542.37","8998.38","20","4356.1","9800","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5811.40","59.3","","1891.61","1609.14","3664.18","25","4900","7688.1","percent of total billed charges",""
"DISC CERVICAL MOBI-C 13X15XH5 COBALT POLY FIX TEETH STERILE DISP","SUP-ITM-10136258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9800.00","7350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7688.10","78.45","","1470.68","1310.06","2481.69","19","4900","7688.1","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","394.35","63.4","","401.12","401.12","401.12","1 through 10","329.66","2109.35","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","MEDICARE [2001]","HB BWF MEDICARE","2047.91","","APC Price ($2,047.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2047.91","1852.43","2047.91","1 through 10","329.66","2109.35","other","OPPS APC"
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","TRICARE [160005]","HB BWF TRICARE","1945.52","","APC Price ($2,047.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1227.31","1227.31","1227.31","1 through 10","329.66","2109.35","other","Tricare OPPS"
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","both","","","622.00","466.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2006.95","","APC Price ($2,047.91). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2013.86","2013.86","2013.86","1 through 10","329.66","2109.35","other","OPPS APC"
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","189.19","","Case rate ($189.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","273.19","267.51","273.19","1 through 10","189.19","567.68","other","ASC "
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.19","","Case rate ($189.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","273.57","267.89","273.57","1 through 10","189.19","567.68","other","ASC "
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","358.89","57.7","","350.90","350.90","350.90","1 through 10","189.19","567.68","percent of total billed charges",""
"Dise Dyn Eval Sleep Disordered Breathing Flx Dx","PX-75000524","CDM","42975","CPT","0750","RC","","","","outpatient","","","622.00","466.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","376.31","60.5","","3779.01","3779.01","3779.01","1 through 10","189.19","567.68","percent of total billed charges",""
"Disopyramide Serum","PX-30003016","CDM","80299","CPT","0301","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Disopyramide Serum","PX-30003016","CDM","80299","CPT","0301","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","165.29","165.29","165.29","1 through 10","14.12","89.43","percent of total billed charges",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","25887.58","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21641.28","","Standard inlier is a Case rate ($21,641.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,071.89) for the length of stay and the standard reimbursement.","28613.44","28613.44","28613.44","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","25887.58","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23458.2168","","Fee schedule rate ($26,176.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23458.2168","26176.50","26176.50","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","25887.58","","MASSHEALTH [3001]","HB BWF MEDICAID","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9358.26","9358.26","9358.26","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","25887.58","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11460.14","11460.14","11460.14","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MAJOR","284","DRG","","","","","","","","inpatient","","","25887.58","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13756.64","13756.64","13756.64","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","27987.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15253.23","","Standard inlier is a Case rate ($15,253.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,165.26) for the length of stay and the standard reimbursement.","14560.10","15253.23","15253.23","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","27987.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16385.01","","Standard inlier is a Case rate ($16,385.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,325.78) for the length of stay and the standard reimbursement.","16385.01","15640.24","16385.01","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","27987.30","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6229.32","","Case rate ($6,887.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,317.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6885.90","1324.12","6885.90","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MINOR","284","DRG","","","","","","","","inpatient","","","27987.30","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6229.32","","Case rate ($6,887.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,317.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6885.90","6885.90","6885.90","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","24379.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20146.43","","Standard inlier is a Case rate ($20,146.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,859.86) for the length of stay and the standard reimbursement.","19230.94","19230.94","19232.60","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","24379.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21641.28","","Standard inlier is a Case rate ($21,641.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,315, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,071.89) for the length of stay and the standard reimbursement.","21641.28","21641.28","21641.28","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","24379.37","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23458.2168","","Fee schedule rate ($16,047.89). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23458.2168","16047.89","16047.89","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","24379.37","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9799.33","","Fee schedule rate ($9,799.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9799.33","9799.33","9799.33","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","24379.37","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9348.30","9348.30","9348.30","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Gallbladder And Biliary Tract,MODERATE","284","DRG","","","","","","","","inpatient","","","24379.37","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8456.94","","Case rate ($9,350.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,780.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9348.30","9348.30","9348.30","1 through 10","6229.32","43190.84","case rate",""
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","36284.48","27213.36","MEDICARE [2001]","HB BWF MEDICARE","9227.20","","Case rate ($9,227.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,241.69, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,243.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,205.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,902.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.43. The transfer capital threshold is the transfer adjustment factor * $682.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9793.73","0.03","9858.53","1 through 10","9042.66","9554.7518","other","Inpatient Replacement Plans DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","442","MS-DRG","","","","","","","","inpatient","","","36284.48","27213.36","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9042.66","","Case rate ($9,227.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,241.69, add-ons for qualifying new technology services are included. If operating cost exceeds $54,765.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,243.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,205.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,902.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $682.43. The transfer capital threshold is the transfer adjustment factor * $682.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8837.54","8837.54","8837.54","1 through 10","9042.66","9554.7518","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","40714.85","30536.14","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","17369.79","","Case rate ($16,863.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,890.81, add-ons for qualifying new technology services are included. If operating cost exceeds $62,414.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,829.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $15,255.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,551.57 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,268.78. The transfer capital threshold is the transfer adjustment factor * $1,268.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","17957.79","17957.79","17957.79","1 through 10","16526.59","18443.77","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC","441","MS-DRG","","","","","","","","inpatient","","","40714.85","30536.14","MEDICARE [2001]","HB BWF MEDICARE","18443.77","","Case rate ($18,443.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,890.81, add-ons for qualifying new technology services are included. If operating cost exceeds $62,414.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,829.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $16,835.76 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,551.57 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,268.78. The transfer capital threshold is the transfer adjustment factor * $1,268.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19048.30","18921.53","19048.30","1 through 10","16526.59","18443.77","other","Inpatient DRG"
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/McC","443","MS-DRG","","","","","","","","inpatient","","","13665.34","10249.00","MEDICARE [2001]","HB BWF MEDICARE","6781.71","","Case rate ($6,781.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,792.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,315.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,055.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $5,947.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,452.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $494.66. The transfer capital threshold is the transfer adjustment factor * $494.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","6646.08","6985.16","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","25194.71","18896.03","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","8084.57","","Case rate ($8,084.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,097.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,620.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,150.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,757.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.69. The transfer capital threshold is the transfer adjustment factor * $594.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7961.06","7961.06","7961.06","1 through 10","7922.88","8634.92","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","25194.71","18896.03","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7922.88","","Case rate ($8,084.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,097.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,620.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,150.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,757.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.69. The transfer capital threshold is the transfer adjustment factor * $594.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7928.53","7928.53","7928.53","1 through 10","7922.88","8634.92","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","25194.71","18896.03","MEDICARE [2001]","HB BWF MEDICARE","8084.57","","Case rate ($8,084.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,097.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,620.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,150.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,757.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.69. The transfer capital threshold is the transfer adjustment factor * $594.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8804.54","1089.21","8804.54","20","7922.88","8634.92","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","25194.71","18896.03","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7922.88","","Case rate ($8,084.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,097.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,620.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,150.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,757.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.69. The transfer capital threshold is the transfer adjustment factor * $594.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8833.26","8833.26","8833.26","1 through 10","7922.88","8634.92","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With Cc","439","MS-DRG","","","","","","","","inpatient","","","25194.71","18896.03","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7922.88","","Case rate ($8,084.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,097.19, add-ons for qualifying new technology services are included. If operating cost exceeds $53,620.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,155.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,150.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,757.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $594.69. The transfer capital threshold is the transfer adjustment factor * $594.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7895.01","7895.01","7895.01","1 through 10","7922.88","8634.92","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","39766.30","29824.72","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15042.27","","Case rate ($15,349.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,373.72, add-ons for qualifying new technology services are included. If operating cost exceeds $60,897.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,713.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,857.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,034.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,152.49. The transfer capital threshold is the transfer adjustment factor * $1,152.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9456.00","9456.00","9456.00","1 through 10","15042.27","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","39766.30","29824.72","MEDICARE [2001]","HB BWF MEDICARE","15349.26","","Case rate ($15,349.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,373.72, add-ons for qualifying new technology services are included. If operating cost exceeds $60,897.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,713.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,857.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,034.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,152.49. The transfer capital threshold is the transfer adjustment factor * $1,152.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16794.09","10590.52","16794.09","1 through 10","15042.27","16452.3293","other","Inpatient Replacement Plans DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","39766.30","29824.72","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15042.27","","Case rate ($15,349.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,373.72, add-ons for qualifying new technology services are included. If operating cost exceeds $60,897.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,713.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,857.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,034.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,152.49. The transfer capital threshold is the transfer adjustment factor * $1,152.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17814.67","17814.67","17814.67","1 through 10","15042.27","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy With McC","438","MS-DRG","","","","","","","","inpatient","","","39766.30","29824.72","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15042.27","","Case rate ($15,349.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,373.72, add-ons for qualifying new technology services are included. If operating cost exceeds $60,897.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,713.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $13,857.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,034.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,152.49. The transfer capital threshold is the transfer adjustment factor * $1,152.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17287.36","17287.36","17287.36","1 through 10","15042.27","16452.3293","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","15989.06","11991.79","MEDICARE [2001]","HB BWF MEDICARE","6607.79","","Case rate ($6,607.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,070.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,593.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,000.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,829.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,730.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.30. The transfer capital threshold is the transfer adjustment factor * $439.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6367.41","6367.41","6367.41","1 through 10","5939.54","6607.79","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy Without Cc/McC","440","MS-DRG","","","","","","","","inpatient","","","15989.06","11991.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","5939.54","","Case rate ($6,060.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,070.09, add-ons for qualifying new technology services are included. If operating cost exceeds $51,593.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,000.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,282.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,730.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $439.30. The transfer capital threshold is the transfer adjustment factor * $439.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","5736.98","5736.98","5736.98","1 through 10","5939.54","6607.79","other","Inpatient DRG"
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","50781.29","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","55318.10","","Standard inlier is a Case rate ($55,318.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $68,397, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,852.62) for the length of stay and the standard reimbursement.","55318.09","55318.09","55318.09","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","50781.29","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","29540.82","","Fee schedule rate ($29,540.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26109.53","26109.53","26109.53","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,EXTREME","282","DRG","","","","","","","","inpatient","","","50781.29","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","62964.82","","Fee schedule rate ($62,964.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","62964.82","62964.82","62964.82","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16410.34","","Standard inlier is a Case rate ($16,410.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,329.51) for the length of stay and the standard reimbursement.","24980.78","24980.78","24980.78","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17627.98","","Standard inlier is a Case rate ($17,627.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $28,484, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,502.22) for the length of stay and the standard reimbursement.","26834.34","26834.34","26834.34","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","FALLON HEALTH [1008]","HB BWF MEDICAID","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11767.77","11767.77","11767.77","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11662.6656","","Fee schedule rate ($28,263.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11662.6656","28263.60","28263.60","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","31089.66","","Fee schedule rate ($31,089.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29890.68","29890.68","29890.68","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","MASSHEALTH [3001]","HB BWF MEDICAID","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11767.77","11767.77","11767.77","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","23900.74","","Fee schedule rate ($23,900.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23900.74","23900.74","23900.74","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11767.77","1004.70","11767.77","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MAJOR","282","DRG","","","","","","","","inpatient","","","35645.70","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11767.77","11767.77","11767.77","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12603.16","","Standard inlier is a Case rate ($12,603.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,789.07) for the length of stay and the standard reimbursement.","12603.16","12030.45","14888.21","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13538.31","","Standard inlier is a Case rate ($13,538.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,921.71) for the length of stay and the standard reimbursement.","13536.26","13536.26","13536.26","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11662.6656","","Fee schedule rate ($15,295.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11662.6656","11662.66","11662.66","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","16824.92","","Fee schedule rate ($16,824.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12828.80","12828.80","12828.80","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4591.17","","Case rate ($5,076.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,506.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5075.08","5075.08","5075.08","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","4591.17","","Case rate ($5,076.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,506.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5075.08","5075.08","5075.08","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MINOR","282","DRG","","","","","","","","inpatient","","","15158.86","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4591.17","","Case rate ($5,076.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,506.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5075.08","1011.19","5075.08","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16410.34","","Standard inlier is a Case rate ($16,410.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,577, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,329.51) for the length of stay and the standard reimbursement.","16410.34","15664.62","16410.34","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17627.98","","Standard inlier is a Case rate ($17,627.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $28,484, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,502.22) for the length of stay and the standard reimbursement.","17627.97","17627.97","17627.97","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","FALLON HEALTH [1008]","HB BWF MEDICAID","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,656.88 and the sum of the standard inlier and any outlier amount.","7172.54","7172.54","7172.54","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11662.6656","","Per diem ($3,059). If length of stay < 5, first 1 days paid at a per diem of $6,118 instead.","11662.6656","15295.52","15295.52","1 through 10","3116","121933.91","per diem","Estimated amount calculated based on 4 day length of stay."
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","3365.00","","Per diem ($3,365). If length of stay < 5, first 1 days paid at a per diem of $6,730 instead.","16824.92","16824.92","16824.92","1 through 10","3116","121933.91","per diem","Estimated amount calculated based on 4 day length of stay."
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","MASSHEALTH [3001]","HB BWF MEDICAID","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,656.88 and the sum of the standard inlier and any outlier amount.","7172.55","2618.82","7172.55","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,656.88 and the sum of the standard inlier and any outlier amount.","7172.54","1172.85","7172.54","1 through 10","3116","121933.91","case rate",""
"Disorders Of Pancreas Except Malignancy,MODERATE","282","DRG","","","","","","","","inpatient","","","25599.41","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6488.64","","Case rate ($7,174.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,604.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,656.88 and the sum of the standard inlier and any outlier amount.","7172.54","299.54","7172.54","1 through 10","3116","121933.91","case rate",""
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","34259.83","25694.87","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","201.76","","Case rate ($201.76) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16872.14","16872.14","16872.14","1 through 10","201.76","18333.2171","other","Inpatient Psych"
"Disorders Of Personality And Impulse Control","883","MS-DRG","","","","","","","","inpatient","","","34259.83","25694.87","MEDICARE [2001]","HB BWF MEDICARE","201.76","","Case rate ($201.76) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","18685.34","18685.34","18685.34","1 through 10","201.76","18333.2171","other","Inpatient Psych"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25887.58","19415.68","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10415.89","","Case rate ($10,415.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,432.32, add-ons for qualifying new technology services are included. If operating cost exceeds $55,956.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,334.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,302.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,093.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.70. The transfer capital threshold is the transfer adjustment factor * $773.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9972.51","9972.51","9972.51","1 through 10","10207.57","10822.5216","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25887.58","19415.68","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10207.57","","Case rate ($10,415.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,432.32, add-ons for qualifying new technology services are included. If operating cost exceeds $55,956.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,334.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,302.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,093.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.70. The transfer capital threshold is the transfer adjustment factor * $773.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9923.00","9923.00","9923.00","1 through 10","10207.57","10822.5216","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25887.58","19415.68","MEDICARE [2001]","HB BWF MEDICARE","10415.89","","Case rate ($10,415.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,432.32, add-ons for qualifying new technology services are included. If operating cost exceeds $55,956.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,334.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,302.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,093.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.70. The transfer capital threshold is the transfer adjustment factor * $773.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10962.15","7392.18","11034.86","1 through 10","10207.57","10822.5216","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25887.58","19415.68","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10207.57","","Case rate ($10,415.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,432.32, add-ons for qualifying new technology services are included. If operating cost exceeds $55,956.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,334.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,302.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,093.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.70. The transfer capital threshold is the transfer adjustment factor * $773.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9922.99","9922.99","9922.99","1 through 10","10207.57","10822.5216","other","Inpatient DRG"
"Disorders Of The Biliary Tract With Cc","445","MS-DRG","","","","","","","","inpatient","","","25887.58","19415.68","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","10207.57","","Case rate ($10,415.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,432.32, add-ons for qualifying new technology services are included. If operating cost exceeds $55,956.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,334.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $9,302.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,093.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $773.70. The transfer capital threshold is the transfer adjustment factor * $773.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9932.58","9932.58","9932.58","1 through 10","10207.57","10822.5216","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","45186.88","33890.16","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","16195.71","","Case rate ($15,723.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,749.07, add-ons for qualifying new technology services are included. If operating cost exceeds $61,272.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,742.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,203.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,409.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.26. The transfer capital threshold is the transfer adjustment factor * $1,181.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","16078.96","16078.96","16078.96","1 through 10","15409.51","16523.5301","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","45186.88","33890.16","MEDICARE [2001]","HB BWF MEDICARE","15723.99","","Case rate ($15,723.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,749.07, add-ons for qualifying new technology services are included. If operating cost exceeds $61,272.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,742.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,203.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,409.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.26. The transfer capital threshold is the transfer adjustment factor * $1,181.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16999.94","16887.00","16999.94","1 through 10","15409.51","16523.5301","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","45186.88","33890.16","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15409.51","","Case rate ($15,723.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,749.07, add-ons for qualifying new technology services are included. If operating cost exceeds $61,272.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,742.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,203.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,409.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.26. The transfer capital threshold is the transfer adjustment factor * $1,181.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17232.60","17232.60","17232.60","1 through 10","15409.51","16523.5301","other","Inpatient DRG"
"Disorders Of The Biliary Tract With McC","444","MS-DRG","","","","","","","","inpatient","","","45186.88","33890.16","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15409.51","","Case rate ($15,723.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,749.07, add-ons for qualifying new technology services are included. If operating cost exceeds $61,272.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,742.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $14,203.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,409.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,181.26. The transfer capital threshold is the transfer adjustment factor * $1,181.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17660.11","17660.11","17660.11","1 through 10","15409.51","16523.5301","other","Inpatient DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","22376.80","16782.60","MEDICARE [2001]","HB BWF MEDICARE","7956.58","","Case rate ($7,956.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,968.99, add-ons for qualifying new technology services are included. If operating cost exceeds $53,492.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,145.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,032.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,629.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.87. The transfer capital threshold is the transfer adjustment factor * $584.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8179.09","7458.43","8179.09","1 through 10","7797.45","8492.23","other","Inpatient Replacement Plans DRG"
"Disorders Of The Biliary Tract Without Cc/McC","446","MS-DRG","","","","","","","","inpatient","","","22376.80","16782.60","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7797.45","","Case rate ($7,956.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,968.99, add-ons for qualifying new technology services are included. If operating cost exceeds $53,492.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,145.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,032.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,629.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $584.87. The transfer capital threshold is the transfer adjustment factor * $584.87. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8298.44","8298.44","8298.44","1 through 10","7797.45","8492.23","other","Inpatient DRG"
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","AETNA [1001]","HB CH AETNA HMO / PPO","380.11","58.3","","554.95","91.85","1421.75","94","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","475.95","73","","2490.03","2490.03","2490.03","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","380.11","58.3","","750.00","750.00","750.00","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.55","53","","1192.50","120.84","4149.90","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","554.19","85","","750.00","75.00","750.00","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.99","100","","657.00","121.50","1971.00","14","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","651.99","100","","75.00","75.00","75.00","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.99","100","","366.00","144.00","1971.00","45","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.95","73","","667.50","667.50","667.50","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.81","44.45","","123.77","123.77","123.77","1 through 10","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","WELLPOINT [1015]","HB CH WELLPOINT","507.97","77.91","","483.51","229.32","1316.08","96","289.81","651.99","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.99","488.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.63","59.3","","439.50","225.34","1872.27","197","326","511.49","percent of total billed charges",""
"DISTAL PLATE 103MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072286","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","385.32","55.36","1815.62","58","326","511.49","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","AETNA [1001]","HB CH AETNA HMO / PPO","2257.24","58.3","","1634.24","1004.95","1718.99","42","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2826.39","73","","2123.89","1900.92","2123.89","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2257.24","58.3","","3729.00","1254.19","3729.00","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.04","53","","939.37","939.37","5593.65","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3291.00","85","","2323.25","1864.50","2882.25","16","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3871.77","100","","2909.44","1772.40","10952.08","45","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3871.77","100","","2323.25","2323.25","2323.25","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3871.77","100","","2882.25","1772.40","10169.17","187","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2826.39","73","","1659.41","1659.41","1659.41","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","WELLPOINT [1015]","HB CH WELLPOINT","3016.50","77.91","","2050.91","1468.48","2902.83","52","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.77","2903.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2295.96","59.3","","1548.60","1092.60","3613.79","82","1935.89","3037.4","percent of total billed charges",""
"DISTAL PLATE 156MM 9 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING NARROW RIGHT","SUP-ITM-10072278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3871.77","2903.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3037.40","78.45","","2085.51","998.68","6202.11","56","1935.89","3037.4","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","AETNA [1001]","HB CH AETNA HMO / PPO","2257.24","58.3","","554.95","91.85","1421.75","94","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2826.39","73","","2490.03","2490.03","2490.03","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2257.24","58.3","","750.00","750.00","750.00","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2052.04","53","","1192.50","120.84","4149.90","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3291.00","85","","750.00","75.00","750.00","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3871.77","100","","657.00","121.50","1971.00","14","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3871.77","100","","75.00","75.00","75.00","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3871.77","100","","366.00","144.00","1971.00","45","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2826.39","73","","667.50","667.50","667.50","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1721.00","44.45","","123.77","123.77","123.77","1 through 10","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","both","","","3871.77","2903.83","WELLPOINT [1015]","HB CH WELLPOINT","3016.50","77.91","","483.51","229.32","1316.08","96","1721","3871.77","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.77","2903.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2295.96","59.3","","439.50","225.34","1872.27","197","1935.89","3037.4","percent of total billed charges",""
"DISTAL PLATE 157MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING WIDE RT ANTEROLATERAL TIBIAL","SUP-ITM-10072270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3871.77","2903.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3037.40","78.45","","385.32","55.36","1815.62","58","1935.89","3037.4","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","AETNA [1001]","HB CH AETNA HMO / PPO","2273.46","58.3","","554.95","91.85","1421.75","94","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2846.69","73","","2490.03","2490.03","2490.03","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.46","58.3","","750.00","750.00","750.00","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2066.78","53","","1192.50","120.84","4149.90","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3314.64","85","","750.00","75.00","750.00","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3899.58","100","","657.00","121.50","1971.00","14","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3899.58","100","","75.00","75.00","75.00","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3899.58","100","","366.00","144.00","1971.00","45","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2846.69","73","","667.50","667.50","667.50","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1733.36","44.45","","123.77","123.77","123.77","1 through 10","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","both","","","3899.58","2924.68","WELLPOINT [1015]","HB CH WELLPOINT","3038.16","77.91","","483.51","229.32","1316.08","96","1733.36","3899.58","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3899.58","2924.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.45","59.3","","439.50","225.34","1872.27","197","1949.79","3059.22","percent of total billed charges",""
"DISTAL PLATE 199MM 12 HOLE BONE A.L.P.S. TITANIUM TIBIAL ANTEROLATERAL LOCKING WIDE RIGHT","SUP-ITM-10072271","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3899.58","2924.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.22","78.45","","385.32","55.36","1815.62","58","1949.79","3059.22","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","AETNA [1001]","HB CH AETNA HMO / PPO","2180.98","58.3","","554.95","91.85","1421.75","94","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2730.90","73","","2490.03","2490.03","2490.03","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2180.98","58.3","","750.00","750.00","750.00","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1982.71","53","","1192.50","120.84","4149.90","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3179.82","85","","750.00","75.00","750.00","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3740.96","100","","657.00","121.50","1971.00","14","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3740.96","100","","75.00","75.00","75.00","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3740.96","100","","366.00","144.00","1971.00","45","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2730.90","73","","667.50","667.50","667.50","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1662.86","44.45","","123.77","123.77","123.77","1 through 10","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","both","","","3740.96","2805.72","WELLPOINT [1015]","HB CH WELLPOINT","2914.58","77.91","","483.51","229.32","1316.08","96","1662.86","3740.96","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3740.96","2805.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","2218.39","59.3","","439.50","225.34","1872.27","197","1870.48","2934.78","percent of total billed charges",""
"DISTAL PLATE 226MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL TIBIAL","SUP-ITM-10045375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3740.96","2805.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2934.78","78.45","","385.32","55.36","1815.62","58","1870.48","2934.78","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","AETNA [1001]","HB CH AETNA HMO / PPO","1451.98","58.3","","554.95","91.85","1421.75","94","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1818.09","73","","2490.03","2490.03","2490.03","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1451.98","58.3","","750.00","750.00","750.00","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1319.99","53","","1192.50","120.84","4149.90","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2116.96","85","","750.00","75.00","750.00","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2490.54","100","","657.00","121.50","1971.00","14","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2490.54","100","","75.00","75.00","75.00","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2490.54","100","","366.00","144.00","1971.00","45","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1818.09","73","","667.50","667.50","667.50","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1107.05","44.45","","123.77","123.77","123.77","1 through 10","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","both","","","2490.54","1867.90","WELLPOINT [1015]","HB CH WELLPOINT","1940.38","77.91","","483.51","229.32","1316.08","96","1107.05","2490.54","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2490.54","1867.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","1476.89","59.3","","439.50","225.34","1872.27","197","1245.27","1953.83","percent of total billed charges",""
"DISTAL PLATE 22X51MM BONE DVR CROSSLOCK COBALT LOCKED RT NARROW","SUP-ITM-10125914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2490.54","1867.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1953.83","78.45","","385.32","55.36","1815.62","58","1245.27","1953.83","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","AETNA [1001]","HB CH AETNA HMO / PPO","1635.73","58.3","","554.95","91.85","1421.75","94","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2048.18","73","","2490.03","2490.03","2490.03","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1635.73","58.3","","750.00","750.00","750.00","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1487.03","53","","1192.50","120.84","4149.90","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2384.86","85","","750.00","75.00","750.00","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2805.72","100","","657.00","121.50","1971.00","14","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2805.72","100","","75.00","75.00","75.00","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2805.72","100","","366.00","144.00","1971.00","45","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2048.18","73","","667.50","667.50","667.50","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1247.14","44.45","","123.77","123.77","123.77","1 through 10","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.72","2104.29","WELLPOINT [1015]","HB CH WELLPOINT","2185.94","77.91","","483.51","229.32","1316.08","96","1247.14","2805.72","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.72","2104.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","1663.79","59.3","","439.50","225.34","1872.27","197","1402.86","2201.09","percent of total billed charges",""
"DISTAL PLATE 24X62MM MD BONE DVR CROSSLOCK COBALT LOCKED RIGHT","SUP-ITM-10134649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.72","2104.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2201.09","78.45","","385.32","55.36","1815.62","58","1402.86","2201.09","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","AETNA [1001]","HB CH AETNA HMO / PPO","1698.28","58.3","","554.95","91.85","1421.75","94","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2126.49","73","","2490.03","2490.03","2490.03","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1698.28","58.3","","750.00","750.00","750.00","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1543.89","53","","1192.50","120.84","4149.90","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2476.05","85","","750.00","75.00","750.00","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2913.00","100","","657.00","121.50","1971.00","14","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2913.00","100","","75.00","75.00","75.00","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2913.00","100","","366.00","144.00","1971.00","45","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2126.49","73","","667.50","667.50","667.50","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.83","44.45","","123.77","123.77","123.77","1 through 10","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","both","","","2913.00","2184.75","WELLPOINT [1015]","HB CH WELLPOINT","2269.52","77.91","","483.51","229.32","1316.08","96","1294.83","2913","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1727.41","59.3","","439.50","225.34","1872.27","197","1456.5","2285.25","percent of total billed charges",""
"DISTAL PLATE 3 HOLE BONE VOLAR RADIAL GEMINUS TITANIUM LT STANDARD","SUP-ITM-10126422","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2913.00","2184.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2285.25","78.45","","385.32","55.36","1815.62","58","1456.5","2285.25","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","AETNA [1001]","HB CH AETNA HMO / PPO","360.29","58.3","","554.95","91.85","1421.75","94","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","451.14","73","","2490.03","2490.03","2490.03","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","360.29","58.3","","750.00","750.00","750.00","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","327.54","53","","1192.50","120.84","4149.90","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","525.30","85","","750.00","75.00","750.00","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","618.00","100","","657.00","121.50","1971.00","14","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","618.00","100","","75.00","75.00","75.00","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","618.00","100","","366.00","144.00","1971.00","45","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","451.14","73","","667.50","667.50","667.50","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","274.70","44.45","","123.77","123.77","123.77","1 through 10","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","both","","","618.00","463.50","WELLPOINT [1015]","HB CH WELLPOINT","481.48","77.91","","483.51","229.32","1316.08","96","274.7","618","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.00","463.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","366.47","59.3","","439.50","225.34","1872.27","197","309","484.82","percent of total billed charges",""
"DISTAL PLATE 77MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL FIBULA","SUP-ITM-10072285","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","618.00","463.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.82","78.45","","385.32","55.36","1815.62","58","309","484.82","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","554.95","91.85","1421.75","94","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","2490.03","2490.03","2490.03","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1136.85","58.3","","750.00","750.00","750.00","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1033.50","53","","1192.50","120.84","4149.90","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1657.50","85","","750.00","75.00","750.00","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1950.00","100","","657.00","121.50","1971.00","14","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1950.00","100","","75.00","75.00","75.00","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1950.00","100","","366.00","144.00","1971.00","45","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","667.50","667.50","667.50","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","123.77","123.77","123.77","1 through 10","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","483.51","229.32","1316.08","96","866.78","1950","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","439.50","225.34","1872.27","197","975","1529.78","percent of total billed charges",""
"DISTAL PLATE 91MM 5 HOLE BONE FIBULA SS LOCKING LEFT","SUP-ITM-10076948","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","385.32","55.36","1815.62","58","975","1529.78","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","AETNA [1001]","HB CH AETNA HMO / PPO","1016.03","58.3","","554.95","91.85","1421.75","94","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1272.21","73","","2490.03","2490.03","2490.03","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1016.03","58.3","","750.00","750.00","750.00","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","923.66","53","","1192.50","120.84","4149.90","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1481.35","85","","750.00","75.00","750.00","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1742.76","100","","657.00","121.50","1971.00","14","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1742.76","100","","75.00","75.00","75.00","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1742.76","100","","366.00","144.00","1971.00","45","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1272.21","73","","667.50","667.50","667.50","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","774.66","44.45","","123.77","123.77","123.77","1 through 10","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","WELLPOINT [1015]","HB CH WELLPOINT","1357.78","77.91","","483.51","229.32","1316.08","96","774.66","1742.76","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1742.76","1307.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","1033.46","59.3","","439.50","225.34","1872.27","197","871.38","1367.2","percent of total billed charges",""
"DISTAL PLATE 95MM 3 HOLE BONE A.L.P.S. TITANIUM LOCKING ANATOMICAL FIBULA LEFT","SUP-ITM-10072290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1742.76","1307.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1367.20","78.45","","385.32","55.36","1815.62","58","871.38","1367.2","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","AETNA [1001]","HB CH AETNA HMO / PPO","3119.05","58.3","","1634.24","1004.95","1718.99","42","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3905.50","73","","2123.89","1900.92","2123.89","1 through 10","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3119.05","58.3","","3729.00","1254.19","3729.00","1 through 10","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2835.50","53","","939.37","939.37","5593.65","1 through 10","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4547.50","85","","2323.25","1864.50","2882.25","16","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5350.00","100","","2909.44","1772.40","10952.08","45","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5350.00","100","","2323.25","2323.25","2323.25","1 through 10","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5350.00","100","","2882.25","1772.40","10169.17","187","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3905.50","73","","1659.41","1659.41","1659.41","1 through 10","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.00","4012.50","WELLPOINT [1015]","HB CH WELLPOINT","4168.19","77.91","","2050.91","1468.48","2902.83","52","2378.08","5350","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5350.00","4012.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3172.55","59.3","","1548.60","1092.60","3613.79","82","2675","4197.08","percent of total billed charges",""
"DISTAL STEM 2CMX4.5MM RADIO ULNAR JOINT EXTENDED DRUJ","SUP-ITM-10077532","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5350.00","4012.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4197.08","78.45","","2085.51","998.68","6202.11","56","2675","4197.08","percent of total billed charges",""
"DISTRACTOR BONE 18MM PIN","SUP-ITM-10033408","CDM","C1889","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","1830.28","315.58","1830.28","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR BONE 18MM PIN","SUP-ITM-10033408","CDM","C1889","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","4170.85","4170.85","4170.85","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR BONE 18MM PIN","SUP-ITM-10033408","CDM","C1889","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","649.55","649.55","649.55","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR BONE 18MM PIN","SUP-ITM-10033408","CDM","C1889","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","8998.38","2542.37","8998.38","20","100.01","225","percent of total billed charges",""
"DISTRACTOR BONE 18MM PIN","SUP-ITM-10033408","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","1891.61","1609.14","3664.18","25","112.5","176.51","percent of total billed charges",""
"DISTRACTOR BONE 18MM PIN","SUP-ITM-10033408","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","1470.68","1310.06","2481.69","19","112.5","176.51","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","554.95","91.85","1421.75","94","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","2490.03","2490.03","2490.03","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","131.18","58.3","","750.00","750.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","1192.50","120.84","4149.90","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","191.25","85","","750.00","75.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.00","100","","657.00","121.50","1971.00","14","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","225.00","100","","75.00","75.00","75.00","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.00","100","","366.00","144.00","1971.00","45","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","667.50","667.50","667.50","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","123.77","123.77","123.77","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","483.51","229.32","1316.08","96","100.01","225","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","439.50","225.34","1872.27","197","112.5","176.51","percent of total billed charges",""
"DISTRACTOR PIN 14MM TITANIUM SE 04.600.023","SUP-ITM-10032617","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","385.32","55.36","1815.62","58","112.5","176.51","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","554.95","91.85","1421.75","94","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","2490.03","2490.03","2490.03","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","131.18","58.3","","750.00","750.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","1192.50","120.84","4149.90","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","191.25","85","","750.00","75.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.00","100","","657.00","121.50","1971.00","14","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","225.00","100","","75.00","75.00","75.00","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.00","100","","366.00","144.00","1971.00","45","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","667.50","667.50","667.50","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","123.77","123.77","123.77","1 through 10","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","483.51","229.32","1316.08","96","100.01","225","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","439.50","225.34","1872.27","197","112.5","176.51","percent of total billed charges",""
"DISTRACTOR SCREW 14MM BONE DISTRACTION PIN POST","SUP-ITM-10005253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","385.32","55.36","1815.62","58","112.5","176.51","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","AETNA [1001]","HB CH AETNA HMO / PPO","416.14","58.3","","554.95","91.85","1421.75","94","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","521.07","73","","2490.03","2490.03","2490.03","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","416.14","58.3","","750.00","750.00","750.00","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","378.31","53","","1192.50","120.84","4149.90","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","606.72","85","","750.00","75.00","750.00","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","713.79","100","","657.00","121.50","1971.00","14","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","713.79","100","","75.00","75.00","75.00","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","713.79","100","","366.00","144.00","1971.00","45","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","521.07","73","","667.50","667.50","667.50","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","317.28","44.45","","123.77","123.77","123.77","1 through 10","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","both","","","713.79","535.34","WELLPOINT [1015]","HB CH WELLPOINT","556.11","77.91","","483.51","229.32","1316.08","96","317.28","713.79","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","CIGNA [1006]","HB CH CIGNA HMO / PPO","423.28","59.3","","439.50","225.34","1872.27","197","356.9","559.97","percent of total billed charges",""
"DISTRACTOR SCREW 3.5MM EASY OUT COUPLE","SUP-ITM-10072392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","713.79","535.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","559.97","78.45","","385.32","55.36","1815.62","58","356.9","559.97","percent of total billed charges",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16331.89","","Standard inlier is a Case rate ($16,331.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,318.38) for the length of stay and the standard reimbursement.","23572.60","23572.60","23572.60","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17543.71","","Standard inlier is a Case rate ($17,543.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $28,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,490.26) for the length of stay and the standard reimbursement.","25320.50","25320.50","25320.50","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10454.97","","Fee schedule rate ($23,485.58). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10454.97","22580.62","22580.62","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","MASSHEALTH [3001]","HB BWF MEDICAID","6039.69","","Case rate ($6,677.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,107.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6033.09","6033.09","6033.09","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9380.69","","Fee schedule rate ($9,380.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9380.69","9380.69","9380.69","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11036.02","","Fee schedule rate ($11,036.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11036.02","11036.02","11036.02","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","23522.74","","Fee schedule rate ($23,522.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23522.74","23522.74","23522.74","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MAJOR","244","DRG","","","","","","","","inpatient","","","28216.85","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6039.69","","Case rate ($6,677.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,107.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12201.64","12201.64","12201.64","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","17219.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12500.20","","Standard inlier is a Case rate ($12,500.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,774.45) for the length of stay and the standard reimbursement.","12500.19","12500.19","12500.19","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","17219.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13427.71","","Standard inlier is a Case rate ($13,427.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,906.01) for the length of stay and the standard reimbursement.","13427.70","13427.70","13427.70","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","17219.78","","MASSHEALTH [3001]","HB BWF MEDICAID","4320.43","","Case rate ($4,776.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,206.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4775.80","4775.80","4775.80","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","17219.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12798.35","","Fee schedule rate ($12,798.35). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12798.35","12798.35","12798.35","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MINOR","244","DRG","","","","","","","","inpatient","","","17219.78","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4320.43","","Case rate ($4,776.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,206.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4775.80","4775.80","4775.80","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13427.71","","Standard inlier is a Case rate ($13,427.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,906.01) for the length of stay and the standard reimbursement.","11206.15","11206.15","11206.15","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10454.97","","Fee schedule rate ($13,992.07). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10454.97","13992.08","13992.08","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","MASSHEALTH [3001]","HB BWF MEDICAID","4320.43","","Case rate ($4,776.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,206.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1852.85","1852.85","1852.85","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6564.61","","Fee schedule rate ($6,564.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6373.19","6373.19","6373.19","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","16461.24","","Fee schedule rate ($16,461.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15981.93","15981.93","15981.93","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4320.43","","Case rate ($4,776.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,206.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6676.28","6676.28","6676.28","1 through 10","2350","45407.72","case rate",""
"Diverticulitis And Diverticulosis,MODERATE","244","DRG","","","","","","","","inpatient","","","27787.78","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4320.43","","Case rate ($4,776.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,206.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6676.28","6676.28","6676.28","1 through 10","2350","45407.72","case rate",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","62.94","62.94","62.94","15","13.47","83.22","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","58.83","58.83","58.83","1 through 10","13.47","83.22","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","49.84","49.84","49.84","1 through 10","13.47","83.22","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","65.05","65.05","195.15","15","14.16","89.43","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","115.26","115.26","115.26","1 through 10","14.16","89.43","percent of total billed charges",""
"Dna Double Strand Antibody","PX-30000806","CDM","86225","CPT","0302","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","85.34","50.57","85.34","14","14.16","89.43","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","AETNA [1001]","HB CH AETNA HMO / PPO","5054.61","58.3","","1634.24","1004.95","1718.99","42","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6329.10","73","","2123.89","1900.92","2123.89","1 through 10","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5054.61","58.3","","3729.00","1254.19","3729.00","1 through 10","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4595.10","53","","939.37","939.37","5593.65","1 through 10","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7369.50","85","","2323.25","1864.50","2882.25","16","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8670.00","100","","2909.44","1772.40","10952.08","45","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8670.00","100","","2323.25","2323.25","2323.25","1 through 10","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8670.00","100","","2882.25","1772.40","10169.17","187","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6329.10","73","","1659.41","1659.41","1659.41","1 through 10","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","both","","","8670.00","6502.50","WELLPOINT [1015]","HB CH WELLPOINT","6754.80","77.91","","2050.91","1468.48","2902.83","52","3853.82","8670","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5141.31","59.3","","1548.60","1092.60","3613.79","82","4335","6801.62","percent of total billed charges",""
"DOME ANKLE SZ 2 PROSTHESIS","SUP-ITM-10132227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8670.00","6502.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6801.62","78.45","","2085.51","998.68","6202.11","56","4335","6801.62","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.84","182.84","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","FALLON HEALTH [1008]","HB BWF MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","MEDICARE [2001]","HB BWF MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","170.48","185.81","33","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","both","","","1558.00","1168.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","182.07","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","185.10","170.48","185.81","1 through 10","176.52","1137.34","other","OPPS APC"
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1558.00","1168.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","923.89","59.3","","887.79","887.79","887.79","1 through 10","224.5","1222.25","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl","PX-92000032","CDM","93923","CPT","0921","RC","","","","outpatient","","","1558.00","1168.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1222.25","78.45","","1164.73","1164.73","1164.73","1 through 10","224.5","1222.25","percent of total billed charges",""
"Doppler Arterial Extrem Cmpl|TECHNICAL COMPONENT","PX-92000032","CDM","93923","CPT","0921","RC","","","TC","both","","","1558.00","1168.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","191.38","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1515.00","192.10","1515.00","1 through 10","182.09","191.38","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","952.00","714.00","HUMANA [1012]","HB BWF MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.94","150.94","150.94","1 through 10","145.42","694.96","other","OPPS APC"
"Doppler Arterial Extrem Ltd Bilat","PX-92000030","CDM","93922","CPT","0921","RC","","","","both","","","952.00","714.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","153.06","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","137.03","137.03","137.03","1 through 10","145.42","694.96","other","OPPS APC"
"Doppler Arterial Extrem W/Stress Bi","PX-92000033","CDM","93924","CPT","0921","RC","","","","both","","","1999.00","1499.25","MEDICARE [2001]","HB BWF MEDICARE","185.79","","APC Price ($185.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","1459.27","other","OPPS APC"
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2416.00","1812.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","460.04","460.04","460.04","1 through 10","119.97","1763.68","other","OPPS APC"
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2416.00","1812.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1763.68","73","","1714.77","1665.13","1714.77","1 through 10","119.97","1763.68","percent of total billed charges",""
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2416.00","1812.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1763.68","other","OPPS APC"
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","both","","","2416.00","1812.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","1763.68","other","OPPS APC"
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","outpatient","","","2416.00","1812.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1432.69","59.3","","1376.51","1376.51","4129.53","18","185.79","1895.35","percent of total billed charges",""
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","outpatient","","","2416.00","1812.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1073.91","44.45","","1070.20","1070.20","1070.20","1 through 10","185.79","1895.35","percent of total billed charges",""
"Doppler Intracranial Emboli W/O","PX-92000028","CDM","93892","CPT","0921","RC","","","","outpatient","","","2416.00","1812.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1895.35","78.45","","1805.91","1070.20","1805.91","20","185.79","1895.35","percent of total billed charges",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","56295.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","67323.09","","Standard inlier is a Case rate ($67,323.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,556.78) for the length of stay and the standard reimbursement.","67323.09","64275.74","67323.09","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","56295.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","72318.43","","Standard inlier is a Case rate ($72,318.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $80,715, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,265.30) for the length of stay and the standard reimbursement.","72318.43","72318.43","72318.43","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","56295.78","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","59712.56","","Fee schedule rate ($59,712.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68976.36","68976.36","68976.36","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","56295.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","68805.36","","Fee schedule rate ($68,805.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","68805.36","68805.36","68805.36","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","56295.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","28137.62","","Case rate ($31,110.97). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $73,540.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31103.34","31103.34","31103.34","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MINOR","304","DRG","","","","","","","","inpatient","","","56295.78","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","28137.62","","Case rate ($31,110.97). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $73,540.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","31103.34","31103.34","31103.34","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","63694.73","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","36783.60","","Fee schedule rate ($36,783.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","30354.55","30354.55","30354.55","1 through 10","27439.05","153306.57","case rate",""
"Dorsal And Lumbar Fusion Procedure Except For Curvature Of Back,MODERATE","304","DRG","","","","","","","","inpatient","","","63694.73","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","78402.45","","Fee schedule rate ($78,402.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","78402.45","78402.45","78402.45","1 through 10","27439.05","153306.57","case rate",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","AETNA [1001]","HB CH AETNA HMO / PPO","969.05","58.3","","1830.28","315.58","1830.28","1 through 10","738.84","1662.18","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1213.39","73","","4170.85","4170.85","4170.85","1 through 10","738.84","1662.18","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","738.84","44.45","","649.55","649.55","649.55","1 through 10","738.84","1662.18","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","both","","","1662.18","1246.63","WELLPOINT [1015]","HB CH WELLPOINT","1295.00","77.91","","8998.38","2542.37","8998.38","20","738.84","1662.18","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.18","1246.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","985.67","59.3","","1891.61","1609.14","3664.18","25","831.09","1303.98","percent of total billed charges",""
"DOWEL CLOWARD 14MM L EQUALS 15 GRAFT BONE MATRIGRAFT FREEZE DRY D MIN","SUP-ITM-10010249","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1662.18","1246.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1303.98","78.45","","1470.68","1310.06","2481.69","19","831.09","1303.98","percent of total billed charges",""
"Drain Abscess Scrotal Wall","PX-76001319","CDM","55100","CPT","0761","RC","","","","outpatient","","","2835.00","2126.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1681.16","59.3","","7538.30","7538.30","7538.30","1 through 10","1134","2224.06","percent of total billed charges",""
"Drainage Catheter Manipulation","PX-76002763","CDM","49999","CPT","0761","RC","","","","both","","","871.00","653.25","WELLPOINT [1015]","HB CH WELLPOINT","678.60","77.91","","3449.15","3449.15","3449.15","1 through 10","373.66","1146.7","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","554.95","91.85","1421.75","94","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","2490.03","2490.03","2490.03","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","271.10","58.3","","750.00","750.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.45","53","","1192.50","120.84","4149.90","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","395.25","85","","750.00","75.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","465.00","100","","657.00","121.50","1971.00","14","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","465.00","100","","75.00","75.00","75.00","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","465.00","100","","366.00","144.00","1971.00","45","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","667.50","667.50","667.50","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","123.77","123.77","123.77","1 through 10","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","483.51","229.32","1316.08","96","206.69","465","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","439.50","225.34","1872.27","197","232.5","364.79","percent of total billed charges",""
"DRILL FLEX 1.8MM KNOTLESS HIP FIBERTAK","SUP-ITM-10330931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","385.32","55.36","1815.62","58","232.5","364.79","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","AETNA [1001]","HB CH AETNA HMO / PPO","693.57","58.3","","554.95","91.85","1421.75","94","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","868.44","73","","2490.03","2490.03","2490.03","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","693.57","58.3","","750.00","750.00","750.00","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","630.51","53","","1192.50","120.84","4149.90","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1011.20","85","","750.00","75.00","750.00","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1189.65","100","","657.00","121.50","1971.00","14","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1189.65","100","","75.00","75.00","75.00","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1189.65","100","","366.00","144.00","1971.00","45","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","868.44","73","","667.50","667.50","667.50","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.80","44.45","","123.77","123.77","123.77","1 through 10","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","both","","","1189.65","892.24","WELLPOINT [1015]","HB CH WELLPOINT","926.86","77.91","","483.51","229.32","1316.08","96","528.8","1189.65","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1189.65","892.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","705.46","59.3","","439.50","225.34","1872.27","197","594.83","933.28","percent of total billed charges",""
"DRIVER T6 RETENTION","SUP-ITM-10334975","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1189.65","892.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","933.28","78.45","","385.32","55.36","1815.62","58","594.83","933.28","percent of total billed charges",""
"Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice,MINOR","770","DRG","","","","","","","","inpatient","","","12210.44","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5245.12","","Fee schedule rate ($5,245.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","811.38","811.38","811.38","1 through 10","954.59","30989.01","case rate",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","1 through 10","18.27","92.71","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","both","","","119.00","89.25","WELLPOINT [1015]","HB CH WELLPOINT","92.71","77.91","","91.36","91.36","91.36","1 through 10","18.27","92.71","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","67.98","67.96","143.04","1 through 10","28.89","93.36","percent of total billed charges",""
"Drug Assay Acetaminophen","PX-30003719","CDM","80143","CPT","0301","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","52.85","52.85","89.18","1 through 10","28.89","93.36","percent of total billed charges",""
"Drug Assay Adalimumab","PX-30003607","CDM","80145","CPT","0300","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","131.26","131.26","131.26","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","both","","","230.00","172.50","WELLPOINT [1015]","HB CH WELLPOINT","179.19","77.91","","176.42","176.42","176.42","1 through 10","37.8","204.81","percent of total billed charges",""
"Drug Assay Infliximab","PX-30003609","CDM","80230","CPT","0300","RC","","","","outpatient","","","230.00","172.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","115.23","50.1","","142.02","115.45","142.02","1 through 10","84.18","180.44","percent of total billed charges",""
"Drug Assay Lacosamide","PX-30003610","CDM","80235","CPT","0300","RC","","","","outpatient","","","134.00","100.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","67.13","50.1","","67.00","67.00","67.00","1 through 10","49.04","105.12","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","both","","","118.00","88.50","WELLPOINT [1015]","HB CH WELLPOINT","91.93","77.91","","90.57","90.57","90.57","1 through 10","18.27","91.93","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.38","143.04","1 through 10","28.89","92.57","percent of total billed charges",""
"Drug Assay Salicylate","PX-30003723","CDM","80179","CPT","0301","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","52.39","52.39","88.41","1 through 10","28.89","92.57","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","86.14","1 through 10","13.67","118.46","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","151.00","113.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.13","86.13","86.13","1 through 10","13.67","118.46","percent of total billed charges",""
"Drug Screen Quan Lamotrigine","PX-30001676","CDM","80175","CPT","0301","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","52.14","113.01","1 through 10","13.67","118.46","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","89.59","89.59","89.59","1 through 10","13.27","118.26","percent of total billed charges",""
"Drug Screen Quant Dipropylacetic Acid Total","PX-30002957","CDM","80164","CPT","0301","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","92.59","92.59","92.59","1 through 10","13.98","127.09","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","63.29","63.29","63.29","1 through 10","13.67","87.08","percent of total billed charges",""
"Drug Screen Quantitative Oxcarbazepine","PX-30003736","CDM","80183","CPT","0301","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.67","87.08","percent of total billed charges",""
"Drug Scrn Quan Mycophenolate","PX-30001678","CDM","80180","CPT","0301","RC","","","","both","","","138.00","103.50","WELLPOINT [1015]","HB CH WELLPOINT","107.52","77.91","","105.54","105.54","105.54","1 through 10","17.69","107.52","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","63.29","63.29","63.29","1 through 10","13.67","87.08","percent of total billed charges",""
"Drug Scrn Quant Oxcarbazepin","PX-30001679","CDM","80183","CPT","0301","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.67","87.08","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","253.64","282.47","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","67","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","TRICARE [160005]","HB BWF TRICARE","272.70","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","272.7","2265.92","other","Tricare OPPS"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.72","210.12","281.92","1 through 10","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","both","","","3104.00","2328.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","263.16","282.47","15","272.7","2265.92","other","OPPS APC"
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3104.00","2328.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1840.67","59.3","","1768.55","1768.55","1768.55","1 through 10","380.73","2435.09","percent of total billed charges",""
"Duplex Abd/Pel/Retro Cmpl","PX-92000042","CDM","93975","CPT","0921","RC","","","","outpatient","","","3104.00","2328.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2435.09","78.45","","2320.24","1375.00","2320.24","1 through 10","380.73","2435.09","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","AETNA [1001]","HB CH AETNA HMO / PPO","988.19","58.3","","934.42","934.42","934.42","1 through 10","119.97","1237.35","percent of total billed charges",""
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","1237.35","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.24","123.76","126.29","1 through 10","119.97","1237.35","other","OPPS APC"
"Duplex Abd/Pel/Retro Ltd","PX-92000043","CDM","93976","CPT","0921","RC","","","","outpatient","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1329.73","78.45","","1266.98","1266.98","1266.98","1 through 10","185.79","1329.73","percent of total billed charges",""
"Duplex Aorta/Ivc/Graft Cmpl","PX-92000044","CDM","93978","CPT","0921","RC","","","","both","","","2071.00","1553.25","MEDICARE [2001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","1511.83","other","OPPS APC"
"Duplex Arterial Lower Ext Bilat","PX-92000034","CDM","93925","CPT","0921","RC","","","","both","","","2663.00","1997.25","MEDICARE [2001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","1 through 10","272.7","1943.99","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","282.47","282.47","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","HUMANA [1012]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.60","283.60","283.60","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","MEDICARE [2001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","67","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.29","","APC Price ($287.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","281.32","286.32","1 through 10","272.7","1533","other","OPPS APC"
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1196.61","1196.61","1196.61","1 through 10","380.73","1647.45","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat","PX-92000023","CDM","93880","CPT","0921","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1569.89","1569.89","1569.89","1 through 10","380.73","1647.45","percent of total billed charges",""
"Duplex Extracranial/Carotid Bilat|TECHNICAL COMPONENT","PX-92000023","CDM","93880","CPT","0921","RC","","","TC","both","","","2100.00","1575.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","295.67","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","296.28","295.38","296.28","1 through 10","281.32","933.45","other","OPPS APC"
"Duplex Extracranial/Carotid Unilat","PX-92000024","CDM","93882","CPT","0921","RC","","","","both","","","1415.00","1061.25","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1032.95","other","OPPS APC"
"Duplex Hemodialysis Access","PX-92000049","CDM","93990","CPT","0921","RC","","","","both","","","1726.00","1294.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","914.78","53","","889.34","889.34","889.34","1 through 10","119.97","1259.98","percent of total billed charges",""
"Duplex Hemodialysis Access","PX-92000049","CDM","93990","CPT","0921","RC","","","","both","","","1726.00","1294.50","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","1259.98","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","AETNA [1001]","HB CH AETNA HMO / PPO","1205.06","58.3","","387.53","387.53","387.53","1 through 10","272.7","1508.91","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","FALLON HEALTH [1008]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","HUMANA [1012]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.62","283.62","283.62","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","82","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.72","281.72","281.72","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.92","263.16","281.92","1 through 10","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","both","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","263.16","286.32","27","272.7","1508.91","other","OPPS APC"
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2067.00","1550.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1225.73","59.3","","1177.86","1177.86","1316.12","1 through 10","380.73","1621.56","percent of total billed charges",""
"Duplex Venous Extremity Bilat","PX-92000039","CDM","93970","CPT","0921","RC","","","","outpatient","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1621.56","78.45","","1545.29","1545.29","1545.29","1 through 10","380.73","1621.56","percent of total billed charges",""
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","both","","","1380.00","1035.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","123.97","126.29","14","119.97","1007.4","other","OPPS APC"
"Duplex Venous Extremity Unilat/Lmtd","PX-92000040","CDM","93971","CPT","0921","RC","","","","outpatient","","","1380.00","1035.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","818.34","59.3","","786.41","786.41","786.41","1 through 10","185.79","1082.61","percent of total billed charges",""
"Dx Endo W Eus Portal Venous Pressures","PX-75000514","CDM","43999","CPT","0750","RC","","","","both","","","3596.00","2697.00","WELLPOINT [1015]","HB CH WELLPOINT","2801.64","77.91","","2383.28","2383.28","2383.28","1 through 10","1057.74","3419.8","percent of total billed charges",""
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","27384.45","20538.34","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7114.39","","Case rate ($7,259.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,270.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,794.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,092.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,388.98 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,931.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.35. The transfer capital threshold is the transfer adjustment factor * $531.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6892.88","6892.88","6892.88","1 through 10","7114.39","7715.17","other","Inpatient DRG"
"Dysequilibrium","149","MS-DRG","","","","","","","","inpatient","","","27384.45","20538.34","MEDICARE [2001]","HB BWF MEDICARE","7259.58","","Case rate ($7,259.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,270.85, add-ons for qualifying new technology services are included. If operating cost exceeds $52,794.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,092.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $6,388.98 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,931.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $531.35. The transfer capital threshold is the transfer adjustment factor * $531.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7683.90","7633.78","7683.90","1 through 10","7114.39","7715.17","other","Inpatient Replacement Plans DRG"
"Ecg Monitor/Report Up to 48 Hrs Rec","PX-73000007","CDM","93225","CPT","0731","RC","","","","both","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","150.00","","APC Price ($153.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","151.02","151.02","151.02","1 through 10","145.42","669.41","other","OPPS APC"
"Ecg Monitor/Report Up to 48 Hrs Rec|RCRDG/STRG IN SLD ST MEMORY","PX-73000007","CDM","93225","CPT","0731","RC","","","QD","both","","","917.00","687.75","MEDICARE [2001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","150.01","407.61","other","OPPS APC"
"Ecg Monitor/Report Up to 48 Hrs Rec|RCRDG/STRG IN SLD ST MEMORY","PX-73000007","CDM","93225","CPT","0731","RC","","","QD","both","","","917.00","687.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","150.02","150.02","150.02","1 through 10","150.01","407.61","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","966.39","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","966.35","966.25","966.35","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","938.24","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","923.23","859.90","923.23","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","HUMANA [1012]","HB BWF MEDICARE","938.24","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","925.10","861.65","925.10","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","MEDICARE [2001]","HB BWF MEDICARE","938.24","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","938.24","938.24","80","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","938.24","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","919.48","919.48","919.48","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","919.48","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.48","919.48","919.48","1 through 10","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","both","","","2401.00","1800.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","919.48","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.48","859.90","920.48","12","678.06","2690.91","other","OPPS APC"
"Echo 2d With Spec/Color Flow M-Mode W/Cont or W/O Fol W/Cont","PX-48000184","CDM","C8929","HCPCS","0483","RC","","","","outpatient","","","2401.00","1800.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1883.58","78.45","","1795.15","1795.15","1795.15","1 through 10","821.51","1996.77","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","561.00","85","","137.43","45.81","137.43","1 through 10","293.37","660","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","660.00","100","","53.87","53.87","88.94","1 through 10","293.37","660","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","660.00","100","","58.87","57.15","176.61","22","293.37","660","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.37","44.45","","292.50","292.50","292.50","1 through 10","293.37","660","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","376.21","376.21","376.21","1 through 10","330","517.77","percent of total billed charges",""
"Echo Color Flow Velocity Mapping","PX-48000201","CDM","93325","CPT","0483","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","493.57","73.56","493.57","1 through 10","330","517.77","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","553.35","85","","291.48","97.16","291.48","1 through 10","289.37","651","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.00","100","","188.64","114.27","188.64","1 through 10","289.37","651","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.00","100","","124.87","121.21","124.87","16","289.37","651","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.37","44.45","","288.39","288.39","288.39","1 through 10","289.37","651","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","651.00","488.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.04","59.3","","370.94","370.94","370.94","1 through 10","325.5","510.71","percent of total billed charges",""
"Echo Doppler","PX-48000199","CDM","93320","CPT","0483","RC","","","","outpatient","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","510.71","78.45","","486.65","486.65","486.65","1 through 10","325.5","510.71","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","377.00","100","","57.03","57.03","57.03","1 through 10","167.58","377","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","both","","","377.00","282.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","377.00","100","","121.00","62.33","121.00","1 through 10","167.58","377","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","377.00","282.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.56","59.3","","215.06","215.06","215.06","1 through 10","188.5","295.76","percent of total billed charges",""
"Echo Doppler Ltd","PX-48000200","CDM","93321","CPT","0483","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.76","78.45","","308.61","170.88","308.61","1 through 10","188.5","295.76","percent of total billed charges",""
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","MEDICARE [2001]","HB BWF MEDICARE","938.24","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","938.24","873.88","938.24","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","919.48","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","919.48","919.48","919.48","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Rest & Stress W/Pro Fee W/Cont or W/O Fol W/Cont","PX-48000202","CDM","C8928","HCPCS","0483","RC","","","","both","","","2283.00","1712.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","919.48","","APC Price ($938.24). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","938.24","920.48","938.24","1 through 10","678.06","1935.24","other","OPPS APC"
"Echo Transesophag R-T 2d W/Prb Img Acquisj I&R","PX-48000420","CDM","93312","CPT","0483","RC","","","","both","","","2767.00","2075.25","MEDICARE [2001]","HB BWF MEDICARE","572.84","","APC Price ($572.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","651.14","1 through 10","572.84","2019.91","other","OPPS APC"
"Echo Transthoracic W/Cont or W/O Fol W/Cont","PX-48000188","CDM","C8924","HCPCS","0483","RC","","","","both","","","1090.00","817.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","436.84","","APC Price ($424.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","437.31","437.31","437.31","1 through 10","316.25","1501.07","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","AETNA [1001]","HB CH AETNA HMO / PPO","574.26","58.3","","543.19","543.19","543.19","1 through 10","272.7","896.88","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","719.05","73","","699.34","699.34","699.34","1 through 10","272.7","896.88","percent of total billed charges",""
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","14","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","281.32","287.06","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthoracic W/WO Fol W/Cont","PX-48000189","CDM","93308","CPT","0483","RC","","","","outpatient","","","985.00","738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","584.11","59.3","","561.39","561.39","958.00","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","AETNA [1001]","HB CH AETNA HMO / PPO","574.26","58.3","","543.19","543.19","543.19","1 through 10","272.7","896.88","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","719.05","73","","699.34","699.34","699.34","1 through 10","272.7","896.88","percent of total billed charges",""
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","14","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","both","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","281.32","287.06","1 through 10","272.7","896.88","other","OPPS APC"
"Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd","PX-48000416","CDM","93308","CPT","0483","RC","","","","outpatient","","","985.00","738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","584.11","59.3","","561.39","561.39","958.00","1 through 10","380.73","1079.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","592.48","640.72","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","MEDICARE [2001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","651.14","59","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.12","590.07","638.52","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","TRICARE [160005]","HB BWF TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","618.58","618.58","618.58","1 through 10","618.58","1935.24","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","both","","","1717.00","1287.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","638.12","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","639.12","590.67","643.12","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","1717.00","1287.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1018.18","59.3","","978.62","978.62","1300.92","1 through 10","763.21","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","1717.00","1287.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","763.21","44.45","","760.85","760.85","760.85","1 through 10","763.21","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/WO M-Mode Complete Rest&St","PX-48000418","CDM","93350","CPT","0483","RC","","","","outpatient","","","1717.00","1287.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1346.99","78.45","","1283.90","747.09","1283.90","1 through 10","763.21","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","AETNA [1001]","HB CH AETNA HMO / PPO","1432.43","58.3","","1354.56","1354.56","1354.56","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","592.48","640.72","63","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","638.12","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","640.72","640.72","640.72","13","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1793.61","73","","1743.97","1743.97","1743.97","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","HUMANA [1012]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","642.02","593.68","647.27","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1432.43","58.3","","1354.56","1354.56","1354.56","1 through 10","618.58","1935.24","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","MEDICARE [2001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","602.11","651.14","842","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.52","590.07","638.52","29","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","MOLINA [1014]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1294.14","1294.14","1294.14","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","TRICARE [160005]","HB BWF TRICARE","618.58","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","618.58","618.58","618.58","1 through 10","618.58","1935.24","other","Tricare OPPS"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","638.12","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.72","638.12","1914.36","36","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","638.12","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.12","593.87","643.12","187","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","both","","","2457.00","1842.75","WELLSENSE [1003]","HB BWF MEDICARE","651.14","","APC Price ($651.14). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","640.72","640.72","640.72","1 through 10","618.58","1935.24","other","OPPS APC"
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","2457.00","1842.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1457.00","59.3","","1399.95","1399.95","2389.00","56","821.51","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","2457.00","1842.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1927.52","78.45","","1836.66","1836.66","1836.66","1 through 10","821.51","1996.77","percent of total billed charges",""
"Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D","PX-48000419","CDM","93306","CPT","0483","RC","","","","outpatient","","","2457.00","1842.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1927.52","78.45","","1836.66","1088.43","1836.66","39","821.51","1996.77","percent of total billed charges",""
"Edg US Guided Transmural Injxn/Fiducial Marker","PX-75000391","CDM","43253","CPT","0750","RC","","","","both","","","3406.00","2554.50","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2653.61","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","1576.00","1182.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","337.09","337.09","337.09","1 through 10","351.32","1150.48","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","1576.00","1182.00","FALLON HEALTH [1008]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1150.48","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","1576.00","1182.00","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1150.48","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","1576.00","1182.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.81","362.81","1 through 10","351.32","1150.48","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","both","","","1576.00","1182.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.89","336.62","363.89","1 through 10","351.32","1150.48","other","OPPS APC"
"Eeg Awake/Asleep","PX-74000019","CDM","95819","CPT","0740","RC","","","","outpatient","","","1576.00","1182.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1236.37","78.45","","443.08","443.08","443.08","1 through 10","416.64","1236.37","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1385.00","1038.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","337.09","337.09","337.09","1 through 10","351.32","1011.05","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","both","","","1385.00","1038.75","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1011.05","other","OPPS APC"
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1385.00","1038.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","821.31","59.3","","789.34","789.34","789.34","1 through 10","416.64","1086.53","percent of total billed charges",""
"Eeg Awake/Drowsy","PX-74000018","CDM","95816","CPT","0740","RC","","","","outpatient","","","1385.00","1038.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1086.53","78.45","","1035.57","613.69","1035.57","1 through 10","416.64","1086.53","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","191.38","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","192.10","191.20","192.10","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","AETNA [1001]","HB CH AETNA HMO / PPO","887.33","58.3","","839.16","839.16","839.16","1 through 10","176.52","1185.79","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","182.09","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.09","182.84","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.84","182.84","182.84","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","HUMANA [1012]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","MEDICARE [2001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","59","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","182.49","182.49","182.49","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","MOLINA [1014]","HB BWF MEDICARE","185.81","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","368.65","368.65","368.65","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","TRICARE [160005]","HB BWF TRICARE","176.52","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","176.52","161.95","176.52","1 through 10","176.52","1185.79","other","Tricare OPPS"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","182.09","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.84","182.84","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","182.09","","APC Price ($185.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.84","183.10","1 through 10","176.52","1185.79","other","OPPS APC"
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","both","","","1522.00","1141.50","WELLPOINT [1015]","HB CH WELLPOINT","1185.79","77.91","","1165.65","1165.65","1165.65","1 through 10","176.52","1185.79","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1522.00","1141.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","902.55","59.3","","867.28","867.28","867.28","1 through 10","400.54","1194.01","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1522.00","1141.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","676.53","44.45","","1137.82","1137.82","1137.82","1 through 10","400.54","1194.01","percent of total billed charges",""
"Eeg Cont Rec W/ or W/Out Video by Tech Min 8 Channels","PX-74000057","CDM","95700","CPT","0740","RC","","","","outpatient","","","1522.00","1141.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1194.01","78.45","","1137.82","674.29","1137.82","1 through 10","400.54","1194.01","percent of total billed charges",""
"Eeg Monitor > 1 Hr","PX-74000017","CDM","95813","CPT","0740","RC","","","","both","","","1678.00","1258.50","MEDICARE [2001]","HB BWF MEDICARE","369.77","","APC Price ($369.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","342.57","342.57","342.57","1 through 10","351.32","1224.94","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.42","363.42","363.42","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.89","363.89","363.89","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","FALLON HEALTH [1008]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","868.67","58.3","","821.58","821.58","821.58","1 through 10","351.32","1087.7","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","18","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","both","","","1490.00","1117.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.42","362.41","363.89","1 through 10","351.32","1087.7","other","OPPS APC"
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1490.00","1117.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","883.57","59.3","","849.11","849.11","849.11","1 through 10","416.64","1168.91","percent of total billed charges",""
"Eeg Monitor 41-60 Min","PX-74000016","CDM","95812","CPT","0740","RC","","","","outpatient","","","1490.00","1117.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1168.91","78.45","","1113.99","660.16","1113.99","1 through 10","416.64","1168.91","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","649.02","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","648.40","648.40","649.30","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","AETNA [1001]","HB CH AETNA HMO / PPO","1476.74","58.3","","1396.52","1396.52","1396.52","1 through 10","598.61","1973.46","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","617.52","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","620.04","617.52","620.04","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","620.04","620.04","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","HUMANA [1012]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","621.91","621.30","621.91","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","MEDICARE [2001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","94","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","617.92","617.52","617.92","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","MOLINA [1014]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1250.16","1250.16","1250.16","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","TRICARE [160005]","HB BWF TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","555.73","555.73","555.73","1 through 10","598.61","1973.46","other","Tricare OPPS"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","617.52","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","618.52","617.52","620.04","1 through 10","598.61","1973.46","other","OPPS APC"
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","both","","","2533.00","1899.75","WELLPOINT [1015]","HB CH WELLPOINT","1973.46","77.91","","1939.86","1939.86","1939.86","1 through 10","598.61","1973.46","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","2533.00","1899.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1502.07","59.3","","1443.32","1443.32","1443.32","1 through 10","768.5","1987.14","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","2533.00","1899.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1125.92","44.45","","1893.56","1893.55","1893.56","1 through 10","768.5","1987.14","percent of total billed charges",""
"Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored","PX-74000061","CDM","95708","CPT","0740","RC","","","","outpatient","","","2533.00","1899.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1987.14","78.45","","1893.55","1124.52","1893.56","1 through 10","768.5","1987.14","percent of total billed charges",""
"Eeg W/O Video by Tech 2-12 Hr Unmonitored","PX-74000058","CDM","95705","CPT","0740","RC","","","","both","","","2172.00","1629.00","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","1692.21","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2253.00","1689.75","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","2252.79","4518.11","1 through 10","1194.09","2320.37","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","both","","","2253.00","1689.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4435.45","4435.45","4435.45","1 through 10","1194.09","2320.37","other","OPPS APC"
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1200.98","1200.98","1226.43","1 through 10","1001.46","1873.9","other","ASC "
"Egd Endo Mucosal Resection","PX-75000357","CDM","43254","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1001.46","1873.9","other","Multiple Surgery"
"Egd Endoscopic Stent Place","PX-75000358","CDM","43266","CPT","0750","RC","","","","both","","","7973.00","5979.75","MEDICARE [2001]","HB BWF MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","7069.32","7069.32","1 through 10","3420.42","7280.66","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1146.81","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1150.37","1145.70","1154.60","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","AETNA [1001]","HB CH AETNA HMO / PPO","1228.96","58.3","","1162.35","1162.35","1162.35","1 through 10","761.55","1538.84","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MEDICARE [2001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","31","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1093.64","1093.64","1093.64","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","761.55","1538.84","per diem",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","761.55","1538.84","per diem",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1098.94","1098.54","1098.94","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.15","973.53","1098.65","1 through 10","761.55","1538.84","other","OPPS APC"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","both","","","2108.00","1581.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","937.01","44.45","","1576.04","1576.04","1576.04","1 through 10","761.55","1538.84","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","628.78","1257.55","1 through 10","761.55","1873.9","other","ASC "
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","1233.17","1259.29","11","761.55","1873.9","other","ASC "
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1250.04","59.3","","1201.30","1201.30","1201.30","1 through 10","761.55","1873.9","percent of total billed charges",""
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5368.92","1789.64","5368.92","1 through 10","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Dx W/Brushing/Washing","PX-75000087","CDM","43235","CPT","0750","RC","","","","outpatient","","","2108.00","1581.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1653.73","78.45","","1576.04","933.98","1576.04","1 through 10","761.55","1873.9","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1146.81","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1145.70","572.85","1152.70","29","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","AETNA [1001]","HB CH AETNA HMO / PPO","1310.58","58.3","","1239.46","1239.46","1239.46","24","761.55","1641.04","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","547.79","1095.60","25","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","973.53","547.80","1095.60","11","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","2238.96","1077.60","2238.96","1 through 10","761.55","1641.04","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1972.41","948.13","3792.52","18","761.55","1641.04","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","HUMANA [1012]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","548.92","222.68","1097.82","1 through 10","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MEDICARE [2001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","556.70","1113.41","375","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1097.14","545.57","2452.79","19","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","11","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","1968.00","5904.00","28","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","2130.00","2068.00","2130.00","1 through 10","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","93","761.55","1641.04","per diem",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","MOLINA [1014]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2209.01","2209.01","2209.01","1 through 10","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1641.04","73","","1558.77","1558.77","1558.77","1 through 10","761.55","1641.04","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","TRICARE [160005]","HB BWF TRICARE","1057.74","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","528.87","528.87","528.87","1 through 10","761.55","1641.04","other","Tricare OPPS"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1095.60","1070.85","3296.82","15","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","999.24","44.45","","1680.60","1680.60","1680.60","1 through 10","761.55","1641.04","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","both","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1091.14","545.58","1099.05","107","761.55","1641.04","other","OPPS APC"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","628.78","1257.55","114","761.55","1873.9","other","ASC "
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1233.17","616.59","1259.29","255","761.55","1873.9","other","ASC "
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1333.06","59.3","","1281.00","1281.00","7197.25","28","761.55","1873.9","percent of total billed charges",""
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1789.64","894.82","2684.46","86","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1881.03","940.52","5643.09","46","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","948.13","948.13","948.13","1 through 10","761.55","1873.9","other","Multiple Surgery"
"Egd Flex Transoral W/Biopsy","PX-75000091","CDM","43239","CPT","0750","RC","","","","outpatient","","","2248.00","1686.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1763.56","78.45","","1680.60","995.94","1680.60","32","761.55","1873.9","percent of total billed charges",""
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1613.07","1613.07","1613.07","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","3924.96","3924.96","3924.96","1 through 10","1335.02","2906.42","other","Multiple Surgery"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.73","2207.73","2207.73","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","both","","","3095.00","2321.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2207.94","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3095.00","2321.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2449.46","2449.46","1 through 10","1335.02","2428.03","other","ASC "
"Egd Flex Transoral W/Endoscopic US","PX-75000089","CDM","43237","CPT","0750","RC","","","","outpatient","","","3095.00","2321.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2401.96","2452.85","1 through 10","1335.02","2428.03","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","3130.00","2347.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","3130.00","2347.50","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","3130.00","2347.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","1335.02","2906.42","per diem",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","both","","","3130.00","2347.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.74","2207.74","2207.74","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3130.00","2347.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2401.96","2398.57","2401.96","1 through 10","1335.02","2455.49","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000090","CDM","43238","CPT","0750","RC","","","","outpatient","","","3130.00","2347.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9411.90","6034.30","9411.90","1 through 10","1335.02","2455.49","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2320.37","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2325.12","2325.12","2327.02","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","AETNA [1001]","HB CH AETNA HMO / PPO","1922.73","58.3","","1818.37","1818.37","1818.37","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","1153.63","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","6758.37","67","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2207.73","2207.73","2207.73","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","1335.02","2906.42","per diem",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4433.15","2210.73","4433.15","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","both","","","3298.00","2473.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.24","2043.15","2215.64","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","2398.57","2449.46","1 through 10","1335.02","4472.66","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2452.85","13","1335.02","4472.66","other","ASC "
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1955.71","59.3","","1879.30","1879.30","1879.30","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9411.90","3137.30","9411.90","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2606.65","2606.65","2606.65","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd Flex Transoral W/US Asp/Bx","PX-75000094","CDM","43242","CPT","0750","RC","","","","outpatient","","","3298.00","2473.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2587.28","78.45","","1461.11","1461.11","2465.54","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2320.37","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2051.86","2051.86","2051.86","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","HUMANA [1012]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2228.98","2228.98","2228.98","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","29","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.13","2215.13","2215.13","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","both","","","2577.00","1932.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2043.55","2216.75","1 through 10","1145.48","2906.42","other","OPPS APC"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2449.46","2449.46","1 through 10","1288.5","2021.66","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2401.96","2452.85","11","1288.5","2021.66","other","ASC "
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1528.16","59.3","","1468.52","1285.84","1468.52","1 through 10","1288.5","2021.66","percent of total billed charges",""
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1288.5","2021.66","other","Multiple Surgery"
"Egd Flex W/Balloon Dilation <30mm","PX-75000101","CDM","43249","CPT","0750","RC","","","","outpatient","","","2577.00","1932.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3297.50","3297.50","3297.50","1 through 10","1288.5","2021.66","other","Multiple Surgery"
"Egd Flex W/Place Gastrostomy Tube","PX-75000098","CDM","43246","CPT","0750","RC","","","","both","","","3406.00","2554.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.51","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","both","","","2077.00","1557.75","AETNA [1001]","HB CH AETNA HMO / PPO","1210.89","58.3","","2020.00","2020.00","2020.00","1 through 10","761.55","1516.21","percent of total billed charges",""
"Egd Flex W/Submucosal Injection","PX-75000088","CDM","43236","CPT","0750","RC","","","","outpatient","","","2077.00","1557.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.29","1259.29","1259.29","1 through 10","761.55","1873.9","other","ASC "
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","both","","","2229.00","1671.75","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","761.55","1627.17","other","OPPS APC"
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2229.00","1671.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1231.42","615.71","1231.42","1 through 10","761.55","4472.66","other","ASC "
"Egd Flexible Foreign Body Removal","PX-75000099","CDM","43247","CPT","0750","RC","","","","outpatient","","","2229.00","1671.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","629.65","629.65","629.65","1 through 10","761.55","4472.66","other","ASC "
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","both","","","3465.00","2598.75","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3295.22","other","OPPS APC"
"Egd W Dilation Sm Bowel Colon","PX-75000347","CDM","44799","CPT","0750","RC","","","","outpatient","","","3465.00","2598.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1735.97","50.1","","6121.00","6121.00","6121.00","1 through 10","1700.28","7178","percent of total billed charges",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3206.00","2404.50","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3206.00","2404.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","both","","","3206.00","2404.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.64","2215.64","2215.64","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2449.46","2449.46","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Band Ligate Varices Esop/Gast","PX-75000096","CDM","43244","CPT","0750","RC","","","","outpatient","","","3206.00","2404.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1901.16","59.3","","1826.56","1826.56","1826.56","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3179.00","2384.25","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","both","","","3179.00","2384.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2210.23","2037.74","2210.23","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","outpatient","","","3179.00","2384.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","outpatient","","","3179.00","2384.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1885.15","59.3","","4352.68","4352.68","4352.68","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Control Bleeding","PX-75000104","CDM","43255","CPT","0750","RC","","","","outpatient","","","3179.00","2384.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2493.93","78.45","","1408.26","1408.26","1408.26","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1146.81","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","572.85","572.85","572.85","1 through 10","761.55","1644.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1091.14","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","486.77","486.77","486.77","1 through 10","761.55","1644.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","both","","","2253.00","1689.75","MEDICARE [2001]","HB BWF MEDICARE","1113.41","","APC Price ($1,113.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","556.70","556.70","556.70","1 through 10","761.55","1644.69","other","OPPS APC"
"Egd W/Dilate Esoph Over Guidewire","PX-75000100","CDM","43248","CPT","0750","RC","","","","outpatient","","","2253.00","1689.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","870.88","","Case rate ($870.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","629.65","616.59","629.65","1 through 10","761.55","4472.66","other","ASC "
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","both","","","3159.00","2369.25","MEDICARE [2001]","HB BWF MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Dilate Gastr/Duodnl Strict","PX-75000097","CDM","43245","CPT","0750","RC","","","","outpatient","","","3159.00","2369.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3137.30","3137.30","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2320.37","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2325.12","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","AETNA [1001]","HB CH AETNA HMO / PPO","1971.71","58.3","","1864.86","1864.86","1864.86","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","3924.96","3778.11","3924.96","1 through 10","1335.02","2906.42","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3457.70","2756.70","3457.70","1 through 10","1335.02","2906.42","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MARTIN'S POINT [160007]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2207.73","2207.73","2207.73","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","87","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6623.19","2207.73","6623.19","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,310). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","2130.00","2130.00","2130.00","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1335.02","2906.42","per diem",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.53","2210.73","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","both","","","3382.00","2536.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2208.14","2035.25","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2449.46","2398.57","2449.46","23","1335.02","4472.66","other","ASC "
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2401.96","2452.85","66","1335.02","4472.66","other","ASC "
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2005.53","59.3","","1927.35","1881.31","1927.35","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","3017.15","3137.30","11","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3924.96","3297.50","6354.70","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3324.20","3324.20","3324.20","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Endo US Duodenum/Jejunum","PX-75000108","CDM","43259","CPT","0750","RC","","","","outpatient","","","3382.00","2536.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2653.18","78.45","","2528.58","1498.47","2528.58","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2320.37","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2325.12","2324.62","2325.12","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","AETNA [1001]","HB CH AETNA HMO / PPO","1824.21","58.3","","1725.38","1725.38","1725.38","1 through 10","1335.02","2906.42","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2216.75","2216.75","2216.75","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3324.20","1735.94","3457.70","1 through 10","1335.02","2906.42","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","42","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4415.46","4415.46","4415.46","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2215.53","2215.53","2215.53","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","both","","","3129.00","2346.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2212.24","2207.73","2215.64","1 through 10","1335.02","2906.42","other","OPPS APC"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","2398.57","2449.46","1 through 10","1335.02","4472.66","other","ASC "
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","1200.98","2452.85","31","1335.02","4472.66","other","ASC "
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1855.50","59.3","","5221.80","5221.80","5221.80","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3137.30","1568.65","3137.30","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1335.02","","Case rate ($1,335.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","3297.50","3297.50","3297.50","1 through 10","1335.02","4472.66","other","Multiple Surgery"
"Egd W/Remove Tumor/Polyp Snare","PX-75000103","CDM","43251","CPT","0750","RC","","","","outpatient","","","3129.00","2346.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2454.70","78.45","","1386.39","1386.39","1386.39","1 through 10","1335.02","4472.66","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","1 through 10","9.98","60.06","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","91.42","91.42","91.42","1 through 10","10.07","62.76","percent of total billed charges",""
"Ehrlichia Antibody","PX-30000929","CDM","86666","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","35.54","35.54","35.54","1 through 10","10.07","62.76","percent of total billed charges",""
"Eia Ql C Difficile Toxin(S) Antigen","PX-30001233","CDM","87324","CPT","0306","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","58.60","58.60","1 through 10","11.81","80.8","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","1 through 10","13.54","73.38","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","59.97","59.97","59.97","1 through 10","13.54","73.38","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","45.71","1 through 10","11.81","72.16","percent of total billed charges",""
"Eia Ql Cryptosporidium Antigen","PX-30001235","CDM","87328","CPT","0306","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","59.97","59.97","59.97","1 through 10","11.81","72.16","percent of total billed charges",""
"Eia Ql E Hystolytica Group Antigen","PX-30001240","CDM","87337","CPT","0306","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.77","76.77","76.77","1 through 10","11.81","105.91","percent of total billed charges",""
"Eia Ql E Hystolytica Group Antigen","PX-30001240","CDM","87337","CPT","0306","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","100.71","100.71","100.71","1 through 10","11.81","105.91","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","72.00","54.00","AETNA [1001]","HB CH AETNA HMO / PPO","41.98","58.3","","39.69","39.69","39.69","1 through 10","11.74","70.73","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","both","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.00","44.45","","53.82","53.82","53.82","1 through 10","11.74","70.73","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","72.00","54.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.70","59.3","","41.02","41.02","41.02","1 through 10","11.81","72.16","percent of total billed charges",""
"Eia Ql Giardia Antigen","PX-30001236","CDM","87329","CPT","0306","RC","","","","outpatient","","","72.00","54.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.48","78.45","","53.82","53.82","53.82","1 through 10","11.81","72.16","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","1 through 10","14.09","99.28","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","both","","","136.00","102.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","1 through 10","14.09","99.28","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","77.35","1 through 10","11.84","106.69","percent of total billed charges",""
"Eia Ql H Pylori Antigen Stool","PX-30001241","CDM","87338","CPT","0306","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","60.14","101.48","1 through 10","11.84","106.69","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","AETNA [1001]","HB CH AETNA HMO / PPO","50.14","58.3","","47.63","47.63","47.63","66","10.12","62.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","62.78","73","","114.93","114.93","114.93","1 through 10","10.12","62.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","both","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.23","44.45","","64.58","64.57","64.58","1 through 10","10.12","62.78","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","86.00","64.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","51.00","59.3","","49.22","49.22","147.66","88","10.66","67.47","percent of total billed charges",""
"Eia Ql Hepatitis B Ag","PX-30001243","CDM","87340","CPT","0306","RC","","","","outpatient","","","86.00","64.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","67.47","78.45","","64.58","38.27","64.58","51","10.66","67.47","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001257","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","83.80","83.80","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001426","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","1 through 10","11.81","87.86","percent of total billed charges",""
"Eia Ql Multi Antigen","PX-30001426","CDM","87449","CPT","0306","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","83.80","83.80","1 through 10","11.81","87.86","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","AETNA [1001]","HB CH AETNA HMO / PPO","130.59","58.3","","123.61","123.61","247.21","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.41","69.41","69.41","66","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","90.81","70.54","90.81","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","69.13","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.41","65.69","69.76","12","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","FALLON HEALTH [1008]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.13","69.13","69.13","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.63","69.13","69.63","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","163.52","73","","159.14","159.14","159.14","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","HUMANA [1012]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.55","69.41","69.69","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","130.59","58.3","","109.00","109.00","109.00","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","118.72","53","","115.54","115.54","115.54","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","MARTIN'S POINT [160007]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.34","69.34","69.34","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","MEDICARE [2001]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.54","66.76","70.54","902","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","69.53","65.42","69.53","30","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","MOLINA [1014]","HB BWF MEDICARE","70.54","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","139.95","139.95","149.37","1 through 10","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","163.52","73","","123.61","123.61","123.61","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","TRICARE [160005]","HB BWF TRICARE","67.01","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","67.01","67.01","67.01","1 through 10","67.01","217.45","other","Tricare OPPS"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","69.13","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.13","10.04","207.99","39","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.57","44.45","","167.60","167.60","167.60","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","69.13","","APC Price ($70.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","69.42","66.23","70.13","129","67.01","217.45","other","OPPS APC"
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","both","","","224.00","168.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.57","44.45","","99.32","99.32","99.32","1 through 10","67.01","217.45","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","inpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.44","56","","124.71","124.71","124.71","1 through 10","125.44","158.14","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","inpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.14","70.6","","167.60","167.60","167.60","1 through 10","125.44","158.14","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.75","127.75","652.55","88","92.3","175.73","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","224.00","168.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.73","127.73","127.73","1 through 10","92.3","175.73","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","224.00","168.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","175.73","78.45","","167.60","167.59","167.60","1 through 10","92.3","175.73","percent of total billed charges",""
"Ekg Routine Tracing Only","PX-73000001","CDM","93005","CPT","0730","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","175.73","78.45","","167.60","99.32","167.60","52","92.3","175.73","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","191.00","143.25","AETNA [1001]","HB CH AETNA HMO / PPO","111.35","58.3","","105.46","105.46","105.46","1 through 10","22.51","181.64","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","both","","","191.00","143.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","111.35","58.3","","105.46","105.46","105.46","1 through 10","22.51","181.64","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","95.69","50.1","","95.87","95.87","95.87","1 through 10","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.26","59.3","","109.00","109.00","109.00","1 through 10","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","110.21","57.7","","112.16","112.16","112.16","1 through 10","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","115.56","60.5","","117.74","117.74","117.74","1 through 10","69.91","149.84","percent of total billed charges",""
"Elastase Pancreatic Fecal Quantitative","PX-30003781","CDM","82653","CPT","0301","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.84","78.45","","143.00","143.00","143.00","1 through 10","69.91","149.84","percent of total billed charges",""
"ELASTOMER SALINE LG PROSTHESIS TESTICULAR TOROSA SILICONE FILLED","SUP-ITM-10011335","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","AETNA [1001]","HB CH AETNA HMO / PPO","2916.17","58.3","","1830.28","315.58","1830.28","1 through 10","2223.39","5002","percent of total billed charges",""
"ELASTOMER SALINE LG PROSTHESIS TESTICULAR TOROSA SILICONE FILLED","SUP-ITM-10011335","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3651.46","73","","4170.85","4170.85","4170.85","1 through 10","2223.39","5002","percent of total billed charges",""
"ELASTOMER SALINE LG PROSTHESIS TESTICULAR TOROSA SILICONE FILLED","SUP-ITM-10011335","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2223.39","44.45","","649.55","649.55","649.55","1 through 10","2223.39","5002","percent of total billed charges",""
"ELASTOMER SALINE LG PROSTHESIS TESTICULAR TOROSA SILICONE FILLED","SUP-ITM-10011335","CDM","C1889","HCPCS","0278","RC","","","","both","","","5002.00","3751.50","WELLPOINT [1015]","HB CH WELLPOINT","3897.06","77.91","","8998.38","2542.37","8998.38","20","2223.39","5002","percent of total billed charges",""
"ELASTOMER SALINE LG PROSTHESIS TESTICULAR TOROSA SILICONE FILLED","SUP-ITM-10011335","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5002.00","3751.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2966.19","59.3","","1891.61","1609.14","3664.18","25","2501","3924.07","percent of total billed charges",""
"ELASTOMER SALINE LG PROSTHESIS TESTICULAR TOROSA SILICONE FILLED","SUP-ITM-10011335","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5002.00","3751.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3924.07","78.45","","1470.68","1310.06","2481.69","19","2501","3924.07","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","AETNA [1001]","HB CH AETNA HMO / PPO","1744.63","58.3","","1634.24","1004.95","1718.99","42","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2184.53","73","","2123.89","1900.92","2123.89","1 through 10","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1744.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1586.03","53","","939.37","939.37","5593.65","1 through 10","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2543.63","85","","2323.25","1864.50","2882.25","16","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2992.50","100","","2909.44","1772.40","10952.08","45","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2992.50","100","","2323.25","2323.25","2323.25","1 through 10","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2992.50","100","","2882.25","1772.40","10169.17","187","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2184.53","73","","1659.41","1659.41","1659.41","1 through 10","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","both","","","2992.50","2244.37","WELLPOINT [1015]","HB CH WELLPOINT","2331.46","77.91","","2050.91","1468.48","2902.83","52","1330.17","2992.5","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2992.50","2244.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1774.55","59.3","","1548.60","1092.60","3613.79","82","1496.25","2347.62","percent of total billed charges",""
"ELBOW 10X20MM EXPLOR MODULAR","SUP-ITM-10016361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2992.50","2244.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2347.62","78.45","","2085.51","998.68","6202.11","56","1496.25","2347.62","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","AETNA [1001]","HB CH AETNA HMO / PPO","2085.68","58.3","","1634.24","1004.95","1718.99","42","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","2123.89","1900.92","2123.89","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2085.68","58.3","","3729.00","1254.19","3729.00","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1896.08","53","","939.37","939.37","5593.65","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3040.88","85","","2323.25","1864.50","2882.25","16","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3577.50","100","","2909.44","1772.40","10952.08","45","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3577.50","100","","2323.25","2323.25","2323.25","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3577.50","100","","2882.25","1772.40","10169.17","187","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2611.58","73","","1659.41","1659.41","1659.41","1 through 10","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","both","","","3577.50","2683.12","WELLPOINT [1015]","HB CH WELLPOINT","2787.23","77.91","","2050.91","1468.48","2902.83","52","1590.2","3577.5","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2121.46","59.3","","1548.60","1092.60","3613.79","82","1788.75","2806.55","percent of total billed charges",""
"ELBOW 2 6.5MM IMPLANT PLUS HD COMPONENT MODULAR EVOLVE 01B","SUP-ITM-10021316","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3577.50","2683.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2806.55","78.45","","2085.51","998.68","6202.11","56","1788.75","2806.55","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","AETNA [1001]","HB CH AETNA HMO / PPO","7070.62","58.3","","1634.24","1004.95","1718.99","42","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8853.44","73","","2123.89","1900.92","2123.89","1 through 10","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7070.62","58.3","","3729.00","1254.19","3729.00","1 through 10","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6427.84","53","","939.37","939.37","5593.65","1 through 10","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10308.80","85","","2323.25","1864.50","2882.25","16","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12128.00","100","","2909.44","1772.40","10952.08","45","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12128.00","100","","2323.25","2323.25","2323.25","1 through 10","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12128.00","100","","2882.25","1772.40","10169.17","187","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8853.44","73","","1659.41","1659.41","1659.41","1 through 10","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","both","","","12128.00","9096.00","WELLPOINT [1015]","HB CH WELLPOINT","9448.92","77.91","","2050.91","1468.48","2902.83","52","5390.9","12128","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12128.00","9096.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7191.90","59.3","","1548.60","1092.60","3613.79","82","6064","9514.42","percent of total billed charges",""
"ELBOW BASEPLATE ASSEMBLY INTERNAL JOINT STABILIZER","SUP-ITM-10170017","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12128.00","9096.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9514.42","78.45","","2085.51","998.68","6202.11","56","6064","9514.42","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","AETNA [1001]","HB CH AETNA HMO / PPO","3290.45","58.3","","1634.24","1004.95","1718.99","42","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4120.12","73","","2123.89","1900.92","2123.89","1 through 10","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3290.45","58.3","","3729.00","1254.19","3729.00","1 through 10","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2991.32","53","","939.37","939.37","5593.65","1 through 10","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4797.40","85","","2323.25","1864.50","2882.25","16","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5644.00","100","","2909.44","1772.40","10952.08","45","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5644.00","100","","2323.25","2323.25","2323.25","1 through 10","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5644.00","100","","2882.25","1772.40","10169.17","187","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4120.12","73","","1659.41","1659.41","1659.41","1 through 10","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","WELLPOINT [1015]","HB CH WELLPOINT","4397.24","77.91","","2050.91","1468.48","2902.83","52","2508.76","5644","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3346.89","59.3","","1548.60","1092.60","3613.79","82","2822","4427.72","percent of total billed charges",""
"ELBOW BEARING 3X115MM ULNAR ORTHO DISY COMPONENT RIGHT","SUP-ITM-10010928","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4427.72","78.45","","2085.51","998.68","6202.11","56","2822","4427.72","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","AETNA [1001]","HB CH AETNA HMO / PPO","2466.09","58.3","","1634.24","1004.95","1718.99","42","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3087.90","73","","2123.89","1900.92","2123.89","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2466.09","58.3","","3729.00","1254.19","3729.00","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2241.90","53","","939.37","939.37","5593.65","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3595.50","85","","2323.25","1864.50","2882.25","16","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4230.00","100","","2909.44","1772.40","10952.08","45","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4230.00","100","","2323.25","2323.25","2323.25","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4230.00","100","","2882.25","1772.40","10169.17","187","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3087.90","73","","1659.41","1659.41","1659.41","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","WELLPOINT [1015]","HB CH WELLPOINT","3295.59","77.91","","2050.91","1468.48","2902.83","52","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4230.00","3172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2508.39","59.3","","1548.60","1092.60","3613.79","82","2115","3318.44","percent of total billed charges",""
"ELBOW HEAD 18MM RADIAL HEMI POLYMER","SUP-ITM-10266624","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4230.00","3172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3318.44","78.45","","2085.51","998.68","6202.11","56","2115","3318.44","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","AETNA [1001]","HB CH AETNA HMO / PPO","2466.09","58.3","","1634.24","1004.95","1718.99","42","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3087.90","73","","2123.89","1900.92","2123.89","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2466.09","58.3","","3729.00","1254.19","3729.00","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2241.90","53","","939.37","939.37","5593.65","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3595.50","85","","2323.25","1864.50","2882.25","16","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4230.00","100","","2909.44","1772.40","10952.08","45","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4230.00","100","","2323.25","2323.25","2323.25","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4230.00","100","","2882.25","1772.40","10169.17","187","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3087.90","73","","1659.41","1659.41","1659.41","1 through 10","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","both","","","4230.00","3172.50","WELLPOINT [1015]","HB CH WELLPOINT","3295.59","77.91","","2050.91","1468.48","2902.83","52","1880.24","4230","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4230.00","3172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2508.39","59.3","","1548.60","1092.60","3613.79","82","2115","3318.44","percent of total billed charges",""
"ELBOW HEAD 22MM RADIAL HEMI POLYMER","SUP-ITM-10266622","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4230.00","3172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3318.44","78.45","","2085.51","998.68","6202.11","56","2115","3318.44","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","AETNA [1001]","HB CH AETNA HMO / PPO","2111.63","58.3","","1634.24","1004.95","1718.99","42","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2644.06","73","","2123.89","1900.92","2123.89","1 through 10","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2111.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1919.66","53","","939.37","939.37","5593.65","1 through 10","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3078.70","85","","2323.25","1864.50","2882.25","16","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3622.00","100","","2909.44","1772.40","10952.08","45","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3622.00","100","","2323.25","2323.25","2323.25","1 through 10","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3622.00","100","","2882.25","1772.40","10169.17","187","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2644.06","73","","1659.41","1659.41","1659.41","1 through 10","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","both","","","3622.00","2716.50","WELLPOINT [1015]","HB CH WELLPOINT","2821.90","77.91","","2050.91","1468.48","2902.83","52","1609.98","3622","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3622.00","2716.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2147.85","59.3","","1548.60","1092.60","3613.79","82","1811","2841.46","percent of total billed charges",""
"ELBOW HUMERAL SZ MED LEFT SPOOL CENTER OFFSET","SUP-ITM-10213271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3622.00","2716.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2841.46","78.45","","2085.51","998.68","6202.11","56","1811","2841.46","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","AETNA [1001]","HB CH AETNA HMO / PPO","3561.49","58.3","","1634.24","1004.95","1718.99","42","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4459.50","73","","2123.89","1900.92","2123.89","1 through 10","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3561.49","58.3","","3729.00","1254.19","3729.00","1 through 10","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3237.72","53","","939.37","939.37","5593.65","1 through 10","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5192.57","85","","2323.25","1864.50","2882.25","16","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6108.90","100","","2909.44","1772.40","10952.08","45","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6108.90","100","","2323.25","2323.25","2323.25","1 through 10","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6108.90","100","","2882.25","1772.40","10169.17","187","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4459.50","73","","1659.41","1659.41","1659.41","1 through 10","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","both","","","6108.90","4581.67","WELLPOINT [1015]","HB CH WELLPOINT","4759.44","77.91","","2050.91","1468.48","2902.83","52","2715.41","6108.9","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6108.90","4581.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","3622.58","59.3","","1548.60","1092.60","3613.79","82","3054.45","4792.43","percent of total billed charges",""
"ELBOW IMPLANT 4IN XSM COMPONENT HUMERAL COONRAD / MORREY TITANIUM ALLOY","SUP-ITM-10007129","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6108.90","4581.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4792.43","78.45","","2085.51","998.68","6202.11","56","3054.45","4792.43","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","AETNA [1001]","HB CH AETNA HMO / PPO","2132.03","58.3","","1634.24","1004.95","1718.99","42","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2669.61","73","","2123.89","1900.92","2123.89","1 through 10","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2132.03","58.3","","3729.00","1254.19","3729.00","1 through 10","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1938.21","53","","939.37","939.37","5593.65","1 through 10","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3108.45","85","","2323.25","1864.50","2882.25","16","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3657.00","100","","2909.44","1772.40","10952.08","45","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3657.00","100","","2323.25","2323.25","2323.25","1 through 10","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3657.00","100","","2882.25","1772.40","10169.17","187","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.61","73","","1659.41","1659.41","1659.41","1 through 10","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","both","","","3657.00","2742.75","WELLPOINT [1015]","HB CH WELLPOINT","2849.17","77.91","","2050.91","1468.48","2902.83","52","1625.54","3657","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3657.00","2742.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.60","59.3","","1548.60","1092.60","3613.79","82","1828.5","2868.92","percent of total billed charges",""
"ELBOW IMPLANT COMPONENT 18MM RADIAL EVOLVE PROLINE MODIFIED","SUP-ITM-10057090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3657.00","2742.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.92","78.45","","2085.51","998.68","6202.11","56","1828.5","2868.92","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"ELBOW STEM 6X24MM EXPLOR MODULAR SCREW","SUP-ITM-10016360","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","AETNA [1001]","HB CH AETNA HMO / PPO","5140.89","58.3","","1634.24","1004.95","1718.99","42","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6437.14","73","","2123.89","1900.92","2123.89","1 through 10","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5140.89","58.3","","3729.00","1254.19","3729.00","1 through 10","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4673.54","53","","939.37","939.37","5593.65","1 through 10","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7495.30","85","","2323.25","1864.50","2882.25","16","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8818.00","100","","2909.44","1772.40","10952.08","45","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8818.00","100","","2323.25","2323.25","2323.25","1 through 10","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8818.00","100","","2882.25","1772.40","10169.17","187","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6437.14","73","","1659.41","1659.41","1659.41","1 through 10","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","both","","","8818.00","6613.50","WELLPOINT [1015]","HB CH WELLPOINT","6870.10","77.91","","2050.91","1468.48","2902.83","52","3919.6","8818","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8818.00","6613.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5229.07","59.3","","1548.60","1092.60","3613.79","82","4409","6917.72","percent of total billed charges",""
"ELBOW STEM 77MM HUMERAL LT LATITUDE EV","SUP-ITM-10123432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8818.00","6613.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6917.72","78.45","","2085.51","998.68","6202.11","56","4409","6917.72","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","AETNA [1001]","HB CH AETNA HMO / PPO","2413.62","58.3","","1634.24","1004.95","1718.99","42","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3022.20","73","","2123.89","1900.92","2123.89","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2413.62","58.3","","3729.00","1254.19","3729.00","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2194.20","53","","939.37","939.37","5593.65","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3519.00","85","","2323.25","1864.50","2882.25","16","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4140.00","100","","2909.44","1772.40","10952.08","45","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4140.00","100","","2323.25","2323.25","2323.25","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4140.00","100","","2882.25","1772.40","10169.17","187","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3022.20","73","","1659.41","1659.41","1659.41","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","WELLPOINT [1015]","HB CH WELLPOINT","3225.47","77.91","","2050.91","1468.48","2902.83","52","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4140.00","3105.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2455.02","59.3","","1548.60","1092.60","3613.79","82","2070","3247.83","percent of total billed charges",""
"ELBOW STEM 9X33MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4140.00","3105.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3247.83","78.45","","2085.51","998.68","6202.11","56","2070","3247.83","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","AETNA [1001]","HB CH AETNA HMO / PPO","2413.62","58.3","","1634.24","1004.95","1718.99","42","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3022.20","73","","2123.89","1900.92","2123.89","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2413.62","58.3","","3729.00","1254.19","3729.00","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2194.20","53","","939.37","939.37","5593.65","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3519.00","85","","2323.25","1864.50","2882.25","16","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4140.00","100","","2909.44","1772.40","10952.08","45","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4140.00","100","","2323.25","2323.25","2323.25","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4140.00","100","","2882.25","1772.40","10169.17","187","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3022.20","73","","1659.41","1659.41","1659.41","1 through 10","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","both","","","4140.00","3105.00","WELLPOINT [1015]","HB CH WELLPOINT","3225.47","77.91","","2050.91","1468.48","2902.83","52","1840.23","4140","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4140.00","3105.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2455.02","59.3","","1548.60","1092.60","3613.79","82","2070","3247.83","percent of total billed charges",""
"ELBOW STEM 9X36MM ALIGN RADIAL HEAD SYSTEM TITANIUM","SUP-ITM-10266638","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4140.00","3105.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3247.83","78.45","","2085.51","998.68","6202.11","56","2070","3247.83","percent of total billed charges",""
"Elective Hip Joint Replacement,MINOR","324","DRG","","","","","","","","inpatient","","","39105.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35904.67","","Standard inlier is a Case rate ($35,904.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,096.81) for the length of stay and the standard reimbursement.","16202.65","16202.65","16202.65","1 through 10","17146.91","42018.53","case rate",""
"Elective Hip Joint Replacement,MINOR","324","DRG","","","","","","","","inpatient","","","39105.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38568.78","","Standard inlier is a Case rate ($38,568.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,482, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,474.67) for the length of stay and the standard reimbursement.","38568.77","38568.77","38568.77","1 through 10","17146.91","42018.53","case rate",""
"Elective Hip Joint Replacement,MINOR","324","DRG","","","","","","","","inpatient","","","39105.39","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","17146.91","","Case rate ($18,958.86). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,388.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19394.85","19394.85","19394.85","1 through 10","17146.91","42018.53","case rate",""
"Elective Hip Joint Replacement,MODERATE","324","DRG","","","","","","","","inpatient","","","57556.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","17464.49","","Case rate ($19,310). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,740, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8017.25","8017.25","19305.26","1 through 10","17146.91","42018.53","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","46080.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35696.29","","Standard inlier is a Case rate ($35,696.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,067.23) for the length of stay and the standard reimbursement.","35696.29","35696.29","35696.29","1 through 10","15175.19","38344.94","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","46080.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38344.94","","Standard inlier is a Case rate ($38,344.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,268, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,442.90) for the length of stay and the standard reimbursement.","38344.93","38344.93","38344.93","1 through 10","15175.19","38344.94","case rate",""
"Elective Knee Joint Replacement,MINOR","326","DRG","","","","","","","","inpatient","","","46080.89","","MASSHEALTH [3001]","HB BWF MEDICAID","15175.19","","Case rate ($16,778.78). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,208.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,474.13 and the sum of the standard inlier and any outlier amount.","16774.66","16774.66","16774.66","1 through 10","15175.19","38344.94","case rate",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","1456.00","1092.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","620.04","575.62","620.04","1 through 10","598.61","1771","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","1456.00","1092.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","771.68","53","","750.48","750.48","750.48","1 through 10","598.61","1771","percent of total billed charges",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","1456.00","1092.00","MEDICARE [2001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","584.98","630.12","55","598.61","1771","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","1456.00","1092.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","617.52","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","617.52","617.52","617.52","1 through 10","598.61","1771","other","OPPS APC"
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","both","","","1456.00","1092.00","WELLPOINT [1015]","HB CH WELLPOINT","1134.37","77.91","","1222.25","1115.24","1222.25","1 through 10","598.61","1771","percent of total billed charges",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","outpatient","","","1456.00","1092.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","714.46","49.07","","736.17","736.17","736.17","31","714.46","1142.23","percent of total billed charges",""
"Electroconvulsive Therapy","PX-90000009","CDM","90870","CPT","0901","RC","","","","outpatient","","","1456.00","1092.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","729.46","50.1","","752.83","737.21","752.83","53","714.46","1142.23","percent of total billed charges",""
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","both","","","441.00","330.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","441.00","100","","3670.50","3670.50","6900.00","1 through 10","233.73","441","percent of total billed charges",""
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","both","","","441.00","330.75","WELLPOINT [1015]","HB CH WELLPOINT","343.58","77.91","","3150.40","3150.40","3150.40","1 through 10","233.73","441","percent of total billed charges",""
"ELECTRODE DISPERSIVE SONATA PK/10EA","SUP-ITM-10287872","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","441.00","330.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","345.96","78.45","","3075.20","1822.40","5304.72","1 through 10","196.02","345.96","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","AETNA [1001]","HB CH AETNA HMO / PPO","1575.09","58.3","","1830.28","315.58","1830.28","1 through 10","1200.91","2701.7","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1972.24","73","","4170.85","4170.85","4170.85","1 through 10","1200.91","2701.7","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1200.91","44.45","","649.55","649.55","649.55","1 through 10","1200.91","2701.7","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","both","","","2701.70","2026.27","WELLPOINT [1015]","HB CH WELLPOINT","2104.89","77.91","","8998.38","2542.37","8998.38","20","1200.91","2701.7","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2701.70","2026.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","1602.11","59.3","","1891.61","1609.14","3664.18","25","1350.85","2119.48","percent of total billed charges",""
"Embolic Agent T1","PX-27000684","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2701.70","2026.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2119.48","78.45","","1470.68","1310.06","2481.69","19","1350.85","2119.48","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","AETNA [1001]","HB CH AETNA HMO / PPO","1918.07","58.3","","1830.28","315.58","1830.28","1 through 10","1462.41","3290","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2401.70","73","","4170.85","4170.85","4170.85","1 through 10","1462.41","3290","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1462.41","44.45","","649.55","649.55","649.55","1 through 10","1462.41","3290","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","both","","","3290.00","2467.50","WELLPOINT [1015]","HB CH WELLPOINT","2563.24","77.91","","8998.38","2542.37","8998.38","20","1462.41","3290","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3290.00","2467.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1950.97","59.3","","1891.61","1609.14","3664.18","25","1645","2581.01","percent of total billed charges",""
"Embolic Agent T2","PX-27000685","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3290.00","2467.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2581.01","78.45","","1470.68","1310.06","2481.69","19","1645","2581.01","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","AETNA [1001]","HB CH AETNA HMO / PPO","2349.47","58.3","","1830.28","315.58","1830.28","1 through 10","1791.32","4029.97","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2941.88","73","","4170.85","4170.85","4170.85","1 through 10","1791.32","4029.97","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1791.32","44.45","","649.55","649.55","649.55","1 through 10","1791.32","4029.97","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","both","","","4029.97","3022.48","WELLPOINT [1015]","HB CH WELLPOINT","3139.75","77.91","","8998.38","2542.37","8998.38","20","1791.32","4029.97","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4029.97","3022.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","2389.77","59.3","","1891.61","1609.14","3664.18","25","2014.99","3161.51","percent of total billed charges",""
"Embolic Agent T3","PX-27000686","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4029.97","3022.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3161.51","78.45","","1470.68","1310.06","2481.69","19","2014.99","3161.51","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","803.10","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3243.43","749.20","3243.43","13","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","AETNA [1001]","HB CH AETNA HMO / PPO","1964.13","58.3","","1857.49","1857.49","1857.49","1 through 10","436","2459.37","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","716.44","3094.03","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.00","125.00","125.00","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3094.03","716.44","3094.03","37","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","ELDER SERVICES [1037]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","855.59","855.59","855.59","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3088.95","3088.95","3088.95","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($816).","1503.68","753.79","1503.68","1 through 10","436","2459.37","other","Emergency Room"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","HUMANA [1012]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2933.20","713.53","3090.35","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","MEDICARE [2001]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","728.09","3144.34","134","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","MOLINA [1014]","HB BWF MEDICARE","779.71","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1443.40","1443.40","1443.40","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2459.37","73","","1857.49","1857.49","1857.49","1 through 10","436","2459.37","percent of total billed charges",""
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3088.85","1375.82","9266.55","1 through 10","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3094.03","728.09","3144.34","12","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","both","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","764.11","","APC Price ($779.71). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3083.96","2930.11","3083.96","157","436","2459.37","other","OPPS APC"
"Emergency Department Visit High Mdm","PX-45000005","CDM","99285","CPT","0450","RC","","","","outpatient","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2642.98","78.45","","3276.00","1492.55","10256.09","1 through 10","867.43","2642.98","percent of total billed charges",""
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","both","","","3369.00","2526.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","713.46","","APC Price ($728.02). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.45","2929.50","3083.25","120","174.28","713.46","other","OPPS APC"
"Emergency Department Visit High Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000005","CDM","99285","CPT","0450","RC","","","25","outpatient","","","3369.00","2526.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1997.82","59.3","","1919.74","1919.74","5759.22","28","1997.82","1997.82","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1244.00","933.00","AETNA [1001]","HB CH AETNA HMO / PPO","725.25","58.3","","686.07","686.07","686.07","1 through 10","312.38","908.12","percent of total billed charges",""
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1244.00","933.00","MEDICARE [2001]","HB BWF MEDICARE","328.79","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","2987.45","8962.35","1 through 10","312.38","908.12","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","both","","","1244.00","933.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","322.21","","APC Price ($328.79). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2929.71","2927.70","3083.96","1 through 10","312.38","908.12","other","OPPS APC"
"Emergency Department Visit Low Mdm","PX-45000003","CDM","99283","CPT","0450","RC","","","","outpatient","","","1244.00","933.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","975.92","78.45","","1224.19","1224.19","1224.19","1 through 10","368.22","975.92","percent of total billed charges",""
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","338.69","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3245.43","3243.43","3245.43","1 through 10","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3086.29","2932.54","3086.29","1 through 10","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","MEDICARE [2001]","HB BWF MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","2987.45","5974.90","13","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","328.82","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3083.25","3083.25","3083.25","1 through 10","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3094.03","3094.03","3094.03","1 through 10","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","328.82","328.82","328.82","1 through 10","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","both","","","1244.00","933.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","322.25","","APC Price ($328.82). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.45","2927.70","3081.45","1 through 10","322.25","552.96","other","OPPS APC"
"Emergency Department Visit Low Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000003","CDM","99283","CPT","0450","RC","","","25","outpatient","","","1244.00","933.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","737.69","59.3","","709.06","709.06","709.06","1 through 10","737.69","737.69","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","AETNA [1001]","HB CH AETNA HMO / PPO","1378.21","58.3","","1303.53","1303.53","1303.53","1 through 10","436","1725.72","percent of total billed charges",""
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","495.57","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3090.65","3090.65","3090.65","1 through 10","436","1725.72","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","ELDER SERVICES [1037]","HB BWF MEDICARE","505.69","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3081.46","3081.46","3081.46","1 through 10","436","1725.72","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($927).","3823.38","3823.38","3823.38","1 through 10","436","1725.72","other","Emergency Room"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","MEDICARE [2001]","HB BWF MEDICARE","505.69","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","3144.34","3144.34","1 through 10","436","1725.72","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","495.57","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","15126.75","2935.10","15126.75","1 through 10","436","1725.72","other","OPPS APC"
"Emergency Department Visit Moderate Mdm","PX-45000004","CDM","99284","CPT","0450","RC","","","","both","","","2364.00","1773.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","495.57","","APC Price ($505.69). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.96","2930.11","3083.96","16","436","1725.72","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","520.80","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3243.43","3243.14","3245.43","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","2939.65","3094.03","11","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3090.65","497.60","5706.63","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","ELDER SERVICES [1037]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2927.70","2927.70","2927.70","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","FALLON HEALTH [1008]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2987.45","2987.45","2987.45","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3081.45","3081.45","3081.45","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","HUMANA [1012]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3088.45","3088.45","3088.45","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","MEDICARE [2001]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","1517.07","9433.02","108","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","9249.75","3081.45","9249.75","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","MOLINA [1014]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6227.99","5916.95","6227.99","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3103.20","2929.20","9266.55","19","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","966.80","966.80","966.80","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","495.52","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3081.45","2927.70","3144.34","12","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","both","","","2364.00","1773.00","WELLSENSE [1003]","HB BWF MEDICARE","505.64","","APC Price ($505.64). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3083.25","3083.25","3083.25","1 through 10","495.52","520.8","other","OPPS APC"
"Emergency Department Visit Moderate Mdm|SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE","PX-45000004","CDM","99284","CPT","0450","RC","","","25","inpatient","","","2364.00","1773.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1323.84","56","","1315.03","1315.03","1315.03","1 through 10","1323.84","1323.84","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","AETNA [1001]","HB CH AETNA HMO / PPO","522.43","58.3","","554.95","91.85","1421.75","94","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","654.15","73","","2490.03","2490.03","2490.03","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","522.43","58.3","","750.00","750.00","750.00","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","474.93","53","","1192.50","120.84","4149.90","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","761.69","85","","750.00","75.00","750.00","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","896.10","100","","657.00","121.50","1971.00","14","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","896.10","100","","75.00","75.00","75.00","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","896.10","100","","366.00","144.00","1971.00","45","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","654.15","73","","667.50","667.50","667.50","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","398.32","44.45","","123.77","123.77","123.77","1 through 10","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","both","","","896.10","672.07","WELLPOINT [1015]","HB CH WELLPOINT","698.15","77.91","","483.51","229.32","1316.08","96","398.32","896.1","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","896.10","672.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","531.39","59.3","","439.50","225.34","1872.27","197","448.05","702.99","percent of total billed charges",""
"ENDCAP CAP 8.0MM END BONE SUPRACONDYLAR FULLY THRDED T2 TITANIUM","SUP-ITM-10016988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","896.10","672.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","702.99","78.45","","385.32","55.36","1815.62","58","448.05","702.99","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","AETNA [1001]","HB CH AETNA HMO / PPO","590.60","58.3","","554.95","91.85","1421.75","94","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","739.52","73","","2490.03","2490.03","2490.03","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","590.60","58.3","","750.00","750.00","750.00","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","536.91","53","","1192.50","120.84","4149.90","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","861.08","85","","750.00","75.00","750.00","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1013.04","100","","657.00","121.50","1971.00","14","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1013.04","100","","75.00","75.00","75.00","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1013.04","100","","366.00","144.00","1971.00","45","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","739.52","73","","667.50","667.50","667.50","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.30","44.45","","123.77","123.77","123.77","1 through 10","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.04","759.78","WELLPOINT [1015]","HB CH WELLPOINT","789.26","77.91","","483.51","229.32","1316.08","96","450.3","1013.04","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.04","759.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","600.73","59.3","","439.50","225.34","1872.27","197","506.52","794.73","percent of total billed charges",""
"ENDCAP LOCKING EXTENSION ANKLE PANTA TITANIUM","SUP-ITM-10090152","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.04","759.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","794.73","78.45","","385.32","55.36","1815.62","58","506.52","794.73","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","AETNA [1001]","HB CH AETNA HMO / PPO","368.93","58.3","","554.95","91.85","1421.75","94","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","461.96","73","","2490.03","2490.03","2490.03","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","368.93","58.3","","750.00","750.00","750.00","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","335.39","53","","1192.50","120.84","4149.90","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","537.90","85","","750.00","75.00","750.00","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","632.82","100","","657.00","121.50","1971.00","14","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","632.82","100","","75.00","75.00","75.00","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","632.82","100","","366.00","144.00","1971.00","45","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","461.96","73","","667.50","667.50","667.50","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","281.29","44.45","","123.77","123.77","123.77","1 through 10","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","both","","","632.82","474.61","WELLPOINT [1015]","HB CH WELLPOINT","493.03","77.91","","483.51","229.32","1316.08","96","281.29","632.82","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","632.82","474.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","375.26","59.3","","439.50","225.34","1872.27","197","316.41","496.45","percent of total billed charges",""
"ENDCAP OFFSET 0.0MM PHOENIX NAIL BONE TITANIUM FEMORAL","SUP-ITM-10072773","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","632.82","474.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","496.45","78.45","","385.32","55.36","1815.62","58","316.41","496.45","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"ENDCAP SHOULDER 50MM HUMERAL PROXIMALIMAL","SUP-ITM-10035507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2405.00","1803.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","1204.47","1204.47","1 through 10","744.89","1886.72","other","ASC "
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2405.00","1803.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","1206.18","1206.18","1 through 10","744.89","1886.72","other","ASC "
"Endo Eval Small Intest Pouch Biopsy","PX-75000156","CDM","44386","CPT","0750","RC","","","","outpatient","","","2405.00","1803.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1426.17","59.3","","1370.65","1370.65","1370.65","1 through 10","744.89","1886.72","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8985.00","6738.75","AETNA [1001]","HB CH AETNA HMO / PPO","5238.26","58.3","","4687.96","4687.96","4687.96","1 through 10","3854.57","7000.21","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8985.00","6738.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5238.26","58.3","","2985.00","2985.00","2985.00","1 through 10","3854.57","7000.21","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8985.00","6738.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4762.05","53","","4382.04","4382.04","4382.04","1 through 10","3854.57","7000.21","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","both","","","8985.00","6738.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","3854.57","7000.21","per diem",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","outpatient","","","8985.00","6738.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4501.49","50.1","","4739.39","2419.90","4839.81","1 through 10","3594","7048.73","percent of total billed charges",""
"Endo Impl Material Urethr/Bldr Neck","PX-76001262","CDM","51715","CPT","0761","RC","","","","outpatient","","","8985.00","6738.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","5328.11","59.3","","4845.05","3498.42","4845.05","1 through 10","3594","7048.73","percent of total billed charges",""
"Endo Nasal/Sinus W/Control Bleeding","PX-76000760","CDM","31238","CPT","0761","RC","","","","outpatient","","","4192.00","3144.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3288.62","78.45","","4589.74","4589.74","4589.74","1 through 10","1232.36","3288.62","percent of total billed charges",""
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","both","","","606.00","454.50","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","259.97","1146.7","other","OPPS APC"
"Endo Small Bowel Pouch W Balloon Dilation","PX-75000493","CDM","44799","CPT","0750","RC","","","","outpatient","","","606.00","454.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","303.61","50.1","","6121.00","6121.00","6121.00","1 through 10","297.36","7178","percent of total billed charges",""
"Endo Small Intest Control Bleed","PX-75000143","CDM","44366","CPT","0750","RC","","","","both","","","4144.00","3108.00","MEDICARE [2001]","HB BWF MEDICARE","2252.56","","APC Price ($2,252.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2252.79","2252.79","1 through 10","1335.02","3025.12","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","both","","","2798.00","2098.50","MEDICARE [2001]","HB BWF MEDICARE","2252.79","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2252.79","2076.78","2252.79","1 through 10","1243.71","2906.42","other","OPPS APC"
"Endo Small Intest W/Biopsy","PX-75000139","CDM","44361","CPT","0750","RC","","","","outpatient","","","2798.00","2098.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2398.57","2398.57","2398.57","1 through 10","1335.02","4472.66","other","ASC "
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","both","","","2814.00","2110.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","2320.37","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2318.12","2318.12","2318.12","1 through 10","1250.82","2906.42","other","OPPS APC"
"Endo Small Intestine","PX-75000138","CDM","44360","CPT","0750","RC","","","","outpatient","","","2814.00","2110.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2452.85","2452.85","2452.85","1 through 10","1335.02","4472.66","other","ASC "
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","23795.36","17846.52","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10070.20","","Case rate ($9,776.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,792.28, add-ons for qualifying new technology services are included. If operating cost exceeds $55,316.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,285.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,713.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,453.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.63. The transfer capital threshold is the transfer adjustment factor * $724.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","9942.34","9942.34","9949.92","1 through 10","9581.35","10679.21","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","23795.36","17846.52","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10679.21","","Case rate ($10,679.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,792.28, add-ons for qualifying new technology services are included. If operating cost exceeds $55,316.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,285.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,615.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,453.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.63. The transfer capital threshold is the transfer adjustment factor * $724.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9488.14","9488.14","9488.14","1 through 10","9581.35","10679.21","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","23795.36","17846.52","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9581.35","","Case rate ($9,776.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,792.28, add-ons for qualifying new technology services are included. If operating cost exceeds $55,316.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,285.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,713.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,453.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.63. The transfer capital threshold is the transfer adjustment factor * $724.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","49272.24","49272.24","49272.24","1 through 10","9581.35","10679.21","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","23795.36","17846.52","MEDICARE [2001]","HB BWF MEDICARE","10679.21","","Case rate ($10,679.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,792.28, add-ons for qualifying new technology services are included. If operating cost exceeds $55,316.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,285.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,615.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,453.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.63. The transfer capital threshold is the transfer adjustment factor * $724.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10526.74","10457.46","10526.74","23","9581.35","10679.21","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","23795.36","17846.52","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9581.35","","Case rate ($9,776.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,792.28, add-ons for qualifying new technology services are included. If operating cost exceeds $55,316.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,285.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,713.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,453.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.63. The transfer capital threshold is the transfer adjustment factor * $724.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9477.59","9477.59","9477.59","1 through 10","9581.35","10679.21","other","Inpatient DRG"
"Endocrine Disorders With Cc","644","MS-DRG","","","","","","","","inpatient","","","23795.36","17846.52","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9581.35","","Case rate ($9,776.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,792.28, add-ons for qualifying new technology services are included. If operating cost exceeds $55,316.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,285.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,713.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,453.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $724.63. The transfer capital threshold is the transfer adjustment factor * $724.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9437.09","9437.09","9437.09","1 through 10","9581.35","10679.21","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42091.24","31568.43","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15185.74","","Case rate ($15,495.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,520.35, add-ons for qualifying new technology services are included. If operating cost exceeds $61,044.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,724.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,992.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,181.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.73. The transfer capital threshold is the transfer adjustment factor * $1,163.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","125474.52","125474.52","125474.52","1 through 10","15185.74","16944.73","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42091.24","31568.43","MEDICARE [2001]","HB BWF MEDICARE","16944.73","","Case rate ($16,944.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,520.35, add-ons for qualifying new technology services are included. If operating cost exceeds $61,044.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,724.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,441.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,181.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.73. The transfer capital threshold is the transfer adjustment factor * $1,163.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16619.33","0.03","16730.46","24","15185.74","16944.73","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42091.24","31568.43","MOLINA [1014]","HB BWF MEDICARE","16944.73","","Case rate ($16,944.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,520.35, add-ons for qualifying new technology services are included. If operating cost exceeds $61,044.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,724.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $15,441.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,181.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.73. The transfer capital threshold is the transfer adjustment factor * $1,163.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","30389.08","30389.08","30389.08","1 through 10","15185.74","16944.73","other","Inpatient DRG"
"Endocrine Disorders With McC","643","MS-DRG","","","","","","","","inpatient","","","42091.24","31568.43","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15185.74","","Case rate ($15,495.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,520.35, add-ons for qualifying new technology services are included. If operating cost exceeds $61,044.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,724.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $13,992.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,181.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,163.73. The transfer capital threshold is the transfer adjustment factor * $1,163.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15024.47","14982.78","15024.47","1 through 10","15185.74","16944.73","other","Inpatient DRG"
"Endocrine Disorders Without Cc/McC","645","MS-DRG","","","","","","","","inpatient","","","17000.93","12750.70","MEDICARE [2001]","HB BWF MEDICARE","7955.93","","Case rate ($7,955.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,423.06, add-ons for qualifying new technology services are included. If operating cost exceeds $60,423.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,509.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,159.19 + an uncompensated DSH payment of $253.75. The transfer operating threshold is the transfer adjustment factor * $7,169.31 + an uncompensated DSH payment of $253.75. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.99. The transfer capital threshold is the transfer adjustment factor * $542.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7994.14","7994.14","7994.14","1 through 10","7700.5643","8194.61","other","Inpatient Replacement Plans DRG"
"Endomysial Antibody Each Immunoglobulin Class","PX-30003767","CDM","86231","CPT","0302","RC","","","","both","","","102.00","76.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","64.67","63.4","","65.64","65.64","65.64","1 through 10","11.85","97","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","AETNA [1001]","HB CH AETNA HMO / PPO","1150.67","58.3","","1634.24","1004.95","1718.99","42","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1440.80","73","","2123.89","1900.92","2123.89","1 through 10","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1150.67","58.3","","3729.00","1254.19","3729.00","1 through 10","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1046.06","53","","939.37","939.37","5593.65","1 through 10","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1677.65","85","","2323.25","1864.50","2882.25","16","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1973.70","100","","2909.44","1772.40","10952.08","45","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1973.70","100","","2323.25","2323.25","2323.25","1 through 10","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1973.70","100","","2882.25","1772.40","10169.17","187","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1440.80","73","","1659.41","1659.41","1659.41","1 through 10","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","both","","","1973.70","1480.27","WELLPOINT [1015]","HB CH WELLPOINT","1537.71","77.91","","2050.91","1468.48","2902.83","52","877.31","1973.7","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1973.70","1480.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","1170.40","59.3","","1548.60","1092.60","3613.79","82","986.85","1548.37","percent of total billed charges",""
"ENDPIECE SURGICAL SS DOUBLE JOINT","SUP-ITM-10039558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1973.70","1480.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1548.37","78.45","","2085.51","998.68","6202.11","56","986.85","1548.37","percent of total billed charges",""
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","both","","","2610.00","1957.50","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","2482.11","other","OPPS APC"
"Enteroscopy Retrograde With Cold Forceps Bx","PX-75000488","CDM","44799","CPT","0750","RC","","","","outpatient","","","2610.00","1957.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1307.61","50.1","","6121.00","6121.00","6121.00","1 through 10","1280.73","7178","percent of total billed charges",""
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","both","","","3269.00","2451.75","MEDICARE [2001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1113.41","1113.41","1113.41","1 through 10","1057.74","3108.82","other","OPPS APC"
"Enteroscopy W/Submucosal Injection Any Substance","PX-75000450","CDM","44799","CPT","0750","RC","","","","outpatient","","","3269.00","2451.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1637.77","50.1","","6121.00","6121.00","6121.00","1 through 10","1604.1","7178","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","1830.28","315.58","1830.28","1 through 10","1193.48","2685","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","4170.85","4170.85","4170.85","1 through 10","1193.48","2685","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","649.55","649.55","649.55","1 through 10","1193.48","2685","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","8998.38","2542.37","8998.38","20","1193.48","2685","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","1891.61","1609.14","3664.18","25","1342.5","2106.38","percent of total billed charges",""
"ENVELOPE NEURO LARGE TYRX ABSORBABLE ANTIBACTERIAL","SUP-ITM-10166012","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","1470.68","1310.06","2481.69","19","1342.5","2106.38","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","both","","","232.24","174.18","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","147.24","63.4","","153.98","153.98","153.98","1 through 10","123.09","931.54","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","both","","","232.24","174.18","WELLPOINT [1015]","HB CH WELLPOINT","180.94","77.91","","182.91","182.91","182.91","1 through 10","123.09","931.54","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","outpatient","","","232.24","174.18","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","134.00","57.7","","140.04","140.04","140.04","1 through 10","103.23","654.19","percent of total billed charges",""
"Eo W/O Joints Custom T1","PX-27000478","CDM","L3702","HCPCS","0274","RC","","","","outpatient","","","232.24","174.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","182.19","78.45","","178.55","105.81","178.55","1 through 10","103.23","654.19","percent of total billed charges",""
"Epistaxis With McC","150","MS-DRG","","","","","","","","inpatient","","","27162.20","20371.65","MEDICARE [2001]","HB BWF MEDICARE","13771.12","","Case rate ($13,771.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,618.96, add-ons for qualifying new technology services are included. If operating cost exceeds $58,142.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,502.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $12,490.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,279.72 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $941.32. The transfer capital threshold is the transfer adjustment factor * $941.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13995.04","13995.04","13995.04","1 through 10","12347","13771.12","other","Inpatient DRG"
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Epstein Barr Virs Quant Pcr","PX-30003295","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Epstein-Barr Early Ag Antibody Ea","PX-30000924","CDM","86663","CPT","0302","RC","","","","outpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","35.99","35.99","35.99","1 through 10","13.53","82.69","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","14.98","90.22","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","14.72","94.92","percent of total billed charges",""
"Epstein-Barr Ebna Ag Antibody","PX-30000925","CDM","86664","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","90.72","90.72","1 through 10","14.72","94.92","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","17.78","107.05","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","14.72","94.92","percent of total billed charges",""
"Epstein-Barr Vca Ag Antibody","PX-30000927","CDM","86665","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","90.72","181.44","1 through 10","14.72","94.92","percent of total billed charges",""
"Ercp Diagnostic","PX-75000109","CDM","43260","CPT","0750","RC","","","","outpatient","","","6310.00","4732.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4670.85","4670.85","4670.85","1 through 10","2542.22","4950.2","other","ASC "
"Ercp Duct Stent Placement","PX-75000360","CDM","43274","CPT","0750","RC","","","","outpatient","","","5548.00","4161.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5141.51","","Case rate ($5,141.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7434.62","7434.62","7434.62","1 through 10","2380.09","5141.51","other","ASC "
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,797). Procedure 2, Per diem ($1,898.50). Procedures 3 - 9999, Per diem ($949.25).","3797.00","3797.00","3797.00","1 through 10","2140.15","3591.65","per diem",""
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","both","","","4610.00","3457.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2207.73","","APC Price ($2,252.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2207.74","2207.74","2207.74","1 through 10","2140.15","3591.65","other","OPPS APC"
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4664.39","4664.39","4664.39","1 through 10","2049.15","4472.66","other","ASC "
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2335.43","2335.43","2335.43","1 through 10","2049.15","4472.66","other","ASC "
"Ercp Remove Forgn Body Duct","PX-75000361","CDM","43275","CPT","0750","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2542.22","","Case rate ($2,542.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5974.22","5974.22","5974.22","1 through 10","2049.15","4472.66","other","Multiple Surgery"
"Ercp Stent Exchange W/Dilate","PX-75000362","CDM","43276","CPT","0750","RC","","","","both","","","5577.00","4182.75","MEDICARE [2001]","HB BWF MEDICARE","7068.60","","APC Price ($7,068.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7069.32","7069.32","7069.32","1 through 10","2392.53","7280.66","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","both","","","5029.00","3771.75","MEDICARE [2001]","HB BWF MEDICARE","4518.11","","APC Price ($4,518.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4518.11","4518.11","1 through 10","2235.39","4653.65","other","OPPS APC"
"Ercp W/Rem Calculi/Debris/Duct(S)","PX-75000113","CDM","43264","CPT","0750","RC","","","","outpatient","","","5029.00","3771.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3230.19","","Case rate ($3,230.19). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4670.85","2335.43","4670.85","1 through 10","2514.5","4472.66","other","ASC "
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","MEDICARE [2001]","HB BWF MEDICARE","4518.11","","APC Price ($4,518.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4518.11","4518.11","4518.11","1 through 10","2224.28","4653.65","other","OPPS APC"
"Ercp W/Sphincterotomy/Papillotomy","PX-75000111","CDM","43262","CPT","0750","RC","","","","both","","","5004.00","3753.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","4427.75","","APC Price ($4,518.11). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4427.75","4427.75","4427.75","1 through 10","2224.28","4653.65","other","OPPS APC"
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","156.00","117.00","AETNA [1001]","HB CH AETNA HMO / PPO","90.95","58.3","","86.18","86.18","86.18","1 through 10","18.41","113.88","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","both","","","156.00","117.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.68","53","","80.56","80.56","80.56","1 through 10","18.41","113.88","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","156.00","117.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.51","59.3","","89.07","89.07","89.07","1 through 10","19.39","122.38","percent of total billed charges",""
"Erythropoietin","PX-30000421","CDM","82668","CPT","0301","RC","","","","outpatient","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.38","78.45","","116.86","116.86","116.86","1 through 10","19.39","122.38","percent of total billed charges",""
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Age >17 Without McC","392","TRIS-DRG","","","","","","","","inpatient","","","23420.09","","TRICARE [160005]","HB BWF TRICARE","5189.79","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,169.44). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $50,990.89 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($5,121.03), capped at $6,561.22. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $50,990.89 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","6785.02","6785.02","6785.02","1 through 10","5189.79","5189.79","other","Inpatient DRGs"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29054.66","21790.99","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","12377.59","","Case rate ($12,017.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,036.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,559.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,457.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,781.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,696.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.64. The transfer capital threshold is the transfer adjustment factor * $896.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","12305.00","12305.00","12305.00","1 through 10","11776.74","13133.58","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29054.66","21790.99","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11776.74","","Case rate ($12,017.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,036.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,559.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,457.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,781.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,696.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.64. The transfer capital threshold is the transfer adjustment factor * $896.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11667.89","11667.89","11667.89","1 through 10","11776.74","13133.58","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29054.66","21790.99","HUMANA [1012]","HB BWF MEDICARE","13133.58","","Case rate ($13,133.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,036.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,559.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,457.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,897.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,696.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.64. The transfer capital threshold is the transfer adjustment factor * $896.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11733.19","11733.19","11733.19","1 through 10","11776.74","13133.58","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29054.66","21790.99","MEDICARE [2001]","HB BWF MEDICARE","13133.58","","Case rate ($13,133.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,036.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,559.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,457.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,897.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,696.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.64. The transfer capital threshold is the transfer adjustment factor * $896.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12937.43","945.45","13023.57","53","11776.74","13133.58","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29054.66","21790.99","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11776.74","","Case rate ($12,017.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,036.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,559.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,457.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,781.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,696.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.64. The transfer capital threshold is the transfer adjustment factor * $896.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11716.69","11716.69","11716.69","1 through 10","11776.74","13133.58","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC","391","MS-DRG","","","","","","","","inpatient","","","29054.66","21790.99","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11776.74","","Case rate ($12,017.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,036.10, add-ons for qualifying new technology services are included. If operating cost exceeds $57,559.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,457.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,781.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,696.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $896.64. The transfer capital threshold is the transfer adjustment factor * $896.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11701.41","11700.19","11730.14","1 through 10","11776.74","13133.58","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","22698.52","17023.89","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7742.89","","Case rate ($7,517.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,529.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,052.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,111.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,627.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,189.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.15. The transfer capital threshold is the transfer adjustment factor * $551.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7551.88","7551.88","7551.88","1 through 10","7367.02","8002.59","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","22698.52","17023.89","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7517.37","","Case rate ($7,517.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,529.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,052.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,111.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,627.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,189.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.15. The transfer capital threshold is the transfer adjustment factor * $551.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7881.90","7881.90","7881.90","1 through 10","7367.02","8002.59","other","Inpatient Replacement Plans DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","22698.52","17023.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7367.02","","Case rate ($7,517.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,529.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,052.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,111.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,627.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,189.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.15. The transfer capital threshold is the transfer adjustment factor * $551.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7218.07","7218.07","7236.82","1 through 10","7367.02","8002.59","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","22698.52","17023.89","MEDICARE [2001]","HB BWF MEDICARE","7517.37","","Case rate ($7,517.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,529.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,052.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,111.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,627.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,189.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.15. The transfer capital threshold is the transfer adjustment factor * $551.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7957.73","0.03","8010.06","100","7367.02","8002.59","other","Inpatient Replacement Plans DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","22698.52","17023.89","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7367.02","","Case rate ($7,517.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,529.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,052.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,111.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,627.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,189.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.15. The transfer capital threshold is the transfer adjustment factor * $551.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7208.17","7198.55","7890.85","1 through 10","7367.02","8002.59","other","Inpatient DRG"
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC","392","MS-DRG","","","","","","","","inpatient","","","22698.52","17023.89","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7367.02","","Case rate ($7,517.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,529.08, add-ons for qualifying new technology services are included. If operating cost exceeds $53,052.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,111.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $6,627.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,189.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $551.15. The transfer capital threshold is the transfer adjustment factor * $551.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7184.55","7184.55","7204.18","1 through 10","7367.02","8002.59","other","Inpatient DRG"
"Esophagoscopy W/Dilate Balloon","PX-75000081","CDM","43220","CPT","0750","RC","","","","outpatient","","","3406.00","2554.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1696.30","","Case rate ($1,696.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2401.96","2401.96","2401.96","1 through 10","1335.02","2672.01","other","ASC "
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","855.89","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","855.43","855.43","855.43","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","830.96","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","824.98","824.98","824.98","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","814.34","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","817.66","747.44","817.66","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","830.96","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","753.54","753.54","753.54","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","MEDICARE [2001]","HB BWF MEDICARE","830.96","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","830.96","762.69","1661.92","18","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","814.34","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","817.66","817.66","817.66","1 through 10","789.41","4711.25","other","OPPS APC"
"Esrd Emergent Hemodialysis OP","PX-82000033","CDM","G0257","HCPCS","0829","RC","","","","both","","","4954.00","3715.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","814.34","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","750.49","750.49","817.67","1 through 10","789.41","4711.25","other","OPPS APC"
"Ethchlorvynol (Quantitative Alcohols)","PX-30002959","CDM","80320","CPT","0301","RC","","","","both","","","85.00","63.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","62.05","73","","47.06","47.06","47.06","1 through 10","37.78","445.13","percent of total billed charges",""
"Eua Pelvic Exam","PX-76001359","CDM","57410","CPT","0761","RC","","","","both","","","4625.00","3468.75","MEDICARE [2001]","HB BWF MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","1 through 10","1984.13","3888.77","other","OPPS APC"
"Eus Guided Drainage Stomach to Jejunum With Stent","PX-75000476","CDM","43999","CPT","0750","RC","","","","both","","","2617.00","1962.75","WELLPOINT [1015]","HB CH WELLPOINT","2038.90","77.91","","2383.28","2383.28","2383.28","1 through 10","1057.74","2488.77","percent of total billed charges",""
"Evaluate Speech Production","PX-44000059","CDM","92522","CPT","0444","RC","","","","both","","","509.00","381.75","AETNA [1001]","HB CH AETNA HMO / PPO","296.75","58.3","","280.67","280.67","280.67","1 through 10","117.48","469.71","percent of total billed charges",""
"Evaluate Speech Production","PX-44000059","CDM","92522","CPT","0444","RC","","","","both","","","509.00","381.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","117.48","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($119.88). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($93.16). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","118.49","118.49","118.49","1 through 10","117.48","469.71","fee schedule",""
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Cyst Pilonidal Smp","PX-76000098","CDM","11770","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3932.70","3932.70","3932.70","1 through 10","2140.46","7178","other","ASC "
"Exc Cyst/Lesn Breast","PX-76000252","CDM","19120","CPT","0761","RC","","","","both","","","6638.00","4978.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2534.41","","Case rate ($2,534.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","6564.12","6564.12","6564.12","1 through 10","2534.41","5171.67","other","Multiple Surgery"
"Exc Cyst/Lesn Breast|BILATERAL PROCEDURE","PX-76000252","CDM","19120","CPT","0761","RC","","","50","outpatient","","","6638.00","4978.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4830.41","","Case rate ($4,830.41). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6839.86","6839.86","6839.86","1 through 10","4830.41","13351.09","other","ASC "
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","2343.98","2343.98","2343.98","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","both","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","11008.22","11008.22","11008.22","1 through 10","1984.13","3888.77","other","Multiple Surgery"
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3823.55","3823.55","3823.55","1 through 10","2125.14","4472.66","other","ASC "
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2742.63","59.3","","9890.51","9890.51","9890.51","1 through 10","2125.14","4472.66","percent of total billed charges",""
"Exc Cyst/Tumor Vaginal","PX-76001348","CDM","57135","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5249.10","5249.10","5249.10","1 through 10","2125.14","4472.66","other","Multiple Surgery"
"Exc Hidradenitis Ingunial Smp","PX-76000067","CDM","11462","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","2140.46","4549.94","per diem",""
"Exc Lesn Bgn Sclp/Hnd/Gen <0.5cm","PX-76000053","CDM","11420","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","1137.25","2274.50","1 through 10","1078","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","both","","","1306.00","979.50","MEDICARE [2001]","HB BWF MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","417.78","835.56","1 through 10","560.27","1707.36","other","OPPS APC"
"Exc Lesn Bgn Sclp/Hnd/Gen 0.6-1.0cm","PX-76000054","CDM","11421","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1990.00","1990.00","1990.00","1 through 10","579.34","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2985.00","2985.00","2985.00","1 through 10","653","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 1.1-2.0cm","PX-76000055","CDM","11422","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","5283.00","2274.50","5283.00","1 through 10","653","1873.9","other","ASC "
"Exc Lesn Bgn Sclp/Hnd/Gen 2.1-3.0cm","PX-76000056","CDM","11423","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1528.87","1528.87","1528.87","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Lesn Bgn Sclp/Hnd/Gen 3.1-4.0cm","PX-76000057","CDM","11424","CPT","0761","RC","","","","both","","","3854.00","2890.50","WELLPOINT [1015]","HB CH WELLPOINT","3002.65","77.91","","9682.54","9682.54","9682.54","1 through 10","1237.95","3002.65","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","both","","","1306.00","979.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","474.47","474.47","474.47","1 through 10","314.08","1017.5","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4051.40","3522.00","4051.40","1 through 10","314.08","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg .6-1.0cm","PX-76000048","CDM","11401","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","508.58","254.29","508.58","1 through 10","314.08","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","both","","","1072.00","804.00","MEDICARE [2001]","HB BWF MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","459.89","1707.36","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4059.00","478.33","4059.00","1 through 10","536","970.06","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","479.00","469.06","479.00","1 through 10","536","970.06","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","635.70","59.3","","6191.68","6191.68","6191.68","1 through 10","536","970.06","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg <0.5cm","PX-76000047","CDM","11400","CPT","0761","RC","","","","outpatient","","","1072.00","804.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1309.32","1309.32","1309.32","1 through 10","536","970.06","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","3854.00","2890.50","AETNA [1001]","HB CH AETNA HMO / PPO","2246.88","58.3","","6044.68","2149.21","6044.68","1 through 10","1237.95","3002.65","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","3854.00","2890.50","MEDICARE [2001]","HB BWF MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3002.65","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","3854.00","2890.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1237.95","3002.65","per diem",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","3854.00","2890.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","1603.15","1603.15","1603.15","1 through 10","1237.95","3002.65","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","both","","","3854.00","2890.50","WELLPOINT [1015]","HB CH WELLPOINT","3002.65","77.91","","3449.15","3449.15","3449.15","1 through 10","1237.95","3002.65","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3293.00","1072.00","5054.00","19","1237.95","4472.66","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1137.25","1113.66","4442.00","26","1237.95","4472.66","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2285.42","59.3","","5115.78","4442.47","9407.98","1 through 10","1237.95","4472.66","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4363.77","1454.59","5595.56","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1528.87","1473.16","1603.15","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg >4.0cm","PX-76000052","CDM","11406","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3023.46","78.45","","5652.22","3797.49","25991.69","1 through 10","1237.95","4472.66","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1306.00","979.50","MEDICARE [2001]","HB BWF MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","560.27","1707.36","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","both","","","1306.00","979.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","822.19","822.19","822.19","1 through 10","560.27","1707.36","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4051.40","4051.40","4051.40","1 through 10","579.34","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","479.00","479.00","957.99","1 through 10","579.34","1024.56","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4084.35","4084.35","4084.35","1 through 10","579.34","1024.56","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 1.1-2.0","PX-76000049","CDM","11402","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1024.56","78.45","","3983.67","3983.67","3983.67","1 through 10","579.34","1024.56","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1306.00","979.50","AETNA [1001]","HB CH AETNA HMO / PPO","761.40","58.3","","2474.96","2474.96","2474.96","1 through 10","560.27","1707.36","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","both","","","1306.00","979.50","MEDICARE [2001]","HB BWF MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","560.27","1707.36","other","OPPS APC"
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","468.40","468.40","468.40","1 through 10","579.34","1873.9","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4288.00","4288.00","4288.00","1 through 10","579.34","1873.9","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 2.1-3.0","PX-76000050","CDM","11403","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","774.46","59.3","","4833.91","4833.91","4833.91","1 through 10","579.34","1873.9","percent of total billed charges",""
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3216.00","1137.25","5181.68","1 through 10","1237.95","3023.46","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1137.25","1113.66","2274.50","1 through 10","1237.95","3023.46","other","ASC "
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2946.32","1528.87","2946.32","1 through 10","1237.95","3023.46","other","Multiple Surgery"
"Exc Lesn Bgn Trunk/Arm/Leg 3.1-4.0","PX-76000051","CDM","11404","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3023.46","78.45","","4098.01","4098.01","4098.01","1 through 10","1237.95","3023.46","percent of total billed charges",""
"Exc Lesn Breast W/Marker","PX-76000253","CDM","19125","CPT","0761","RC","","","","both","","","6997.00","5247.75","AETNA [1001]","HB CH AETNA HMO / PPO","4079.25","58.3","","14956.32","5601.39","14956.32","1 through 10","3001.71","5451.36","percent of total billed charges",""
"Exc Lesn Mal Sclp/Hnd/Gen 2.1-3.0cm","PX-76000077","CDM","11623","CPT","0761","RC","","","","both","","","2156.00","1617.00","MEDICARE [2001]","HB BWF MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","924.92","3916.38","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","3854.00","2890.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1885.46","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1968.44","1968.44","1968.44","1 through 10","1237.95","3002.65","other","OPPS APC"
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","both","","","3854.00","2890.50","WELLPOINT [1015]","HB CH WELLPOINT","3002.65","77.91","","7802.87","7802.87","7802.87","1 through 10","1237.95","3002.65","percent of total billed charges",""
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1135.68","1135.68","1135.68","1 through 10","1237.95","4472.66","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg >4.0cm","PX-76000073","CDM","11606","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1237.95","4472.66","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg 1.1-2.0","PX-76000070","CDM","11602","CPT","0761","RC","","","","outpatient","","","1306.00","979.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","259.68","259.68","259.68","1 through 10","314.08","1024.56","other","ASC "
"Exc Lesn Mal Trunk/Arm/Leg 3.1-4.0","PX-76000072","CDM","11604","CPT","0761","RC","","","","both","","","2876.00","2157.00","MEDICARE [2001]","HB BWF MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","2240.69","other","OPPS APC"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","both","","","5840.00","4380.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5329.75","5329.75","5329.75","1 through 10","2140.46","4549.94","other","Multiple Surgery"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3101.27","3101.27","3101.27","1 through 10","2140.46","4549.94","other","OPPS APC"
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3927.26","3927.26","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tiss Back/Flnk Subfscl 5 +","PX-76000354","CDM","21933","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","1966.35","3932.70","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6157.00","4617.75","MEDICARE [2001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","2140.46","4796.92","other","OPPS APC"
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","both","","","6157.00","4617.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","2140.46","4796.92","per diem",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1963.63","1963.63","1963.63","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3651.10","59.3","","9894.61","9894.61","9894.61","1 through 10","2140.46","7939.38","percent of total billed charges",""
"Exc Tum Tiss Neck/Ant Thx Subq 3+","PX-76000341","CDM","21552","CPT","0761","RC","","","","outpatient","","","6157.00","4617.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","7930.41","7930.41","7930.41","1 through 10","2140.46","7939.38","other","Multiple Surgery"
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3927.26","3927.26","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tum Tiss Neck/Ant Thx Subq 5+","PX-76000342","CDM","21554","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2140.46","7939.38","other","ASC "
"Exc Tumor Abd Wall Subfascial","PX-76000377","CDM","22900","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3463.12","59.3","","8482.35","8482.35","8482.35","1 through 10","2336","4581.48","percent of total billed charges",""
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","both","","","3854.00","2890.50","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3082.50","3082.50","3082.50","1 through 10","1237.95","3002.65","other","Multiple Surgery"
"Exc Tumor Back/Flank <3cm","PX-76000352","CDM","21930","CPT","0761","RC","","","","outpatient","","","3854.00","2890.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8727.54","8727.54","8727.54","1 through 10","1237.95","4472.66","other","Multiple Surgery"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1893.34","1893.34","1893.34","1 through 10","1237.95","4549.94","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB BWF MEDICARE","2060.54","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","4549.94","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","2019.33","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1891.05","1891.05","1891.05","1 through 10","1237.95","4549.94","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2505.36","42.9","","6356.44","6356.44","6356.44","1 through 10","1237.95","4549.94","percent of total billed charges",""
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","both","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2019.33","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","1237.95","4549.94","other","OPPS APC"
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2271.35","2271.35","2271.35","1 through 10","1237.95","7939.38","other","ASC "
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1237.95","7939.38","other","ASC "
"Exc Tumor Back/Flank Subq 3cm or Gr","PX-76000353","CDM","21931","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","8727.54","8727.54","8727.54","1 through 10","1237.95","7939.38","other","Multiple Surgery"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","3951.00","2963.25","MEDICARE [2001]","HB BWF MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3078.22","other","OPPS APC"
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","both","","","3951.00","2963.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","1237.95","3078.22","per diem",""
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","3951.00","2963.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1135.68","1135.68","1135.68","1 through 10","1237.95","4472.66","other","ASC "
"Exc Tumor Neck/Thorax Sq <3cm","PX-76000343","CDM","21555","CPT","0761","RC","","","","outpatient","","","3951.00","2963.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","2274.50","2274.50","1 through 10","1237.95","4472.66","other","ASC "
"Exc Tumor Soft Tiss Back/Flank Subfascial <5cm","PX-36000143","CDM","21932","CPT","0361","RC","","","","both","","","4063.00","3047.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3344.48","3344.48","3344.48","1 through 10","2140.46","3500.47","other","OPPS APC"
"Exc Tumor Soft Tiss Back/Flank Subfascial <5cm","PX-36000143","CDM","21932","CPT","0361","RC","","","","both","","","4063.00","3047.25","MEDICARE [2001]","HB BWF MEDICARE","3398.51","","APC Price ($3,398.51). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","1 through 10","2140.46","3500.47","other","OPPS APC"
"Exc Tumor Soft Tiss Back/Flank Subfascial <5cm","PX-36000143","CDM","21932","CPT","0361","RC","","","","both","","","4063.00","3047.25","WELLPOINT [1015]","HB CH WELLPOINT","3165.48","77.91","","14779.88","14779.88","14779.88","1 through 10","2140.46","3500.47","percent of total billed charges",""
"Exc Tumr Face/Scalp Subq 2+Cm","PX-76000311","CDM","21012","CPT","0761","RC","","","","outpatient","","","2156.00","1617.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1691.38","78.45","","9889.84","9889.84","9889.84","1 through 10","1078","1873.9","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","both","","","4063.00","3047.25","AETNA [1001]","HB CH AETNA HMO / PPO","2368.73","58.3","","3299.94","3299.94","3299.94","1 through 10","781.54","3228.91","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1925.56","1925.56","1966.35","1 through 10","1873.9","3187.42","other","ASC "
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2409.36","59.3","","2.46","2.46","2.46","12","1873.9","3187.42","percent of total billed charges",""
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","2515.04","2515.04","2515.04","1 through 10","1873.9","3187.42","other","Multiple Surgery"
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2140.46","","Case rate ($2,140.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2643.47","2643.47","2643.47","1 through 10","1873.9","3187.42","other","Multiple Surgery"
"Excise Excess Skin Tissue,Other","PX-36000462","CDM","15839","CPT","0361","RC","","","","outpatient","","","4063.00","3047.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3187.42","78.45","","3797.49","3797.49","3797.49","1 through 10","1873.9","3187.42","percent of total billed charges",""
"Excision of Ext Anus Papillae/Tags","PX-75000216","CDM","46230","CPT","0750","RC","","","","outpatient","","","5034.00","3775.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3780.34","1890.17","3780.34","1 through 10","1873.9","3949.17","other","ASC "
"EXPANDER TISSUE 225CC 6X9.5CM CRESCENT 2 STAGE SMOOTH","SUP-ITM-10328814","CDM","C1889","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","AETNA [1001]","HB CH AETNA HMO / PPO","2046.33","58.3","","1830.28","315.58","1830.28","1 through 10","1560.2","3510","percent of total billed charges",""
"EXPANDER TISSUE 225CC 6X9.5CM CRESCENT 2 STAGE SMOOTH","SUP-ITM-10328814","CDM","C1889","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2562.30","73","","4170.85","4170.85","4170.85","1 through 10","1560.2","3510","percent of total billed charges",""
"EXPANDER TISSUE 225CC 6X9.5CM CRESCENT 2 STAGE SMOOTH","SUP-ITM-10328814","CDM","C1889","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1560.20","44.45","","649.55","649.55","649.55","1 through 10","1560.2","3510","percent of total billed charges",""
"EXPANDER TISSUE 225CC 6X9.5CM CRESCENT 2 STAGE SMOOTH","SUP-ITM-10328814","CDM","C1889","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","WELLPOINT [1015]","HB CH WELLPOINT","2734.64","77.91","","8998.38","2542.37","8998.38","20","1560.2","3510","percent of total billed charges",""
"EXPANDER TISSUE 225CC 6X9.5CM CRESCENT 2 STAGE SMOOTH","SUP-ITM-10328814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.43","59.3","","1891.61","1609.14","3664.18","25","1755","2753.6","percent of total billed charges",""
"EXPANDER TISSUE 225CC 6X9.5CM CRESCENT 2 STAGE SMOOTH","SUP-ITM-10328814","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.60","78.45","","1470.68","1310.06","2481.69","19","1755","2753.6","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","1830.28","315.58","1830.28","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","4170.85","4170.85","4170.85","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1434.85","44.45","","649.55","649.55","649.55","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","8998.38","2542.37","8998.38","20","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","1891.61","1609.14","3664.18","25","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 250CC W11CM H10CM P4.9CM SMOOTH NATRELLE FOURTE W/SUTURE TABS","SUP-ITM-10241029","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","1470.68","1310.06","2481.69","19","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","1830.28","315.58","1830.28","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","4170.85","4170.85","4170.85","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1434.85","44.45","","649.55","649.55","649.55","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","8998.38","2542.37","8998.38","20","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","1891.61","1609.14","3664.18","25","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 300CC W11CM H11.5CM P5CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","1470.68","1310.06","2481.69","19","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","1830.28","315.58","1830.28","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","4170.85","4170.85","4170.85","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1434.85","44.45","","649.55","649.55","649.55","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","8998.38","2542.37","8998.38","20","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","1891.61","1609.14","3664.18","25","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H12CM P6.7CM STYLE 133S SMOOTH NATRELLE FOURTE MODERATE EXTRA","SUP-ITM-10241088","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","1470.68","1310.06","2481.69","19","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","AETNA [1001]","HB CH AETNA HMO / PPO","1881.92","58.3","","1830.28","315.58","1830.28","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2356.44","73","","4170.85","4170.85","4170.85","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1434.85","44.45","","649.55","649.55","649.55","1 through 10","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","both","","","3228.00","2421.00","WELLPOINT [1015]","HB CH WELLPOINT","2514.93","77.91","","8998.38","2542.37","8998.38","20","1434.85","3228","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1914.20","59.3","","1891.61","1609.14","3664.18","25","1614","2532.37","percent of total billed charges",""
"EXPANDER TISSUE 500CC W13CM H13.5CM P5.7CM STYLE 133S SMOOTH NATRELLE FOURTE FULL VARIABLE","SUP-ITM-10241076","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3228.00","2421.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2532.37","78.45","","1470.68","1310.06","2481.69","19","1614","2532.37","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","554.95","91.85","1421.75","94","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","2490.03","2490.03","2490.03","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","750.00","750.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","1192.50","120.84","4149.90","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","573.75","85","","750.00","75.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","675.00","100","","657.00","121.50","1971.00","14","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","675.00","100","","75.00","75.00","75.00","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","675.00","100","","366.00","144.00","1971.00","45","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","667.50","667.50","667.50","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","123.77","123.77","123.77","1 through 10","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","483.51","229.32","1316.08","96","300.04","675","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","439.50","225.34","1872.27","197","337.5","529.54","percent of total billed charges",""
"EXTENDER BUTTON TRACTION FIXATION TIGHTROPE","SUP-ITM-10115493","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","385.32","55.36","1815.62","58","337.5","529.54","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","AETNA [1001]","HB CH AETNA HMO / PPO","1213.89","58.3","","1634.24","1004.95","1718.99","42","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1519.97","73","","2123.89","1900.92","2123.89","1 through 10","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1213.89","58.3","","3729.00","1254.19","3729.00","1 through 10","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1103.54","53","","939.37","939.37","5593.65","1 through 10","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1769.83","85","","2323.25","1864.50","2882.25","16","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2082.15","100","","2909.44","1772.40","10952.08","45","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2082.15","100","","2323.25","2323.25","2323.25","1 through 10","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2082.15","100","","2882.25","1772.40","10169.17","187","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1519.97","73","","1659.41","1659.41","1659.41","1 through 10","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2082.15","1561.61","WELLPOINT [1015]","HB CH WELLPOINT","1622.20","77.91","","2050.91","1468.48","2902.83","52","925.52","2082.15","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2082.15","1561.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","1234.71","59.3","","1548.60","1092.60","3613.79","82","1041.08","1633.45","percent of total billed charges",""
"EXTENDER COMPONENT L 30MM OD 14 KNEE PERSONA EXTENSION TIVANIUM CEMENTED TAPERED","SUP-ITM-10130706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2082.15","1561.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1633.45","78.45","","2085.51","998.68","6202.11","56","1041.08","1633.45","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","AETNA [1001]","HB CH AETNA HMO / PPO","1658.05","58.3","","1634.24","1004.95","1718.99","42","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2076.12","73","","2123.89","1900.92","2123.89","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1658.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1507.32","53","","939.37","939.37","5593.65","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2417.40","85","","2323.25","1864.50","2882.25","16","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2844.00","100","","2909.44","1772.40","10952.08","45","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2844.00","100","","2323.25","2323.25","2323.25","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2844.00","100","","2882.25","1772.40","10169.17","187","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2076.12","73","","1659.41","1659.41","1659.41","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","WELLPOINT [1015]","HB CH WELLPOINT","2215.76","77.91","","2050.91","1468.48","2902.83","52","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1686.49","59.3","","1548.60","1092.60","3613.79","82","1422","2231.12","percent of total billed charges",""
"EXTENDER STEM 25MM OD COBALT KNEE PRIMARY REVISION TOTAL STABILIZED WITH TRIAL CUTTING GUIDE IMPL TRIATHLON TS","SUP-ITM-10120233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2231.12","78.45","","2085.51","998.68","6202.11","56","1422","2231.12","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","AETNA [1001]","HB CH AETNA HMO / PPO","1658.05","58.3","","1634.24","1004.95","1718.99","42","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2076.12","73","","2123.89","1900.92","2123.89","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1658.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1507.32","53","","939.37","939.37","5593.65","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2417.40","85","","2323.25","1864.50","2882.25","16","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2844.00","100","","2909.44","1772.40","10952.08","45","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2844.00","100","","2323.25","2323.25","2323.25","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2844.00","100","","2882.25","1772.40","10169.17","187","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2076.12","73","","1659.41","1659.41","1659.41","1 through 10","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","both","","","2844.00","2133.00","WELLPOINT [1015]","HB CH WELLPOINT","2215.76","77.91","","2050.91","1468.48","2902.83","52","1264.16","2844","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1686.49","59.3","","1548.60","1092.60","3613.79","82","1422","2231.12","percent of total billed charges",""
"EXTENDER STEM L 50MM OD KNEE PRIMARY STABILIZING Y IMPL TRIATHLON TS","SUP-ITM-10120234","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2844.00","2133.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2231.12","78.45","","2085.51","998.68","6202.11","56","1422","2231.12","percent of total billed charges",""
"Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","950","DRG","","","","","","","","inpatient","","","66239.83","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","26313.5656","","Fee schedule rate ($49,483.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26313.5656","21445.27","21445.27","1 through 10","18898.78","77759.63","case rate",""
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","982","MS-DRG","","","","","","","","inpatient","","","55534.99","41651.24","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","22975.81","","Case rate ($22,975.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,012.69, add-ons for qualifying new technology services are included. If operating cost exceeds $68,536.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,298.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $20,898.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,673.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,738.06. The transfer capital threshold is the transfer adjustment factor * $1,738.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","22140.63","22140.63","22140.63","1 through 10","22516.29","24211.2387","other","Inpatient Replacement Plans DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","981","MS-DRG","","","","","","","","inpatient","","","75250.22","56437.66","MEDICARE [2001]","HB BWF MEDICARE","47669.10","","Case rate ($47,669.10). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $43,609.24, add-ons for qualifying new technology services are included. If operating cost exceeds $89,132.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,877.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $44,012.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $43,270.00 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,316.91. The transfer capital threshold is the transfer adjustment factor * $3,316.91. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","47521.40","47521.40","47521.40","1 through 10","42668.06","48161.33","other","Inpatient DRG"
"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC","983","MS-DRG","","","","","","","","inpatient","","","28995.71","21746.78","MEDICARE [2001]","HB BWF MEDICARE","17629.69","","Case rate ($17,629.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,146.56, add-ons for qualifying new technology services are included. If operating cost exceeds $61,670.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,772.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $16,078.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,807.32 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,211.73. The transfer capital threshold is the transfer adjustment factor * $1,211.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16838.85","16838.85","16838.85","1 through 10","15798.41","17629.69","other","Inpatient DRG"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.86","48.86","48.86","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","AETNA [1001]","HB CH AETNA HMO / PPO","293.83","58.3","","277.83","277.83","277.83","1 through 10","44.28","414.21","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","45.86","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","MEDICARE [2001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","40","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.68","45.68","46.08","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","45.68","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.78","45.68","46.61","1 through 10","44.28","414.21","other","OPPS APC"
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","both","","","504.00","378.00","WELLPOINT [1015]","HB CH WELLPOINT","392.67","77.91","","385.92","385.92","385.92","1 through 10","44.28","414.21","percent of total billed charges",""
"External Ecg Rec>48hr<7d Recording","PX-73000029","CDM","93242","CPT","0731","RC","","","","outpatient","","","504.00","378.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","298.87","59.3","","287.14","287.14","287.14","1 through 10","55.54","897.29","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","48.01","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","48.16","47.96","48.86","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","AETNA [1001]","HB CH AETNA HMO / PPO","798.71","58.3","","755.24","755.24","755.24","1 through 10","44.28","1067.37","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","45.86","45.86","45.86","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","GENERIC COMMERCIAL [1009]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","12.63","12.63","12.63","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","MEDICARE [2001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.61","46.61","46.61","50","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","46.08","42.89","46.08","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","MOLINA [1014]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","92.47","92.47","92.47","1 through 10","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","45.68","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","45.86","45.68","46.61","18","44.28","1067.37","other","OPPS APC"
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","both","","","1370.00","1027.50","WELLPOINT [1015]","HB CH WELLPOINT","1067.37","77.91","","1049.08","263.01","1049.08","1 through 10","44.28","1067.37","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1370.00","1027.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","812.41","59.3","","780.55","761.90","780.55","1 through 10","91.36","1074.77","percent of total billed charges",""
"External Ecg Rec>7d<15d Recording","PX-73000033","CDM","93246","CPT","0731","RC","","","","outpatient","","","1370.00","1027.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1074.77","78.45","","1024.04","606.86","1024.04","1 through 10","91.36","1074.77","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","60","17.57","129.94","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.34","53","","458.45","458.45","458.45","1 through 10","17.57","129.94","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","both","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.12","44.45","","77.68","77.68","77.68","1 through 10","17.57","129.94","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","304.14","100","18.49","139.64","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","304.84","304.84","304.84","1 through 10","18.49","139.64","percent of total billed charges",""
"Extract Nuclear Antigen","PX-30000808","CDM","86235","CPT","0302","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","133.00","78.82","133.01","69","18.49","139.64","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","AETNA [1001]","HB CH AETNA HMO / PPO","579.27","58.3","","554.95","91.85","1421.75","94","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","725.33","73","","2490.03","2490.03","2490.03","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","579.27","58.3","","750.00","750.00","750.00","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","526.61","53","","1192.50","120.84","4149.90","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","844.56","85","","750.00","75.00","750.00","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","993.60","100","","657.00","121.50","1971.00","14","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","993.60","100","","75.00","75.00","75.00","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","993.60","100","","366.00","144.00","1971.00","45","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","725.33","73","","667.50","667.50","667.50","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","441.66","44.45","","123.77","123.77","123.77","1 through 10","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","both","","","993.60","745.20","WELLPOINT [1015]","HB CH WELLPOINT","774.11","77.91","","483.51","229.32","1316.08","96","441.66","993.6","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.60","745.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","589.20","59.3","","439.50","225.34","1872.27","197","496.8","779.48","percent of total billed charges",""
"EXTREMITY PLATE 30.5X71.4 13MM SM 3 HOLE BONE PERI TIMAX LOWER","SUP-ITM-10028846","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","993.60","745.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","779.48","78.45","","385.32","55.36","1815.62","58","496.8","779.48","percent of total billed charges",""
"Eye Infections And Other Eye Disorders,MINOR","082","DRG","","","","","","","","inpatient","","","8176.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13888.55","","Standard inlier is a Case rate ($13,888.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,912, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,971.42) for the length of stay and the standard reimbursement.","13257.25","13257.25","13257.25","1 through 10","2250","13888.55","case rate",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","both","","","2319.00","1739.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","2205.37","other","OPPS APC"
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2319.00","1739.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1137.93","49.07","","2115.00","2115.00","2115.00","1 through 10","567.68","1819.26","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2319.00","1739.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1161.82","50.1","","331.25","331.25","331.25","1 through 10","567.68","1819.26","percent of total billed charges",""
"Facet Cyst Aspiration/Rupture","PX-76002927","CDM","64999","CPT","0761","RC","","","","outpatient","","","2319.00","1739.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1819.26","78.45","","282.15","282.15","282.15","1 through 10","567.68","1819.26","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","both","","","256.00","192.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","135.68","731.58","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","125.62","49.07","","2115.00","2115.00","2115.00","1 through 10","113.79","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","128.26","50.1","","331.25","331.25","331.25","1 through 10","113.79","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Each Additional","PX-76002298","CDM","64999","CPT","0761","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.83","78.45","","282.15","282.15","282.15","1 through 10","113.79","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","both","","","295.00","221.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","156.35","731.58","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","295.00","221.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","144.76","49.07","","2115.00","2115.00","2115.00","1 through 10","131.13","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","295.00","221.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","147.80","50.1","","331.25","331.25","331.25","1 through 10","131.13","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Each Additional","PX-76002296","CDM","64999","CPT","0761","RC","","","","outpatient","","","295.00","221.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.43","78.45","","282.15","282.15","282.15","1 through 10","131.13","567.68","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","both","","","995.00","746.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","946.25","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","995.00","746.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","488.25","49.07","","2115.00","2115.00","2115.00","1 through 10","442.28","780.58","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","995.00","746.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","498.50","50.1","","331.25","331.25","331.25","1 through 10","442.28","780.58","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Cervical or Thoracic; Single","PX-76002295","CDM","64999","CPT","0761","RC","","","","outpatient","","","995.00","746.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","780.58","78.45","","282.15","282.15","282.15","1 through 10","442.28","780.58","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","both","","","977.00","732.75","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","929.13","other","OPPS APC"
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","977.00","732.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","479.41","49.07","","2115.00","2115.00","2115.00","1 through 10","434.28","766.46","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","977.00","732.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","489.48","50.1","","331.25","331.25","331.25","1 through 10","434.28","766.46","percent of total billed charges",""
"Facet Denervation  <80 Degrees Celcius: Lumbar or Sacral; Single","PX-76002297","CDM","64999","CPT","0761","RC","","","","outpatient","","","977.00","732.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","766.46","78.45","","282.15","282.15","282.15","1 through 10","434.28","766.46","percent of total billed charges",""
"Factor Inhibitor","PX-30001078","CDM","85335","CPT","0305","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.81","78.81","78.81","1 through 10","12.61","104.39","percent of total billed charges",""
"Factor Inhibitor","PX-30001078","CDM","85335","CPT","0305","RC","","","","both","","","143.00","107.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.79","53","","73.67","73.67","73.67","1 through 10","12.61","104.39","percent of total billed charges",""
"Factor Inhibitor","PX-30001078","CDM","85335","CPT","0305","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.45","81.45","287.72","13","13.27","112.18","percent of total billed charges",""
"Factor Inhibitor","PX-30001078","CDM","85335","CPT","0305","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.86","106.86","106.86","1 through 10","13.27","112.18","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","both","","","219.00","164.25","AETNA [1001]","HB CH AETNA HMO / PPO","127.68","58.3","","120.77","120.77","120.77","1 through 10","18.66","159.87","percent of total billed charges",""
"Factor IX (Christmas/Ptc)","PX-30001063","CDM","85250","CPT","0305","RC","","","","outpatient","","","219.00","164.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.87","59.3","","124.82","124.82","336.95","1 through 10","19.63","171.81","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","84.48","84.48","84.48","1 through 10","17.54","111.69","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.09","53","","78.97","78.97","157.94","1 through 10","17.54","111.69","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.32","11","18.47","120.03","percent of total billed charges",""
"Factor VIII Ahg","PX-30001055","CDM","85240","CPT","0305","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","114.55","109.95","114.55","1 through 10","18.47","120.03","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","188.00","141.00","AETNA [1001]","HB CH AETNA HMO / PPO","109.60","58.3","","103.76","103.75","103.76","1 through 10","22.48","137.24","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","both","","","188.00","141.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","99.64","53","","96.99","96.99","96.99","1 through 10","22.48","137.24","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","188.00","141.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","111.48","59.3","","107.24","107.24","107.24","1 through 10","23.65","147.49","percent of total billed charges",""
"Factor VIII Vw Antigen","PX-30001059","CDM","85246","CPT","0305","RC","","","","outpatient","","","188.00","141.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","147.49","78.45","","140.69","140.69","140.69","1 through 10","23.65","147.49","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","189.00","141.75","AETNA [1001]","HB CH AETNA HMO / PPO","110.19","58.3","","104.33","104.33","104.33","1 through 10","22.48","137.97","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","both","","","189.00","141.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","100.17","53","","97.52","97.52","97.52","1 through 10","22.48","137.97","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","189.00","141.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","112.08","59.3","","107.82","107.82","107.82","1 through 10","23.65","148.27","percent of total billed charges",""
"Factor VIII Vw Ristocetin Cofactor","PX-30001058","CDM","85245","CPT","0305","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","148.27","78.45","","141.46","141.46","141.46","1 through 10","23.65","148.27","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","both","","","157.00","117.75","AETNA [1001]","HB CH AETNA HMO / PPO","91.53","58.3","","86.75","86.75","86.75","1 through 10","17.54","114.61","percent of total billed charges",""
"Factor XI (Pta)","PX-30001065","CDM","85270","CPT","0305","RC","","","","outpatient","","","157.00","117.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.10","59.3","","89.66","89.66","89.66","1 through 10","18.47","123.17","percent of total billed charges",""
"Factor XII (Hageman)","PX-30001066","CDM","85280","CPT","0305","RC","","","","outpatient","","","221.00","165.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.05","59.3","","125.99","125.99","125.99","1 through 10","19.95","173.37","percent of total billed charges",""
"Factor XII Snp Analysis Factor 12 Snp Gene Sequencing Fxiis Njc Fxiisa","PX-31001310","CDM","81403","CPT","0310","RC","","","","outpatient","","","1294.00","970.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1015.14","78.45","","562.39","562.39","562.39","1 through 10","456.38","1015.14","percent of total billed charges",""
"Factor XIII (Fibrin Stablizing)","PX-30001067","CDM","85290","CPT","0305","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","133.46","133.46","133.46","1 through 10","16.85","145.92","percent of total billed charges",""
"Fat/Lipids Feces Qn","PX-30000431","CDM","82710","CPT","0301","RC","","","","both","","","140.00","105.00","AETNA [1001]","HB CH AETNA HMO / PPO","81.62","58.3","","77.11","77.11","77.11","1 through 10","16.46","102.2","percent of total billed charges",""
"Female Reproductive System Infections,MAJOR","531","DRG","","","","","","","","inpatient","","","25459.59","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25299.07","","Standard inlier is a Case rate ($25,299.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,810, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,591.10) for the length of stay and the standard reimbursement.","25299.07","25299.07","25299.07","1 through 10","5761.55","36413.15","case rate",""
"Female Reproductive System Infections,MAJOR","531","DRG","","","","","","","","inpatient","","","25459.59","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8340.41","","Case rate ($9,221.76). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,651.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9219.50","9219.50","9219.50","1 through 10","5761.55","36413.15","case rate",""
"Female Reproductive System Infections,MODERATE","531","DRG","","","","","","","","inpatient","","","8767.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5761.55","","Fee schedule rate ($5,761.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5761.55","5761.55","5761.55","1 through 10","5761.55","36413.15","case rate",""
"Female Reproductive System Infections,MODERATE","531","DRG","","","","","","","","inpatient","","","8767.77","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6131.08","","Case rate ($6,778.96). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,208.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6777.30","6777.30","6777.30","1 through 10","5761.55","36413.15","case rate",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","AETNA [1001]","HB CH AETNA HMO / PPO","1985.12","58.3","","1634.24","1004.95","1718.99","42","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2485.65","73","","2123.89","1900.92","2123.89","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1985.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1804.65","53","","939.37","939.37","5593.65","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2894.25","85","","2323.25","1864.50","2882.25","16","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3405.00","100","","2909.44","1772.40","10952.08","45","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3405.00","100","","2323.25","2323.25","2323.25","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3405.00","100","","2882.25","1772.40","10169.17","187","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2485.65","73","","1659.41","1659.41","1659.41","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","WELLPOINT [1015]","HB CH WELLPOINT","2652.84","77.91","","2050.91","1468.48","2902.83","52","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2019.17","59.3","","1548.60","1092.60","3613.79","82","1702.5","2671.22","percent of total billed charges",""
"FEMORAL COMPONENT ITOTAL IDENTITY PS","SUP-ITM-10281670","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2671.22","78.45","","2085.51","998.68","6202.11","56","1702.5","2671.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1634.24","1004.95","1718.99","42","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","2123.89","1900.92","2123.89","1 through 10","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2635.16","58.3","","3729.00","1254.19","3729.00","1 through 10","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","939.37","939.37","5593.65","1 through 10","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3842.00","85","","2323.25","1864.50","2882.25","16","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4520.00","100","","2909.44","1772.40","10952.08","45","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4520.00","100","","2323.25","2323.25","2323.25","1 through 10","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4520.00","100","","2882.25","1772.40","10169.17","187","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","1659.41","1659.41","1659.41","1 through 10","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","2050.91","1468.48","2902.83","52","2009.14","4520","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1548.60","1092.60","3613.79","82","2260","3545.94","percent of total billed charges",""
"FEMORAL COMPONENT SZ 2 SIGMA TC3 REVISION NONPOROUS LT","SUP-ITM-10004857","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","2085.51","998.68","6202.11","56","2260","3545.94","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","AETNA [1001]","HB CH AETNA HMO / PPO","1985.12","58.3","","1634.24","1004.95","1718.99","42","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2485.65","73","","2123.89","1900.92","2123.89","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1985.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1804.65","53","","939.37","939.37","5593.65","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2894.25","85","","2323.25","1864.50","2882.25","16","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3405.00","100","","2909.44","1772.40","10952.08","45","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3405.00","100","","2323.25","2323.25","2323.25","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3405.00","100","","2882.25","1772.40","10169.17","187","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2485.65","73","","1659.41","1659.41","1659.41","1 through 10","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","both","","","3405.00","2553.75","WELLPOINT [1015]","HB CH WELLPOINT","2652.84","77.91","","2050.91","1468.48","2902.83","52","1513.52","3405","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2019.17","59.3","","1548.60","1092.60","3613.79","82","1702.5","2671.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 3 IDENTITY IMPRINT CR","SUP-ITM-10283849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3405.00","2553.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2671.22","78.45","","2085.51","998.68","6202.11","56","1702.5","2671.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1634.24","1004.95","1718.99","42","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","2123.89","1900.92","2123.89","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2142.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","939.37","939.37","5593.65","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3123.75","85","","2323.25","1864.50","2882.25","16","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3675.00","100","","2909.44","1772.40","10952.08","45","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3675.00","100","","2323.25","2323.25","2323.25","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3675.00","100","","2882.25","1772.40","10169.17","187","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","1659.41","1659.41","1659.41","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","2050.91","1468.48","2902.83","52","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1548.60","1092.60","3613.79","82","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 PERSONA CR CEMENTED TIV STANDARD RT","SUP-ITM-10307175","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","2085.51","998.68","6202.11","56","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1634.24","1004.95","1718.99","42","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2123.89","1900.92","2123.89","1 through 10","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","939.37","939.37","5593.65","1 through 10","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","2323.25","1864.50","2882.25","16","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","2909.44","1772.40","10952.08","45","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","2323.25","2323.25","2323.25","1 through 10","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","2882.25","1772.40","10169.17","187","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","1659.41","1659.41","1659.41","1 through 10","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","2050.91","1468.48","2902.83","52","1466.85","3300","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1548.60","1092.60","3613.79","82","1650","2588.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4 SIGMA COBALT CRUCIATE RETAINING CEMENTED LT NARROW","SUP-ITM-10025851","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","2085.51","998.68","6202.11","56","1650","2588.85","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","AETNA [1001]","HB CH AETNA HMO / PPO","1191.07","58.3","","1634.24","1004.95","1718.99","42","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1491.39","73","","2123.89","1900.92","2123.89","1 through 10","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1191.07","58.3","","3729.00","1254.19","3729.00","1 through 10","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1082.79","53","","939.37","939.37","5593.65","1 through 10","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1736.55","85","","2323.25","1864.50","2882.25","16","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2043.00","100","","2909.44","1772.40","10952.08","45","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2043.00","100","","2323.25","2323.25","2323.25","1 through 10","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2043.00","100","","2882.25","1772.40","10169.17","187","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1491.39","73","","1659.41","1659.41","1659.41","1 through 10","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","both","","","2043.00","1532.25","WELLPOINT [1015]","HB CH WELLPOINT","1591.70","77.91","","2050.91","1468.48","2902.83","52","908.11","2043","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2043.00","1532.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1211.50","59.3","","1548.60","1092.60","3613.79","82","1021.5","1602.73","percent of total billed charges",""
"FEMORAL COMPONENT SZ 4N 10MM CR INSERT IDENTITY IMPRINT","SUP-ITM-10283793","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2043.00","1532.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1602.73","78.45","","2085.51","998.68","6202.11","56","1021.5","1602.73","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1634.24","1004.95","1718.99","42","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","2123.89","1900.92","2123.89","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2895.47","58.3","","3729.00","1254.19","3729.00","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","939.37","939.37","5593.65","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4221.53","85","","2323.25","1864.50","2882.25","16","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4966.50","100","","2909.44","1772.40","10952.08","45","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4966.50","100","","2323.25","2323.25","2323.25","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4966.50","100","","2882.25","1772.40","10169.17","187","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","1659.41","1659.41","1659.41","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","2050.91","1468.48","2902.83","52","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1548.60","1092.60","3613.79","82","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 CR PPS CCR STANDARD PERSONA LT","SUP-ITM-10307925","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","2085.51","998.68","6202.11","56","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 LM/RL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 6 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281545","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1634.24","1004.95","1718.99","42","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","2123.89","1900.92","2123.89","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2895.47","58.3","","3729.00","1254.19","3729.00","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","939.37","939.37","5593.65","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4221.53","85","","2323.25","1864.50","2882.25","16","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4966.50","100","","2909.44","1772.40","10952.08","45","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4966.50","100","","2323.25","2323.25","2323.25","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4966.50","100","","2882.25","1772.40","10169.17","187","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","1659.41","1659.41","1659.41","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","2050.91","1468.48","2902.83","52","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1548.60","1092.60","3613.79","82","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 CR PPS CCR NARROW PERSONA LT","SUP-ITM-10307909","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","2085.51","998.68","6202.11","56","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","AETNA [1001]","HB CH AETNA HMO / PPO","2136.70","58.3","","1634.24","1004.95","1718.99","42","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2675.45","73","","2123.89","1900.92","2123.89","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2136.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1942.45","53","","939.37","939.37","5593.65","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3115.25","85","","2323.25","1864.50","2882.25","16","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3665.00","100","","2909.44","1772.40","10952.08","45","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3665.00","100","","2323.25","2323.25","2323.25","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3665.00","100","","2882.25","1772.40","10169.17","187","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2675.45","73","","1659.41","1659.41","1659.41","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","WELLPOINT [1015]","HB CH WELLPOINT","2855.40","77.91","","2050.91","1468.48","2902.83","52","1629.09","3665","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1548.60","1092.60","3613.79","82","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 LT ATTUNE POROUS CRUCIATE RETAINING CEMENTLESS","SUP-ITM-10276368","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2875.19","78.45","","2085.51","998.68","6202.11","56","1832.5","2875.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 7 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281544","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1634.24","1004.95","1718.99","42","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","2123.89","1900.92","2123.89","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2895.47","58.3","","3729.00","1254.19","3729.00","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","939.37","939.37","5593.65","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4221.53","85","","2323.25","1864.50","2882.25","16","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4966.50","100","","2909.44","1772.40","10952.08","45","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4966.50","100","","2323.25","2323.25","2323.25","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4966.50","100","","2882.25","1772.40","10169.17","187","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","1659.41","1659.41","1659.41","1 through 10","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","2050.91","1468.48","2902.83","52","2207.61","4966.5","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1548.60","1092.60","3613.79","82","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 CR PPS CCR STANDARD PERSONA RT","SUP-ITM-10307930","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","2085.51","998.68","6202.11","56","2483.25","3896.22","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8 RM/LL KNEE JOURNEY II UNI OXINUM","SUP-ITM-10281543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1634.24","1004.95","1718.99","42","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","2123.89","1900.92","2123.89","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2142.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","939.37","939.37","5593.65","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3123.75","85","","2323.25","1864.50","2882.25","16","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3675.00","100","","2909.44","1772.40","10952.08","45","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3675.00","100","","2323.25","2323.25","2323.25","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3675.00","100","","2882.25","1772.40","10169.17","187","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","1659.41","1659.41","1659.41","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","2050.91","1468.48","2902.83","52","1633.54","3675","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1548.60","1092.60","3613.79","82","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ 8L PSN CRUCIATING CEMENTED TIV STD","SUP-ITM-10287955","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","2085.51","998.68","6202.11","56","1837.5","2883.04","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","AETNA [1001]","HB CH AETNA HMO / PPO","2477.75","58.3","","1634.24","1004.95","1718.99","42","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3102.50","73","","2123.89","1900.92","2123.89","1 through 10","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2477.75","58.3","","3729.00","1254.19","3729.00","1 through 10","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2252.50","53","","939.37","939.37","5593.65","1 through 10","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3612.50","85","","2323.25","1864.50","2882.25","16","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4250.00","100","","2909.44","1772.40","10952.08","45","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4250.00","100","","2323.25","2323.25","2323.25","1 through 10","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4250.00","100","","2882.25","1772.40","10169.17","187","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3102.50","73","","1659.41","1659.41","1659.41","1 through 10","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","both","","","4250.00","3187.50","WELLPOINT [1015]","HB CH WELLPOINT","3311.18","77.91","","2050.91","1468.48","2902.83","52","1889.13","4250","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4250.00","3187.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2520.25","59.3","","1548.60","1092.60","3613.79","82","2125","3334.13","percent of total billed charges",""
"FEMORAL COMPONENT SZ5 LEFT PRESS FIT EMPOWR 3D","SUP-ITM-10312096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4250.00","3187.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3334.13","78.45","","2085.51","998.68","6202.11","56","2125","3334.13","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","AETNA [1001]","HB CH AETNA HMO / PPO","2382.04","58.3","","1634.24","1004.95","1718.99","42","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2982.66","73","","2123.89","1900.92","2123.89","1 through 10","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2382.04","58.3","","3729.00","1254.19","3729.00","1 through 10","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2165.49","53","","939.37","939.37","5593.65","1 through 10","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3472.96","85","","2323.25","1864.50","2882.25","16","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4085.83","100","","2909.44","1772.40","10952.08","45","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4085.83","100","","2323.25","2323.25","2323.25","1 through 10","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4085.83","100","","2882.25","1772.40","10169.17","187","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2982.66","73","","1659.41","1659.41","1659.41","1 through 10","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","both","","","4085.83","3064.37","WELLPOINT [1015]","HB CH WELLPOINT","3183.27","77.91","","2050.91","1468.48","2902.83","52","1816.15","4085.83","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4085.83","3064.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2422.90","59.3","","1548.60","1092.60","3613.79","82","2042.92","3205.33","percent of total billed charges",""
"FEMORAL HEAD 32MM PLUS 3MM 12/14 TAPER HIP FREEDOM CONSTRAINED COBALT","SUP-ITM-10275359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4085.83","3064.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3205.33","78.45","","2085.51","998.68","6202.11","56","2042.92","3205.33","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","AETNA [1001]","HB CH AETNA HMO / PPO","949.71","58.3","","1634.24","1004.95","1718.99","42","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1189.17","73","","2123.89","1900.92","2123.89","1 through 10","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","949.71","58.3","","3729.00","1254.19","3729.00","1 through 10","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","863.37","53","","939.37","939.37","5593.65","1 through 10","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1384.65","85","","2323.25","1864.50","2882.25","16","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1629.00","100","","2909.44","1772.40","10952.08","45","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1629.00","100","","2323.25","2323.25","2323.25","1 through 10","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1629.00","100","","2882.25","1772.40","10169.17","187","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1189.17","73","","1659.41","1659.41","1659.41","1 through 10","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","both","","","1629.00","1221.75","WELLPOINT [1015]","HB CH WELLPOINT","1269.15","77.91","","2050.91","1468.48","2902.83","52","724.09","1629","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1629.00","1221.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","966.00","59.3","","1548.60","1092.60","3613.79","82","814.5","1277.95","percent of total billed charges",""
"FEMORAL HEAD 32MM ROM CERAMIC","SUP-ITM-10010089","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1629.00","1221.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1277.95","78.45","","2085.51","998.68","6202.11","56","814.5","1277.95","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","AETNA [1001]","HB CH AETNA HMO / PPO","1780.48","58.3","","1634.24","1004.95","1718.99","42","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2229.42","73","","2123.89","1900.92","2123.89","1 through 10","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1780.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1618.62","53","","939.37","939.37","5593.65","1 through 10","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2595.90","85","","2323.25","1864.50","2882.25","16","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3054.00","100","","2909.44","1772.40","10952.08","45","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3054.00","100","","2323.25","2323.25","2323.25","1 through 10","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3054.00","100","","2882.25","1772.40","10169.17","187","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2229.42","73","","1659.41","1659.41","1659.41","1 through 10","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","WELLPOINT [1015]","HB CH WELLPOINT","2379.37","77.91","","2050.91","1468.48","2902.83","52","1357.5","3054","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1811.02","59.3","","1548.60","1092.60","3613.79","82","1527","2395.86","percent of total billed charges",""
"FEMORAL HEAD 36MM 1.5 ARTICULEZE BIOLOX DELTA TS CERAMIC REVISION 12/14 TAPERED","SUP-ITM-10087701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2395.86","78.45","","2085.51","998.68","6202.11","56","1527","2395.86","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 25MM COMPONENT LPS TI ALLOY SEGMENTAL MODIFIED","SUP-ITM-10015439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 35MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10100981","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 65MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10018164","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT 85MM COMPONENT TI ALLOY LPS SEGMENTAL MODIFIED","SUP-ITM-10016737","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED RIGHT","SUP-ITM-10020121","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 3 COMPONENT LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR LEFT 71421233","SUP-ITM-10024449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"FEMORAL IMPLANT SIZE 7 COMPONENT GENESIS II SPC CR POR LEFT","SUP-ITM-10199352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","AETNA [1001]","HB CH AETNA HMO / PPO","2136.70","58.3","","1634.24","1004.95","1718.99","42","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2675.45","73","","2123.89","1900.92","2123.89","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2136.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1942.45","53","","939.37","939.37","5593.65","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3115.25","85","","2323.25","1864.50","2882.25","16","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3665.00","100","","2909.44","1772.40","10952.08","45","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3665.00","100","","2323.25","2323.25","2323.25","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3665.00","100","","2882.25","1772.40","10169.17","187","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2675.45","73","","1659.41","1659.41","1659.41","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","WELLPOINT [1015]","HB CH WELLPOINT","2855.40","77.91","","2050.91","1468.48","2902.83","52","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1548.60","1092.60","3613.79","82","1832.5","2875.19","percent of total billed charges",""
"FEMORAL IMPLANT SZ 3 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL RT MEDIAL LT LATERAL","SUP-ITM-10030267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2875.19","78.45","","2085.51","998.68","6202.11","56","1832.5","2875.19","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","AETNA [1001]","HB CH AETNA HMO / PPO","2136.70","58.3","","1634.24","1004.95","1718.99","42","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2675.45","73","","2123.89","1900.92","2123.89","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2136.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1942.45","53","","939.37","939.37","5593.65","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3115.25","85","","2323.25","1864.50","2882.25","16","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3665.00","100","","2909.44","1772.40","10952.08","45","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3665.00","100","","2323.25","2323.25","2323.25","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3665.00","100","","2882.25","1772.40","10169.17","187","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2675.45","73","","1659.41","1659.41","1659.41","1 through 10","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","both","","","3665.00","2748.75","WELLPOINT [1015]","HB CH WELLPOINT","2855.40","77.91","","2050.91","1468.48","2902.83","52","1629.09","3665","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2173.35","59.3","","1548.60","1092.60","3613.79","82","1832.5","2875.19","percent of total billed charges",""
"FEMORAL IMPLANT SZ 5 COMPONENT SIGMA UNICONDYLAR CEMENTED PARTIAL LT MEDIAL RT LATERAL","SUP-ITM-10118555","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3665.00","2748.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2875.19","78.45","","2085.51","998.68","6202.11","56","1832.5","2875.19","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1634.24","1004.95","1718.99","42","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","2123.89","1900.92","2123.89","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2142.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","939.37","939.37","5593.65","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3123.75","85","","2323.25","1864.50","2882.25","16","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3675.00","100","","2909.44","1772.40","10952.08","45","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3675.00","100","","2323.25","2323.25","2323.25","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3675.00","100","","2882.25","1772.40","10169.17","187","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","1659.41","1659.41","1659.41","1 through 10","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","2050.91","1468.48","2902.83","52","1633.54","3675","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1548.60","1092.60","3613.79","82","1837.5","2883.04","percent of total billed charges",""
"FEMORAL IMPLANT XLARGE COMPONENT OXFORD POSTERIOR TWIN PEGGED CEMENTED","SUP-ITM-10122141","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","2085.51","998.68","6202.11","56","1837.5","2883.04","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","AETNA [1001]","HB CH AETNA HMO / PPO","7299.16","58.3","","1634.24","1004.95","1718.99","42","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9139.60","73","","2123.89","1900.92","2123.89","1 through 10","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7299.16","58.3","","3729.00","1254.19","3729.00","1 through 10","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6635.60","53","","939.37","939.37","5593.65","1 through 10","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10642.00","85","","2323.25","1864.50","2882.25","16","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12520.00","100","","2909.44","1772.40","10952.08","45","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12520.00","100","","2323.25","2323.25","2323.25","1 through 10","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12520.00","100","","2882.25","1772.40","10169.17","187","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9139.60","73","","1659.41","1659.41","1659.41","1 through 10","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","WELLPOINT [1015]","HB CH WELLPOINT","9754.33","77.91","","2050.91","1468.48","2902.83","52","5565.14","12520","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12520.00","9390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7424.36","59.3","","1548.60","1092.60","3613.79","82","6260","9821.94","percent of total billed charges",""
"FEMORAL IMPLANT XSM COMPONEMT LPS COBALT ALLOY DISTAL RT","SUP-ITM-10018014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12520.00","9390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9821.94","78.45","","2085.51","998.68","6202.11","56","6260","9821.94","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"FEMORAL RESTORIS MULTICOMPARTMENTAL KNEE LEFT MEDIAL/RIGHT LATERAL SIZE 1","SUP-ITM-10236325","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"FEMORAL RESTORIS SIZE 8 MULTICOMPARTMENTAL KNEE RIGHT MEDIAL/LEFT LATERAL","SUP-ITM-10236307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","AETNA [1001]","HB CH AETNA HMO / PPO","4664.00","58.3","","1634.24","1004.95","1718.99","42","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","2123.89","1900.92","2123.89","1 through 10","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4664.00","58.3","","3729.00","1254.19","3729.00","1 through 10","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4240.00","53","","939.37","939.37","5593.65","1 through 10","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6800.00","85","","2323.25","1864.50","2882.25","16","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8000.00","100","","2909.44","1772.40","10952.08","45","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8000.00","100","","2323.25","2323.25","2323.25","1 through 10","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8000.00","100","","2882.25","1772.40","10169.17","187","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","1659.41","1659.41","1659.41","1 through 10","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","WELLPOINT [1015]","HB CH WELLPOINT","6232.80","77.91","","2050.91","1468.48","2902.83","52","3556","8000","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4744.00","59.3","","1548.60","1092.60","3613.79","82","4000","6276","percent of total billed charges",""
"FEMORAL SPACER PATELLO 7X5MM KNEE COMPONENT RESURFACING HEMICAP TROCHLEAR ARTICULAR OFFSET","SUP-ITM-10074807","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","2085.51","998.68","6202.11","56","4000","6276","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"FEMORAL SPHERE SZ 2 CEMENTED LT","SUP-ITM-10300184","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"FEMORAL STEM 127X15MM KNEE DISTAL MODULAR REPLACEMENT SY CEMENTED CURVED MINUS BODY","SUP-ITM-10030843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","AETNA [1001]","HB CH AETNA HMO / PPO","6257.92","58.3","","1634.24","1004.95","1718.99","42","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7835.82","73","","2123.89","1900.92","2123.89","1 through 10","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6257.92","58.3","","3729.00","1254.19","3729.00","1 through 10","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5689.02","53","","939.37","939.37","5593.65","1 through 10","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9123.90","85","","2323.25","1864.50","2882.25","16","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10734.00","100","","2909.44","1772.40","10952.08","45","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","10734.00","100","","2323.25","2323.25","2323.25","1 through 10","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10734.00","100","","2882.25","1772.40","10169.17","187","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7835.82","73","","1659.41","1659.41","1659.41","1 through 10","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","both","","","10734.00","8050.50","WELLPOINT [1015]","HB CH WELLPOINT","8362.86","77.91","","2050.91","1468.48","2902.83","52","4771.26","10734","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10734.00","8050.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","6365.26","59.3","","1548.60","1092.60","3613.79","82","5367","8420.82","percent of total billed charges",""
"FEMORAL STEM 200MM SZ 2S1 AMIS-K LONG","SUP-ITM-10298674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10734.00","8050.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8420.82","78.45","","2085.51","998.68","6202.11","56","5367","8420.82","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"FEMORAL STEM SZ 3 HIP SUMMIT COBALT CHROME 12/14 TAPERED STANDARD OFFSET CEMENTED","SUP-ITM-10012778","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","554.95","91.85","1421.75","94","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","2490.03","2490.03","2490.03","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","750.00","750.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","1192.50","120.84","4149.90","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1861.50","85","","750.00","75.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2190.00","100","","657.00","121.50","1971.00","14","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2190.00","100","","75.00","75.00","75.00","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2190.00","100","","366.00","144.00","1971.00","45","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","667.50","667.50","667.50","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","123.77","123.77","123.77","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","483.51","229.32","1316.08","96","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","439.50","225.34","1872.27","197","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 5.0MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010924","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","385.32","55.36","1815.62","58","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","554.95","91.85","1421.75","94","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","2490.03","2490.03","2490.03","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","750.00","750.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","1192.50","120.84","4149.90","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1861.50","85","","750.00","75.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2190.00","100","","657.00","121.50","1971.00","14","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2190.00","100","","75.00","75.00","75.00","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2190.00","100","","366.00","144.00","1971.00","45","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","667.50","667.50","667.50","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","123.77","123.77","123.77","1 through 10","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","483.51","229.32","1316.08","96","973.46","2190","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","439.50","225.34","1872.27","197","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 7.5MM BONE FEMORAL OSTEOTOMY OPENING WEDGE","SUP-ITM-10010925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","385.32","55.36","1815.62","58","1095","1718.06","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","554.95","91.85","1421.75","94","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","2490.03","2490.03","2490.03","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1565.36","58.3","","750.00","750.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","1192.50","120.84","4149.90","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2282.25","85","","750.00","75.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2685.00","100","","657.00","121.50","1971.00","14","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2685.00","100","","75.00","75.00","75.00","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2685.00","100","","366.00","144.00","1971.00","45","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","667.50","667.50","667.50","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","123.77","123.77","123.77","1 through 10","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","483.51","229.32","1316.08","96","1193.48","2685","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","439.50","225.34","1872.27","197","1342.5","2106.38","percent of total billed charges",""
"FEMUR PLATE 9MM TITANIUM","SUP-ITM-10041729","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","385.32","55.36","1815.62","58","1342.5","2106.38","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","AETNA [1001]","HB CH AETNA HMO / PPO","4562.56","58.3","","1634.24","1004.95","1718.99","42","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","2123.89","1900.92","2123.89","1 through 10","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4562.56","58.3","","3729.00","1254.19","3729.00","1 through 10","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4147.78","53","","939.37","939.37","5593.65","1 through 10","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6652.10","85","","2323.25","1864.50","2882.25","16","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7826.00","100","","2909.44","1772.40","10952.08","45","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7826.00","100","","2323.25","2323.25","2323.25","1 through 10","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7826.00","100","","2882.25","1772.40","10169.17","187","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","1659.41","1659.41","1659.41","1 through 10","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","WELLPOINT [1015]","HB CH WELLPOINT","6097.24","77.91","","2050.91","1468.48","2902.83","52","3478.66","7826","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1548.60","1092.60","3613.79","82","3913","6139.5","percent of total billed charges",""
"FEMUR POST 15DEG FEMORAL HIP GMRS COMPONENT PROXIMALIMAL ANTEVERTED STANDARD LEFT","SUP-ITM-10035508","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6139.50","78.45","","2085.51","998.68","6202.11","56","3913","6139.5","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","AETNA [1001]","HB CH AETNA HMO / PPO","90.95","58.3","","86.18","86.18","86.18","95","13.36","113.88","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.68","53","","80.56","80.56","80.56","1 through 10","13.36","113.88","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","both","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.34","44.45","","116.87","116.86","116.87","1 through 10","13.36","113.88","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.51","59.3","","89.07","89.07","89.07","112","14.05","122.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","92.51","59.3","","89.07","89.07","89.07","1 through 10","14.05","122.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","122.38","78.45","","112.23","112.23","112.23","1 through 10","14.05","122.38","percent of total billed charges",""
"Ferritin","PX-30000435","CDM","82728","CPT","0301","RC","","","","outpatient","","","156.00","117.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.38","78.45","","116.86","69.25","116.86","100","14.05","122.38","percent of total billed charges",""
"Fever And Inflammatory Conditions","864","MS-DRG","","","","","","","","inpatient","","","18765.48","14074.11","MEDICARE [2001]","HB BWF MEDICARE","8512.71","","Case rate ($8,512.71). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,526.03, add-ons for qualifying new technology services are included. If operating cost exceeds $54,049.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,188.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,545.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,186.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $627.57. The transfer capital threshold is the transfer adjustment factor * $627.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9180.39","9180.39","9180.39","1 through 10","8342.46","9112.24","other","Inpatient Replacement Plans DRG"
"Fever And Inflammatory Conditions,EXTREME","722","DRG","","","","","","","","inpatient","","","71928.20","","MASSHEALTH [3001]","HB BWF MEDICAID","14639.42","","Case rate ($16,186.40). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,616.40, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","22832.18","22832.18","1 through 10","5633.01","34956.3","case rate",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","554.95","91.85","1421.75","94","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2490.03","2490.03","2490.03","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","750.00","750.00","750.00","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","1192.50","120.84","4149.90","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","750.00","75.00","750.00","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","657.00","121.50","1971.00","14","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","75.00","75.00","75.00","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","366.00","144.00","1971.00","45","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","667.50","667.50","667.50","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.43","44.45","","123.77","123.77","123.77","1 through 10","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","483.51","229.32","1316.08","96","733.43","1650","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","439.50","225.34","1872.27","197","825","1294.43","percent of total billed charges",""
"FIBERSTITCH 1.524 DEGREE CURVED","SUP-ITM-10320770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","385.32","55.36","1815.62","58","825","1294.43","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0300","RC","","","","inpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.01","70.6","","89.18","89.18","89.18","1 through 10","66.64","84.01","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","1 through 10","9.98","86.87","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","both","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.90","44.45","","89.18","89.18","89.18","1 through 10","9.98","86.87","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","67.98","67.98","116.00","1 through 10","10.5","93.36","percent of total billed charges",""
"Fibrin Degradation D-Dimer Qn","PX-30001088","CDM","85379","CPT","0305","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","89.18","33.55","89.18","1 through 10","10.5","93.36","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","73.00","54.75","AETNA [1001]","HB CH AETNA HMO / PPO","42.56","58.3","","40.26","40.26","40.26","1 through 10","9.53","53.29","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","both","","","73.00","54.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","38.69","53","","37.63","37.63","37.63","1 through 10","9.53","53.29","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","73.00","54.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.29","59.3","","41.61","41.61","41.61","1 through 10","8.76","57.27","percent of total billed charges",""
"Fibrinogen Activity","PX-30001090","CDM","85384","CPT","0305","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.27","78.45","","54.58","32.35","60.66","1 through 10","8.76","57.27","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","AETNA [1001]","HB CH AETNA HMO / PPO","1786.34","58.3","","1634.24","1004.95","1718.99","42","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2236.76","73","","2123.89","1900.92","2123.89","1 through 10","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1786.34","58.3","","3729.00","1254.19","3729.00","1 through 10","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1623.95","53","","939.37","939.37","5593.65","1 through 10","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2604.44","85","","2323.25","1864.50","2882.25","16","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3064.05","100","","2909.44","1772.40","10952.08","45","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3064.05","100","","2323.25","2323.25","2323.25","1 through 10","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3064.05","100","","2882.25","1772.40","10169.17","187","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2236.76","73","","1659.41","1659.41","1659.41","1 through 10","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","both","","","3064.05","2298.04","WELLPOINT [1015]","HB CH WELLPOINT","2387.20","77.91","","2050.91","1468.48","2902.83","52","1361.97","3064.05","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1816.98","59.3","","1548.60","1092.60","3613.79","82","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 101X3.5MM 5 HOLE VARIA TITANIUM LOCKING LOW PROFILE","SUP-ITM-10114311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3064.05","2298.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2403.75","78.45","","2085.51","998.68","6202.11","56","1532.03","2403.75","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","AETNA [1001]","HB CH AETNA HMO / PPO","1268.03","58.3","","554.95","91.85","1421.75","94","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1587.75","73","","2490.03","2490.03","2490.03","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1268.03","58.3","","750.00","750.00","750.00","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1152.75","53","","1192.50","120.84","4149.90","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1848.75","85","","750.00","75.00","750.00","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2175.00","100","","657.00","121.50","1971.00","14","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2175.00","100","","75.00","75.00","75.00","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2175.00","100","","366.00","144.00","1971.00","45","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1587.75","73","","667.50","667.50","667.50","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","966.79","44.45","","123.77","123.77","123.77","1 through 10","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","both","","","2175.00","1631.25","WELLPOINT [1015]","HB CH WELLPOINT","1694.54","77.91","","483.51","229.32","1316.08","96","966.79","2175","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.00","1631.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1289.78","59.3","","439.50","225.34","1872.27","197","1087.5","1706.29","percent of total billed charges",""
"FIBULA PLATE 104MM 6 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076949","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2175.00","1631.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1706.29","78.45","","385.32","55.36","1815.62","58","1087.5","1706.29","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","AETNA [1001]","HB CH AETNA HMO / PPO","1041.25","58.3","","554.95","91.85","1421.75","94","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1303.79","73","","2490.03","2490.03","2490.03","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1041.25","58.3","","750.00","750.00","750.00","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","946.59","53","","1192.50","120.84","4149.90","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1518.12","85","","750.00","75.00","750.00","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1786.02","100","","657.00","121.50","1971.00","14","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1786.02","100","","75.00","75.00","75.00","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1786.02","100","","366.00","144.00","1971.00","45","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1303.79","73","","667.50","667.50","667.50","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","793.89","44.45","","123.77","123.77","123.77","1 through 10","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","both","","","1786.02","1339.51","WELLPOINT [1015]","HB CH WELLPOINT","1391.49","77.91","","483.51","229.32","1316.08","96","793.89","1786.02","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.02","1339.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","1059.11","59.3","","439.50","225.34","1872.27","197","893.01","1401.13","percent of total billed charges",""
"FIBULA PLATE 109MM 4 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072291","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1786.02","1339.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1401.13","78.45","","385.32","55.36","1815.62","58","893.01","1401.13","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","AETNA [1001]","HB CH AETNA HMO / PPO","1390.46","58.3","","554.95","91.85","1421.75","94","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","2490.03","2490.03","2490.03","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.46","58.3","","750.00","750.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1264.05","53","","1192.50","120.84","4149.90","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2027.25","85","","750.00","75.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2385.00","100","","657.00","121.50","1971.00","14","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2385.00","100","","75.00","75.00","75.00","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2385.00","100","","366.00","144.00","1971.00","45","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","667.50","667.50","667.50","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","123.77","123.77","123.77","1 through 10","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","WELLPOINT [1015]","HB CH WELLPOINT","1858.15","77.91","","483.51","229.32","1316.08","96","1060.13","2385","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.31","59.3","","439.50","225.34","1872.27","197","1192.5","1871.03","percent of total billed charges",""
"FIBULA PLATE 130MM 8 HOLE BONE DISTAL SS LOCKING LEFT","SUP-ITM-10076950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","385.32","55.36","1815.62","58","1192.5","1871.03","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","AETNA [1001]","HB CH AETNA HMO / PPO","385.51","58.3","","554.95","91.85","1421.75","94","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","482.72","73","","2490.03","2490.03","2490.03","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","385.51","58.3","","750.00","750.00","750.00","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","350.47","53","","1192.50","120.84","4149.90","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","562.07","85","","750.00","75.00","750.00","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","661.26","100","","657.00","121.50","1971.00","14","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","661.26","100","","75.00","75.00","75.00","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","661.26","100","","366.00","144.00","1971.00","45","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","482.72","73","","667.50","667.50","667.50","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.93","44.45","","123.77","123.77","123.77","1 through 10","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","both","","","661.26","495.94","WELLPOINT [1015]","HB CH WELLPOINT","515.19","77.91","","483.51","229.32","1316.08","96","293.93","661.26","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","661.26","495.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","392.13","59.3","","439.50","225.34","1872.27","197","330.63","518.76","percent of total billed charges",""
"FIBULA PLATE 133MM 10 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","661.26","495.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","518.76","78.45","","385.32","55.36","1815.62","58","330.63","518.76","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","AETNA [1001]","HB CH AETNA HMO / PPO","1199.78","58.3","","554.95","91.85","1421.75","94","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1502.30","73","","2490.03","2490.03","2490.03","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1199.78","58.3","","750.00","750.00","750.00","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1090.71","53","","1192.50","120.84","4149.90","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1749.25","85","","750.00","75.00","750.00","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2057.94","100","","657.00","121.50","1971.00","14","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2057.94","100","","75.00","75.00","75.00","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2057.94","100","","366.00","144.00","1971.00","45","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1502.30","73","","667.50","667.50","667.50","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","914.75","44.45","","123.77","123.77","123.77","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","WELLPOINT [1015]","HB CH WELLPOINT","1603.34","77.91","","483.51","229.32","1316.08","96","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2057.94","1543.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1220.36","59.3","","439.50","225.34","1872.27","197","1028.97","1614.45","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072292","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2057.94","1543.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1614.45","78.45","","385.32","55.36","1815.62","58","1028.97","1614.45","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","AETNA [1001]","HB CH AETNA HMO / PPO","1199.78","58.3","","554.95","91.85","1421.75","94","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1502.30","73","","2490.03","2490.03","2490.03","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1199.78","58.3","","750.00","750.00","750.00","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1090.71","53","","1192.50","120.84","4149.90","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1749.25","85","","750.00","75.00","750.00","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2057.94","100","","657.00","121.50","1971.00","14","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2057.94","100","","75.00","75.00","75.00","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2057.94","100","","366.00","144.00","1971.00","45","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1502.30","73","","667.50","667.50","667.50","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","914.75","44.45","","123.77","123.77","123.77","1 through 10","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2057.94","1543.45","WELLPOINT [1015]","HB CH WELLPOINT","1603.34","77.91","","483.51","229.32","1316.08","96","914.75","2057.94","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2057.94","1543.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1220.36","59.3","","439.50","225.34","1872.27","197","1028.97","1614.45","percent of total billed charges",""
"FIBULA PLATE 139MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2057.94","1543.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1614.45","78.45","","385.32","55.36","1815.62","58","1028.97","1614.45","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","AETNA [1001]","HB CH AETNA HMO / PPO","392.72","58.3","","554.95","91.85","1421.75","94","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","491.74","73","","2490.03","2490.03","2490.03","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","392.72","58.3","","750.00","750.00","750.00","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.02","53","","1192.50","120.84","4149.90","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","572.58","85","","750.00","75.00","750.00","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","673.62","100","","657.00","121.50","1971.00","14","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","673.62","100","","75.00","75.00","75.00","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","673.62","100","","366.00","144.00","1971.00","45","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","491.74","73","","667.50","667.50","667.50","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","299.42","44.45","","123.77","123.77","123.77","1 through 10","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","both","","","673.62","505.21","WELLPOINT [1015]","HB CH WELLPOINT","524.82","77.91","","483.51","229.32","1316.08","96","299.42","673.62","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.62","505.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","399.46","59.3","","439.50","225.34","1872.27","197","336.81","528.45","percent of total billed charges",""
"FIBULA PLATE 164MM 12 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","673.62","505.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","528.45","78.45","","385.32","55.36","1815.62","58","336.81","528.45","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","AETNA [1001]","HB CH AETNA HMO / PPO","1279.04","58.3","","554.95","91.85","1421.75","94","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1601.55","73","","2490.03","2490.03","2490.03","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1279.04","58.3","","750.00","750.00","750.00","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1162.77","53","","1192.50","120.84","4149.90","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1864.82","85","","750.00","75.00","750.00","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2193.90","100","","657.00","121.50","1971.00","14","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2193.90","100","","75.00","75.00","75.00","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2193.90","100","","366.00","144.00","1971.00","45","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1601.55","73","","667.50","667.50","667.50","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","975.19","44.45","","123.77","123.77","123.77","1 through 10","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2193.90","1645.42","WELLPOINT [1015]","HB CH WELLPOINT","1709.27","77.91","","483.51","229.32","1316.08","96","975.19","2193.9","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2193.90","1645.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","1300.98","59.3","","439.50","225.34","1872.27","197","1096.95","1721.11","percent of total billed charges",""
"FIBULA PLATE 169MM 8 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL LEFT","SUP-ITM-10072293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2193.90","1645.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1721.11","78.45","","385.32","55.36","1815.62","58","1096.95","1721.11","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","AETNA [1001]","HB CH AETNA HMO / PPO","421.54","58.3","","554.95","91.85","1421.75","94","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","527.83","73","","2490.03","2490.03","2490.03","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","421.54","58.3","","750.00","750.00","750.00","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","383.22","53","","1192.50","120.84","4149.90","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","614.60","85","","750.00","75.00","750.00","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","723.06","100","","657.00","121.50","1971.00","14","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","723.06","100","","75.00","75.00","75.00","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","723.06","100","","366.00","144.00","1971.00","45","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","527.83","73","","667.50","667.50","667.50","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.40","44.45","","123.77","123.77","123.77","1 through 10","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","WELLPOINT [1015]","HB CH WELLPOINT","563.34","77.91","","483.51","229.32","1316.08","96","321.4","723.06","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","723.06","542.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","428.77","59.3","","439.50","225.34","1872.27","197","361.53","567.24","percent of total billed charges",""
"FIBULA PLATE 193MM 14 HOLE LEG A.L.P.S. TITANIUM LOCKING COMPOSITE BILATERAL DISTAL","SUP-ITM-10072289","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","723.06","542.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.24","78.45","","385.32","55.36","1815.62","58","361.53","567.24","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","AETNA [1001]","HB CH AETNA HMO / PPO","655.94","58.3","","554.95","91.85","1421.75","94","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","821.34","73","","2490.03","2490.03","2490.03","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.94","58.3","","750.00","750.00","750.00","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.31","53","","1192.50","120.84","4149.90","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","956.35","85","","750.00","75.00","750.00","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1125.12","100","","657.00","121.50","1971.00","14","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1125.12","100","","75.00","75.00","75.00","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1125.12","100","","366.00","144.00","1971.00","45","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.34","73","","667.50","667.50","667.50","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.12","44.45","","123.77","123.77","123.77","1 through 10","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.12","843.84","WELLPOINT [1015]","HB CH WELLPOINT","876.58","77.91","","483.51","229.32","1316.08","96","500.12","1125.12","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.12","843.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.20","59.3","","439.50","225.34","1872.27","197","562.56","882.66","percent of total billed charges",""
"FIBULA PLATE 2.7-3.5X99MM 5 HOLE BONE DISTAL LATERAL LCP RIGHT","SUP-ITM-10072421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.12","843.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.66","78.45","","385.32","55.36","1815.62","58","562.56","882.66","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","554.95","91.85","1421.75","94","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","2490.03","2490.03","2490.03","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1136.85","58.3","","750.00","750.00","750.00","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1033.50","53","","1192.50","120.84","4149.90","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1657.50","85","","750.00","75.00","750.00","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1950.00","100","","657.00","121.50","1971.00","14","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1950.00","100","","75.00","75.00","75.00","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1950.00","100","","366.00","144.00","1971.00","45","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","667.50","667.50","667.50","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","123.77","123.77","123.77","1 through 10","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","483.51","229.32","1316.08","96","866.78","1950","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","439.50","225.34","1872.27","197","975","1529.78","percent of total billed charges",""
"FIBULA PLATE 91MM 5 HOLE BONE DISTAL SS LOCKING RIGHT","SUP-ITM-10076952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","385.32","55.36","1815.62","58","975","1529.78","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","AETNA [1001]","HB CH AETNA HMO / PPO","1016.03","58.3","","554.95","91.85","1421.75","94","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1272.21","73","","2490.03","2490.03","2490.03","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1016.03","58.3","","750.00","750.00","750.00","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","923.66","53","","1192.50","120.84","4149.90","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1481.35","85","","750.00","75.00","750.00","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1742.76","100","","657.00","121.50","1971.00","14","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1742.76","100","","75.00","75.00","75.00","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1742.76","100","","366.00","144.00","1971.00","45","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1272.21","73","","667.50","667.50","667.50","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","774.66","44.45","","123.77","123.77","123.77","1 through 10","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","both","","","1742.76","1307.07","WELLPOINT [1015]","HB CH WELLPOINT","1357.78","77.91","","483.51","229.32","1316.08","96","774.66","1742.76","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1742.76","1307.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","1033.46","59.3","","439.50","225.34","1872.27","197","871.38","1367.2","percent of total billed charges",""
"FIBULA PLATE 95MM 3 HOLE LEG A.L.P.S. TITANIUM LOCKING ANATOMIC DISTAL RIGHT","SUP-ITM-10072295","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1742.76","1307.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1367.20","78.45","","385.32","55.36","1815.62","58","871.38","1367.2","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","AETNA [1001]","HB CH AETNA HMO / PPO","2363.70","58.3","","554.95","91.85","1421.75","94","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","2490.03","2490.03","2490.03","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.70","58.3","","750.00","750.00","750.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.82","53","","1192.50","120.84","4149.90","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3446.22","85","","750.00","75.00","750.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4054.38","100","","657.00","121.50","1971.00","14","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4054.38","100","","75.00","75.00","75.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4054.38","100","","366.00","144.00","1971.00","45","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","667.50","667.50","667.50","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","123.77","123.77","123.77","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","WELLPOINT [1015]","HB CH WELLPOINT","3158.77","77.91","","483.51","229.32","1316.08","96","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.25","59.3","","439.50","225.34","1872.27","197","2027.19","3180.66","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 7-HOLE ANATOMICAL UNIVERSAL L OR R P53-208-1007","SUP-ITM-10241312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","385.32","55.36","1815.62","58","2027.19","3180.66","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","AETNA [1001]","HB CH AETNA HMO / PPO","2363.70","58.3","","554.95","91.85","1421.75","94","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","2490.03","2490.03","2490.03","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.70","58.3","","750.00","750.00","750.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.82","53","","1192.50","120.84","4149.90","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3446.22","85","","750.00","75.00","750.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4054.38","100","","657.00","121.50","1971.00","14","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4054.38","100","","75.00","75.00","75.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4054.38","100","","366.00","144.00","1971.00","45","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","667.50","667.50","667.50","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","123.77","123.77","123.77","1 through 10","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","WELLPOINT [1015]","HB CH WELLPOINT","3158.77","77.91","","483.51","229.32","1316.08","96","1802.17","4054.38","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.25","59.3","","439.50","225.34","1872.27","197","2027.19","3180.66","percent of total billed charges",""
"FIBULAR POSTERIOR ANTI-GLIDE 9-HOLE ANATOMICAL W/COMP UNIVERSAL L OR R P53-208-1009","SUP-ITM-10241311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","385.32","55.36","1815.62","58","2027.19","3180.66","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","AETNA [1001]","HB CH AETNA HMO / PPO","1909.33","58.3","","554.95","91.85","1421.75","94","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2390.75","73","","2490.03","2490.03","2490.03","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1909.33","58.3","","750.00","750.00","750.00","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1735.75","53","","1192.50","120.84","4149.90","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2783.75","85","","750.00","75.00","750.00","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3275.00","100","","657.00","121.50","1971.00","14","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3275.00","100","","75.00","75.00","75.00","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3275.00","100","","366.00","144.00","1971.00","45","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2390.75","73","","667.50","667.50","667.50","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.74","44.45","","123.77","123.77","123.77","1 through 10","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","both","","","3275.00","2456.25","WELLPOINT [1015]","HB CH WELLPOINT","2551.55","77.91","","483.51","229.32","1316.08","96","1455.74","3275","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1942.08","59.3","","439.50","225.34","1872.27","197","1637.5","2569.24","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 10CC","SUP-ITM-10212437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3275.00","2456.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2569.24","78.45","","385.32","55.36","1815.62","58","1637.5","2569.24","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","AETNA [1001]","HB CH AETNA HMO / PPO","2716.78","58.3","","554.95","91.85","1421.75","94","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3401.80","73","","2490.03","2490.03","2490.03","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2716.78","58.3","","750.00","750.00","750.00","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2469.80","53","","1192.50","120.84","4149.90","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3961.00","85","","750.00","75.00","750.00","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4660.00","100","","657.00","121.50","1971.00","14","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4660.00","100","","75.00","75.00","75.00","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4660.00","100","","366.00","144.00","1971.00","45","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3401.80","73","","667.50","667.50","667.50","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2071.37","44.45","","123.77","123.77","123.77","1 through 10","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","both","","","4660.00","3495.00","WELLPOINT [1015]","HB CH WELLPOINT","3630.61","77.91","","483.51","229.32","1316.08","96","2071.37","4660","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.00","3495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2763.38","59.3","","439.50","225.34","1872.27","197","2330","3655.77","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 20CC","SUP-ITM-10212438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4660.00","3495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3655.77","78.45","","385.32","55.36","1815.62","58","2330","3655.77","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","554.95","91.85","1421.75","94","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","2490.03","2490.03","2490.03","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1565.36","58.3","","750.00","750.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","1192.50","120.84","4149.90","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2282.25","85","","750.00","75.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2685.00","100","","657.00","121.50","1971.00","14","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2685.00","100","","75.00","75.00","75.00","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2685.00","100","","366.00","144.00","1971.00","45","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","667.50","667.50","667.50","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","123.77","123.77","123.77","1 through 10","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","483.51","229.32","1316.08","96","1193.48","2685","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","439.50","225.34","1872.27","197","1342.5","2106.38","percent of total billed charges",""
"FILLER STIMULAN BONE LF STERILE DISPOSABLE RAPID CURE 5CC","SUP-ITM-10212436","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","385.32","55.36","1815.62","58","1342.5","2106.38","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","AETNA [1001]","HB CH AETNA HMO / PPO","1729.13","58.3","","554.95","91.85","1421.75","94","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2165.12","73","","2490.03","2490.03","2490.03","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1729.13","58.3","","750.00","750.00","750.00","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1571.94","53","","1192.50","120.84","4149.90","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2521.03","85","","750.00","75.00","750.00","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2965.92","100","","657.00","121.50","1971.00","14","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2965.92","100","","75.00","75.00","75.00","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2965.92","100","","366.00","144.00","1971.00","45","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2165.12","73","","667.50","667.50","667.50","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1318.35","44.45","","123.77","123.77","123.77","1 through 10","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","both","","","2965.92","2224.44","WELLPOINT [1015]","HB CH WELLPOINT","2310.75","77.91","","483.51","229.32","1316.08","96","1318.35","2965.92","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2965.92","2224.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1758.79","59.3","","439.50","225.34","1872.27","197","1482.96","2326.76","percent of total billed charges",""
"FILLER VOID 5ML BONE CALCIUM PHOSPHATE INJECTABLE DRILLABLE BIOCOMPATIBLE ROTARY MIX REACTANT N/S IMPL NORIAN SRS","SUP-ITM-10118185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2965.92","2224.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2326.76","78.45","","385.32","55.36","1815.62","58","1482.96","2326.76","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","AETNA [1001]","HB CH AETNA HMO / PPO","1086.13","58.3","","554.95","91.85","1421.75","94","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1359.99","73","","2490.03","2490.03","2490.03","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1086.13","58.3","","750.00","750.00","750.00","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","987.39","53","","1192.50","120.84","4149.90","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1583.55","85","","750.00","75.00","750.00","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1863.00","100","","657.00","121.50","1971.00","14","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1863.00","100","","75.00","75.00","75.00","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1863.00","100","","366.00","144.00","1971.00","45","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1359.99","73","","667.50","667.50","667.50","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","828.10","44.45","","123.77","123.77","123.77","1 through 10","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","both","","","1863.00","1397.25","WELLPOINT [1015]","HB CH WELLPOINT","1451.46","77.91","","483.51","229.32","1316.08","96","828.1","1863","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1863.00","1397.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1104.76","59.3","","439.50","225.34","1872.27","197","931.5","1461.52","percent of total billed charges",""
"FILTER FILLER 3.0MM VOID 8400 0310 OSTEOSET BONE SUBSTITUTE","SUP-ITM-10021578","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1863.00","1397.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1461.52","78.45","","385.32","55.36","1815.62","58","931.5","1461.52","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3308.88","2481.66","AETNA [1001]","HB CH AETNA HMO / PPO","1929.08","58.3","","1830.28","315.58","1830.28","1 through 10","1470.8","3308.88","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3308.88","2481.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2415.48","73","","4170.85","4170.85","4170.85","1 through 10","1470.8","3308.88","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3308.88","2481.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1470.80","44.45","","649.55","649.55","649.55","1 through 10","1470.8","3308.88","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","both","","","3308.88","2481.66","WELLPOINT [1015]","HB CH WELLPOINT","2577.95","77.91","","8998.38","2542.37","8998.38","20","1470.8","3308.88","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3308.88","2481.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","1962.17","59.3","","1891.61","1609.14","3664.18","25","1654.44","2595.82","percent of total billed charges",""
"FILTER GRAFT SM BONE ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3308.88","2481.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2595.82","78.45","","1470.68","1310.06","2481.69","19","1654.44","2595.82","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","860.62","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.59","859.79","860.59","1 through 10","579.34","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","AETNA [1001]","HB CH AETNA HMO / PPO","700.18","58.3","","1324.52","1324.52","1324.52","1 through 10","579.34","935.7","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","835.56","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","579.34","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2586.01","2586.01","2586.01","1 through 10","579.34","935.7","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","MEDICARE [2001]","HB BWF MEDICARE","835.56","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","579.34","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","579.34","935.7","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","9334.32","2216.00","9334.32","1 through 10","579.34","935.7","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","both","","","1201.00","900.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","818.84","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","753.55","826.75","1 through 10","579.34","935.7","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","956.66","936.79","956.66","1 through 10","533.84","970.06","other","ASC "
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","957.99","938.11","957.99","12","533.84","970.06","other","ASC "
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","712.19","59.3","","684.45","684.45","684.45","1 through 10","533.84","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4084.35","1361.45","4084.35","1 through 10","533.84","970.06","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","4292.91","1433.29","4292.91","1 through 10","533.84","970.06","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-76002556","CDM","10005","CPT","0761","RC","","","","outpatient","","","1201.00","900.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","942.18","78.45","","532.14","532.14","532.14","1 through 10","533.84","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","860.62","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","860.59","859.79","860.59","1 through 10","201.4","860.62","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","AETNA [1001]","HB CH AETNA HMO / PPO","221.54","58.3","","1324.52","1324.52","1324.52","1 through 10","201.4","860.62","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","835.56","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.19","822.19","822.19","1 through 10","201.4","860.62","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2586.01","2586.01","2586.01","1 through 10","201.4","860.62","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MEDICARE [2001]","HB BWF MEDICARE","835.56","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","201.4","860.62","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","201.4","860.62","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","9334.32","2216.00","9334.32","1 through 10","201.4","860.62","per diem",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","both","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","818.84","","APC Price ($835.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","818.85","753.55","826.75","1 through 10","201.4","860.62","other","OPPS APC"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","225.34","59.3","","684.45","684.45","684.45","1 through 10","168.91","970.06","percent of total billed charges",""
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4084.35","1361.45","4084.35","1 through 10","168.91","970.06","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","579.34","","Case rate ($579.34). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","4292.91","1433.29","4292.91","1 through 10","168.91","970.06","other","Multiple Surgery"
"Fine Needle Aspiration Bx W/US Gdn 1st Lesion","PX-98301808","CDM","10005","CPT","0983","RC","","","","outpatient","","","380.00","285.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","298.11","78.45","","532.14","532.14","532.14","1 through 10","168.91","970.06","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","MEDICARE [2001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","59.14","63.45","1 through 10","60.28","270.7","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","both","","","277.00","207.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.45","63.45","63.45","1 through 10","60.28","270.7","other","OPPS APC"
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","277.00","207.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","164.26","59.3","","157.63","153.87","157.63","1 through 10","90.37","217.31","percent of total billed charges",""
"Fine Needle Interp.Aspiration","PX-31000093","CDM","88173","CPT","0311","RC","","","","outpatient","","","277.00","207.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","217.31","78.45","","122.56","122.56","206.81","1 through 10","90.37","217.31","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","AETNA [1001]","HB CH AETNA HMO / PPO","1954.59","58.3","","554.95","91.85","1421.75","94","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","2490.03","2490.03","2490.03","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1954.59","58.3","","750.00","750.00","750.00","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1776.90","53","","1192.50","120.84","4149.90","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2849.75","85","","750.00","75.00","750.00","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3352.65","100","","657.00","121.50","1971.00","14","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3352.65","100","","75.00","75.00","75.00","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3352.65","100","","366.00","144.00","1971.00","45","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","667.50","667.50","667.50","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1490.25","44.45","","123.77","123.77","123.77","1 through 10","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","WELLPOINT [1015]","HB CH WELLPOINT","2612.05","77.91","","483.51","229.32","1316.08","96","1490.25","3352.65","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1988.12","59.3","","439.50","225.34","1872.27","197","1676.33","2630.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 3 FINGER JOINT PIP SILICONE PROXIMAL","SUP-ITM-10117441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2630.15","78.45","","385.32","55.36","1815.62","58","1676.33","2630.15","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","AETNA [1001]","HB CH AETNA HMO / PPO","2318.01","58.3","","1770.74","1285.96","2571.91","24","1767.33","3976","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","WELLPOINT [1015]","HB CH WELLPOINT","3097.70","77.91","","2459.68","1786.28","4054.28","11","1767.33","3976","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3976.00","2982.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2357.77","59.3","","4926.10","1830.08","18282.10","21","1988","3119.17","percent of total billed charges",""
"FINGER PROSTHESIS SZ 5 FINGER JOINT METACARPOPHALAGEAL DISTAL","SUP-ITM-10117434","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","3976.00","2982.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3119.17","78.45","","1743.64","1033.30","4801.93","1 through 10","1988","3119.17","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","AETNA [1001]","HB CH AETNA HMO / PPO","2784.41","58.3","","1634.24","1004.95","1718.99","42","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3486.48","73","","2123.89","1900.92","2123.89","1 through 10","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2784.41","58.3","","3729.00","1254.19","3729.00","1 through 10","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2531.28","53","","939.37","939.37","5593.65","1 through 10","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4059.60","85","","2323.25","1864.50","2882.25","16","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4776.00","100","","2909.44","1772.40","10952.08","45","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4776.00","100","","2323.25","2323.25","2323.25","1 through 10","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4776.00","100","","2882.25","1772.40","10169.17","187","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3486.48","73","","1659.41","1659.41","1659.41","1 through 10","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","both","","","4776.00","3582.00","WELLPOINT [1015]","HB CH WELLPOINT","3720.98","77.91","","2050.91","1468.48","2902.83","52","2122.93","4776","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4776.00","3582.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2832.17","59.3","","1548.60","1092.60","3613.79","82","2388","3746.77","percent of total billed charges",""
"FINGER STEM 13.8X2.8MM SZ 30 PROSTHESIS JOINT INTERPHALANGEAL PIP PYROCARBON PROXIMALIMAL","SUP-ITM-10021758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4776.00","3582.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3746.77","78.45","","2085.51","998.68","6202.11","56","2388","3746.77","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","AETNA [1001]","HB CH AETNA HMO / PPO","3623.93","58.3","","1634.24","1004.95","1718.99","42","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4537.68","73","","2123.89","1900.92","2123.89","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3623.93","58.3","","3729.00","1254.19","3729.00","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3294.48","53","","939.37","939.37","5593.65","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5283.60","85","","2323.25","1864.50","2882.25","16","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6216.00","100","","2909.44","1772.40","10952.08","45","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6216.00","100","","2323.25","2323.25","2323.25","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6216.00","100","","2882.25","1772.40","10169.17","187","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4537.68","73","","1659.41","1659.41","1659.41","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","WELLPOINT [1015]","HB CH WELLPOINT","4842.89","77.91","","2050.91","1468.48","2902.83","52","2763.01","6216","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3686.09","59.3","","1548.60","1092.60","3613.79","82","3108","4876.45","percent of total billed charges",""
"FINGER STEM 16.7X2.2X12.5MM SZ 20 METACARPOPHALANGEL PROXIMAL PYROCARBON","SUP-ITM-10019746","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.45","78.45","","2085.51","998.68","6202.11","56","3108","4876.45","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","AETNA [1001]","HB CH AETNA HMO / PPO","2042.10","58.3","","1634.24","1004.95","1718.99","42","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2557.00","73","","2123.89","1900.92","2123.89","1 through 10","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2042.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.45","53","","939.37","939.37","5593.65","1 through 10","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2977.33","85","","2323.25","1864.50","2882.25","16","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3502.74","100","","2909.44","1772.40","10952.08","45","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3502.74","100","","2323.25","2323.25","2323.25","1 through 10","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3502.74","100","","2882.25","1772.40","10169.17","187","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2557.00","73","","1659.41","1659.41","1659.41","1 through 10","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","WELLPOINT [1015]","HB CH WELLPOINT","2728.98","77.91","","2050.91","1468.48","2902.83","52","1556.97","3502.74","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.74","2627.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.12","59.3","","1548.60","1092.60","3613.79","82","1751.37","2747.9","percent of total billed charges",""
"FINGER STEM 23X16.7 12.3MM SZ 20 PROSTHESIS JOINT ASCENSION SILICONE METACARPOPHALANGEAL","SUP-ITM-10115275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.74","2627.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.90","78.45","","2085.51","998.68","6202.11","56","1751.37","2747.9","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","AETNA [1001]","HB CH AETNA HMO / PPO","2318.01","58.3","","1634.24","1004.95","1718.99","42","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2902.48","73","","2123.89","1900.92","2123.89","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2318.01","58.3","","3729.00","1254.19","3729.00","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2107.28","53","","939.37","939.37","5593.65","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3379.60","85","","2323.25","1864.50","2882.25","16","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3976.00","100","","2909.44","1772.40","10952.08","45","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3976.00","100","","2323.25","2323.25","2323.25","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3976.00","100","","2882.25","1772.40","10169.17","187","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2902.48","73","","1659.41","1659.41","1659.41","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","WELLPOINT [1015]","HB CH WELLPOINT","3097.70","77.91","","2050.91","1468.48","2902.83","52","1767.33","3976","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3976.00","2982.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2357.77","59.3","","1548.60","1092.60","3613.79","82","1988","3119.17","percent of total billed charges",""
"FINGER STEM 23X3.6X11.3MM SZ 20 METACARPOPHALANGEL DISTAL PYROCARBON","SUP-ITM-10019745","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3976.00","2982.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3119.17","78.45","","2085.51","998.68","6202.11","56","1988","3119.17","percent of total billed charges",""
"FINGER STEM SZ 10 PROSTHESIS JOINT PYROCARBON METACARPOPHALAGEAL PROXIMALIMAL","SUP-ITM-10104834","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","AETNA [1001]","HB CH AETNA HMO / PPO","3623.93","58.3","","1830.28","315.58","1830.28","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 10 PROSTHESIS JOINT PYROCARBON METACARPOPHALAGEAL PROXIMALIMAL","SUP-ITM-10104834","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4537.68","73","","4170.85","4170.85","4170.85","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 10 PROSTHESIS JOINT PYROCARBON METACARPOPHALAGEAL PROXIMALIMAL","SUP-ITM-10104834","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2763.01","44.45","","649.55","649.55","649.55","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 10 PROSTHESIS JOINT PYROCARBON METACARPOPHALAGEAL PROXIMALIMAL","SUP-ITM-10104834","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","WELLPOINT [1015]","HB CH WELLPOINT","4842.89","77.91","","8998.38","2542.37","8998.38","20","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 10 PROSTHESIS JOINT PYROCARBON METACARPOPHALAGEAL PROXIMALIMAL","SUP-ITM-10104834","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3686.09","59.3","","1891.61","1609.14","3664.18","25","3108","4876.45","percent of total billed charges",""
"FINGER STEM SZ 10 PROSTHESIS JOINT PYROCARBON METACARPOPHALAGEAL PROXIMALIMAL","SUP-ITM-10104834","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.45","78.45","","1470.68","1310.06","2481.69","19","3108","4876.45","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALAGEAL PROXIMAL PYROCARBON","SUP-ITM-10117433","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","AETNA [1001]","HB CH AETNA HMO / PPO","3623.93","58.3","","1830.28","315.58","1830.28","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALAGEAL PROXIMAL PYROCARBON","SUP-ITM-10117433","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4537.68","73","","4170.85","4170.85","4170.85","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALAGEAL PROXIMAL PYROCARBON","SUP-ITM-10117433","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2763.01","44.45","","649.55","649.55","649.55","1 through 10","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALAGEAL PROXIMAL PYROCARBON","SUP-ITM-10117433","CDM","C1889","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","WELLPOINT [1015]","HB CH WELLPOINT","4842.89","77.91","","8998.38","2542.37","8998.38","20","2763.01","6216","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALAGEAL PROXIMAL PYROCARBON","SUP-ITM-10117433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3686.09","59.3","","1891.61","1609.14","3664.18","25","3108","4876.45","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALAGEAL PROXIMAL PYROCARBON","SUP-ITM-10117433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.45","78.45","","1470.68","1310.06","2481.69","19","3108","4876.45","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALANGEAL DISTAL PYROCARBON","SUP-ITM-10117432","CDM","C1889","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","AETNA [1001]","HB CH AETNA HMO / PPO","2318.01","58.3","","1830.28","315.58","1830.28","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALANGEAL DISTAL PYROCARBON","SUP-ITM-10117432","CDM","C1889","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2902.48","73","","4170.85","4170.85","4170.85","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALANGEAL DISTAL PYROCARBON","SUP-ITM-10117432","CDM","C1889","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1767.33","44.45","","649.55","649.55","649.55","1 through 10","1767.33","3976","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALANGEAL DISTAL PYROCARBON","SUP-ITM-10117432","CDM","C1889","HCPCS","0278","RC","","","","both","","","3976.00","2982.00","WELLPOINT [1015]","HB CH WELLPOINT","3097.70","77.91","","8998.38","2542.37","8998.38","20","1767.33","3976","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALANGEAL DISTAL PYROCARBON","SUP-ITM-10117432","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3976.00","2982.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2357.77","59.3","","1891.61","1609.14","3664.18","25","1988","3119.17","percent of total billed charges",""
"FINGER STEM SZ 50 METACARPOPHALANGEAL DISTAL PYROCARBON","SUP-ITM-10117432","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3976.00","2982.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3119.17","78.45","","1470.68","1310.06","2481.69","19","1988","3119.17","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","AETNA [1001]","HB CH AETNA HMO / PPO","209.88","58.3","","554.95","91.85","1421.75","94","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","262.80","73","","2490.03","2490.03","2490.03","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.88","58.3","","750.00","750.00","750.00","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.80","53","","1192.50","120.84","4149.90","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","306.00","85","","750.00","75.00","750.00","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","360.00","100","","657.00","121.50","1971.00","14","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","360.00","100","","75.00","75.00","75.00","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","360.00","100","","366.00","144.00","1971.00","45","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.80","73","","667.50","667.50","667.50","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","44.45","","123.77","123.77","123.77","1 through 10","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","WELLPOINT [1015]","HB CH WELLPOINT","280.48","77.91","","483.51","229.32","1316.08","96","160.02","360","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.00","270.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","213.48","59.3","","439.50","225.34","1872.27","197","180","282.42","percent of total billed charges",""
"FIXATION EXTERNAL 40MM SOCKET ILIZAROV SS THREADED","SUP-ITM-10015539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","282.42","78.45","","385.32","55.36","1815.62","58","180","282.42","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1634.24","1004.95","1718.99","42","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","2123.89","1900.92","2123.89","1 through 10","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2984.96","58.3","","3729.00","1254.19","3729.00","1 through 10","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","939.37","939.37","5593.65","1 through 10","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4352.00","85","","2323.25","1864.50","2882.25","16","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5120.00","100","","2909.44","1772.40","10952.08","45","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5120.00","100","","2323.25","2323.25","2323.25","1 through 10","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5120.00","100","","2882.25","1772.40","10169.17","187","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","1659.41","1659.41","1659.41","1 through 10","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","2050.91","1468.48","2902.83","52","2275.84","5120","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1548.60","1092.60","3613.79","82","2560","4016.64","percent of total billed charges",""
"FLANGE IMPLANT 100MM 4 ELBOW HUMERAL COMPONENT DISCOVERY D LT 02","SUP-ITM-10008817","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","2085.51","998.68","6202.11","56","2560","4016.64","percent of total billed charges",""
"Flecainide, Serum","PX-30003519","CDM","80299","CPT","0301","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","121.91","121.91","121.91","1 through 10","18.27","120.45","percent of total billed charges",""
"Flecainide, Serum","PX-30003519","CDM","80299","CPT","0301","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","165.29","165.29","165.29","1 through 10","14.12","129.44","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","440.00","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","439.58","439.58","439.58","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","AETNA [1001]","HB CH AETNA HMO / PPO","117.77","58.3","","111.13","111.13","111.13","1 through 10","89.79","1456.11","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","420.35","420.35","420.35","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","418.65","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","HUMANA [1012]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","422.57","422.57","422.57","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","107.06","53","","103.88","103.88","103.88","1 through 10","89.79","1456.11","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","427.19","427.19","22","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","418.65","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1255.95","59.32","1255.95","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","418.65","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","384.47","427.19","1 through 10","89.79","1456.11","other","OPPS APC"
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","both","","","202.00","151.50","WELLPOINT [1015]","HB CH WELLPOINT","157.38","77.91","","196.00","194.20","196.00","1 through 10","89.79","1456.11","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","202.00","151.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.79","59.3","","344.58","114.86","344.58","1 through 10","101","926.86","percent of total billed charges",""
"Flow Cytometry 1st Marker Tc","PX-31000099","CDM","88184","CPT","0311","RC","","","","outpatient","","","202.00","151.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.47","78.45","","150.68","89.30","150.68","1 through 10","101","926.86","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","158.76","158.76","158.76","39","128.02","288","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","152.64","53","","148.40","148.40","148.40","1 through 10","128.02","288","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","288.00","100","","81.98","81.98","81.98","18","128.02","288","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","288.00","100","","250.88","250.88","250.88","51","128.02","288","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","288.00","100","","89.59","89.59","89.59","63","128.02","288","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","5320.00","5037.42","5320.00","1 through 10","128.02","288","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","492.24","164.08","492.24","144","144","225.94","percent of total billed charges",""
"Flow Cytometry Ea Addl Marker Tc","PX-31000101","CDM","88185","CPT","0311","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","127.57","127.57","215.26","53","144","225.94","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","37","11.81","71.1","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","35.02","35.02","35.02","1 through 10","11.81","71.1","percent of total billed charges",""
"Fluorescent Antibody Scrn","PX-30000811","CDM","86255","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","59.97","35.54","539.70","11","8.98","62.76","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","AETNA [1001]","HB CH AETNA HMO / PPO","100.05","58.3","","97.30","97.30","97.31","1 through 10","90.95","688.25","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","163.20","95.1","","170.75","170.75","170.75","1 through 10","90.95","688.25","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","108.80","63.4","","109.49","109.49","109.49","1 through 10","90.95","688.25","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","both","","","171.61","128.71","WELLPOINT [1015]","HB CH WELLPOINT","133.70","77.91","","135.16","135.16","135.16","1 through 10","90.95","688.25","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","171.61","128.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.76","59.3","","100.56","100.56","100.56","1 through 10","76.28","483.39","percent of total billed charges",""
"Fo W/O Joint Custom T1","PX-27000506","CDM","L3933","HCPCS","0274","RC","","","","outpatient","","","171.61","128.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.63","78.45","","131.93","78.19","131.93","1 through 10","76.28","483.39","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","AETNA [1001]","HB CH AETNA HMO / PPO","72.29","58.3","","68.61","68.61","68.61","23","14.41","90.52","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","both","","","124.00","93.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","90.52","73","","68.61","68.61","68.61","1 through 10","14.41","90.52","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","124.00","93.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","7.82","70.91","1 through 10","15.17","97.28","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","124.00","93.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","70.91","70.91","1 through 10","15.17","97.28","percent of total billed charges",""
"Folic Acid Serum","PX-30000440","CDM","82746","CPT","0301","RC","","","","outpatient","","","124.00","93.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.28","78.45","","93.02","55.13","93.02","16","15.17","97.28","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","both","","","218.00","163.50","AETNA [1001]","HB CH AETNA HMO / PPO","127.09","58.3","","120.20","120.20","120.20","12","18.21","159.14","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","218.00","163.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.27","59.3","","124.23","124.23","124.23","1 through 10","19.16","171.02","percent of total billed charges",""
"Follicle Stimulating Hormone (Fsh)","PX-30000481","CDM","83001","CPT","0301","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.02","78.45","","162.99","96.59","162.99","1 through 10","19.16","171.02","percent of total billed charges",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","97454.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","37549.63","","Standard inlier is a Case rate ($37,549.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $50,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,330.32) for the length of stay and the standard reimbursement.","37549.62","37549.62","37549.62","1 through 10","9834.31","66841.81","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","97454.64","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","40335.79","","Standard inlier is a Case rate ($40,335.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $50,169, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,725.49) for the length of stay and the standard reimbursement.","40335.78","40335.78","40335.78","1 through 10","9834.31","66841.81","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","97454.64","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","20063.7714","","Fee schedule rate ($40,510.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20063.7714","38949.60","38949.60","1 through 10","9834.31","66841.81","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","97454.64","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","17927.26","","Fee schedule rate ($17,927.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17927.26","17927.26","17927.26","1 through 10","9834.31","66841.81","case rate",""
"Foot And Toe Procedures,MAJOR","314","DRG","","","","","","","","inpatient","","","97454.64","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","14926.15","","Case rate ($16,503.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,933.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,419.86 and the sum of the standard inlier and any outlier amount.","16499.38","16499.38","16499.38","1 through 10","9834.31","66841.81","case rate",""
"Foot And Toe Procedures,MODERATE","314","DRG","","","","","","","","inpatient","","","47376.04","","MASSHEALTH [3001]","HB BWF MEDICAID","11264.87","","Case rate ($12,455.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,885.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12452.20","12452.20","12452.20","1 through 10","9834.31","66841.81","case rate",""
"Foot And Toe Procedures,MODERATE","314","DRG","","","","","","","","inpatient","","","47376.04","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11264.87","","Case rate ($12,455.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,885.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12452.19","12452.19","12452.19","1 through 10","9834.31","66841.81","case rate",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","AETNA [1001]","HB CH AETNA HMO / PPO","1799.72","58.3","","554.95","91.85","1421.75","94","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2253.51","73","","2490.03","2490.03","2490.03","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1799.72","58.3","","750.00","750.00","750.00","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1636.11","53","","1192.50","120.84","4149.90","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2623.95","85","","750.00","75.00","750.00","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3087.00","100","","657.00","121.50","1971.00","14","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3087.00","100","","75.00","75.00","75.00","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3087.00","100","","366.00","144.00","1971.00","45","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2253.51","73","","667.50","667.50","667.50","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1372.17","44.45","","123.77","123.77","123.77","1 through 10","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","both","","","3087.00","2315.25","WELLPOINT [1015]","HB CH WELLPOINT","2405.08","77.91","","483.51","229.32","1316.08","96","1372.17","3087","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3087.00","2315.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1830.59","59.3","","439.50","225.34","1872.27","197","1543.5","2421.75","percent of total billed charges",""
"FOOT PLATE 2.7X20MM BONE CHARLOTTE CLAW SS COMPRESSION INTERAXIS","SUP-ITM-10019595","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3087.00","2315.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2421.75","78.45","","385.32","55.36","1815.62","58","1543.5","2421.75","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","AETNA [1001]","HB CH AETNA HMO / PPO","2428.65","58.3","","554.95","91.85","1421.75","94","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3041.02","73","","2490.03","2490.03","2490.03","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2428.65","58.3","","750.00","750.00","750.00","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2207.86","53","","1192.50","120.84","4149.90","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3540.91","85","","750.00","75.00","750.00","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4165.78","100","","657.00","121.50","1971.00","14","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4165.78","100","","75.00","75.00","75.00","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4165.78","100","","366.00","144.00","1971.00","45","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3041.02","73","","667.50","667.50","667.50","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1851.69","44.45","","123.77","123.77","123.77","1 through 10","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","both","","","4165.78","3124.33","WELLPOINT [1015]","HB CH WELLPOINT","3245.56","77.91","","483.51","229.32","1316.08","96","1851.69","4165.78","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.78","3124.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","2470.31","59.3","","439.50","225.34","1872.27","197","2082.89","3268.05","percent of total billed charges",""
"FOOT PLATE 20MM 2 HOLE UNI CP TITANIUM COMPRESSION","SUP-ITM-10075188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4165.78","3124.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3268.05","78.45","","385.32","55.36","1815.62","58","2082.89","3268.05","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","AETNA [1001]","HB CH AETNA HMO / PPO","1241.21","58.3","","554.95","91.85","1421.75","94","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1554.18","73","","2490.03","2490.03","2490.03","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1241.21","58.3","","750.00","750.00","750.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1128.38","53","","1192.50","120.84","4149.90","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1809.66","85","","750.00","75.00","750.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2129.01","100","","657.00","121.50","1971.00","14","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2129.01","100","","75.00","75.00","75.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2129.01","100","","366.00","144.00","1971.00","45","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1554.18","73","","667.50","667.50","667.50","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.34","44.45","","123.77","123.77","123.77","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","WELLPOINT [1015]","HB CH WELLPOINT","1658.71","77.91","","483.51","229.32","1316.08","96","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2129.01","1596.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","1262.50","59.3","","439.50","225.34","1872.27","197","1064.51","1670.21","percent of total billed charges",""
"FOOT PLATE 3.5MM SM BONE A.L.P.S. FUSION CLOSED SINGLE JOINT","SUP-ITM-10117375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2129.01","1596.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1670.21","78.45","","385.32","55.36","1815.62","58","1064.51","1670.21","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","554.95","91.85","1421.75","94","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2490.03","2490.03","2490.03","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","750.00","750.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","1192.50","120.84","4149.90","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","750.00","75.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","657.00","121.50","1971.00","14","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","75.00","75.00","75.00","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","366.00","144.00","1971.00","45","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","667.50","667.50","667.50","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","123.77","123.77","123.77","1 through 10","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","483.51","229.32","1316.08","96","800.1","1800","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","439.50","225.34","1872.27","197","900","1412.1","percent of total billed charges",""
"FOOT PLATE 38X4.0MM 4 HOLE BONE LAPIDUS TITANIUM LOW PROFILE LEFT","SUP-ITM-10029843","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","385.32","55.36","1815.62","58","900","1412.1","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2129.01","100","","6010.00","6010.00","6010.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"FOOT PLATE LG 3.5MM FUSION A.L.P.S. CLOSED","SUP-ITM-10117150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","2129.01","1596.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1670.21","78.45","","5181.71","4620.49","5181.71","1 through 10","1064.51","1670.21","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","AETNA [1001]","HB CH AETNA HMO / PPO","1387.13","58.3","","554.95","91.85","1421.75","94","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1736.89","73","","2490.03","2490.03","2490.03","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1387.13","58.3","","750.00","750.00","750.00","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1261.03","53","","1192.50","120.84","4149.90","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2022.41","85","","750.00","75.00","750.00","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2379.30","100","","657.00","121.50","1971.00","14","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2379.30","100","","75.00","75.00","75.00","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2379.30","100","","366.00","144.00","1971.00","45","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1736.89","73","","667.50","667.50","667.50","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1057.60","44.45","","123.77","123.77","123.77","1 through 10","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","both","","","2379.30","1784.47","WELLPOINT [1015]","HB CH WELLPOINT","1853.71","77.91","","483.51","229.32","1316.08","96","1057.6","2379.3","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2379.30","1784.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","1410.92","59.3","","439.50","225.34","1872.27","197","1189.65","1866.56","percent of total billed charges",""
"FOOT PLATE LG CALCANEUS LOCKING A.L.P.S. LEFT","SUP-ITM-10092101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2379.30","1784.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1866.56","78.45","","385.32","55.36","1815.62","58","1189.65","1866.56","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","AETNA [1001]","HB CH AETNA HMO / PPO","1605.11","58.3","","554.95","91.85","1421.75","94","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2009.83","73","","2490.03","2490.03","2490.03","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1605.11","58.3","","750.00","750.00","750.00","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1459.19","53","","1192.50","120.84","4149.90","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2340.21","85","","750.00","75.00","750.00","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2753.19","100","","657.00","121.50","1971.00","14","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2753.19","100","","75.00","75.00","75.00","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2753.19","100","","366.00","144.00","1971.00","45","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2009.83","73","","667.50","667.50","667.50","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1223.79","44.45","","123.77","123.77","123.77","1 through 10","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","both","","","2753.19","2064.89","WELLPOINT [1015]","HB CH WELLPOINT","2145.01","77.91","","483.51","229.32","1316.08","96","1223.79","2753.19","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2753.19","2064.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","1632.64","59.3","","439.50","225.34","1872.27","197","1376.6","2159.88","percent of total billed charges",""
"FOOT PLATE MEDIAL A.L.P.S. FUSION 11 HOLE","SUP-ITM-10117374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2753.19","2064.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2159.88","78.45","","385.32","55.36","1815.62","58","1376.6","2159.88","percent of total billed charges",""
"Foot Procedures With Cc","504","MS-DRG","","","","","","","","inpatient","","","52624.65","39468.49","MEDICARE [2001]","HB BWF MEDICARE","19195.33","","Case rate ($19,195.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,577.89, add-ons for qualifying new technology services are included. If operating cost exceeds $63,101.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,882.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $17,534.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,238.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,321.45. The transfer capital threshold is the transfer adjustment factor * $1,321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17584.27","17584.27","17584.27","1 through 10","17079.2919","19195.33","other","Inpatient DRG"
"Foot Procedures With Cc","504","MS-DRG","","","","","","","","inpatient","","","52624.65","39468.49","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","17198.85","","Case rate ($17,549.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,577.89, add-ons for qualifying new technology services are included. If operating cost exceeds $63,101.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,882.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,889.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,238.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,321.45. The transfer capital threshold is the transfer adjustment factor * $1,321.45. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15895.69","15895.69","15895.69","1 through 10","17079.2919","19195.33","other","Inpatient DRG"
"Foot Procedures With McC","503","MS-DRG","","","","","","","","inpatient","","","54430.37","40822.78","MEDICARE [2001]","HB BWF MEDICARE","28495.25","","Case rate ($28,495.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $26,080.08, add-ons for qualifying new technology services are included. If operating cost exceeds $71,603.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,533.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.1. The base transfer operating payment is the transfer adjustment factor * $26,182.81 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,740.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,973.20. The transfer capital threshold is the transfer adjustment factor * $1,973.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","25517.45","28495.25","other","Inpatient DRG"
"Foot Procedures Without Cc/McC","505","MS-DRG","","","","","","","","inpatient","","","42350.72","31763.04","MEDICARE [2001]","HB BWF MEDICARE","18424.63","","Case rate ($18,424.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,873.30, add-ons for qualifying new technology services are included. If operating cost exceeds $62,397.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,828.22, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $16,817.94 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,534.05 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,267.44. The transfer capital threshold is the transfer adjustment factor * $1,267.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8677.04","8677.04","17701.94","1 through 10","16509.47","18424.63","other","Inpatient DRG"
"FOOT WEDGE 12MM SUBTALAR DISTRACTION ARTHRODESIS","SUP-ITM-10203856","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","AETNA [1001]","HB CH AETNA HMO / PPO","2690.55","58.3","","1830.28","315.58","1830.28","1 through 10","2051.37","4615","percent of total billed charges",""
"FOOT WEDGE 12MM SUBTALAR DISTRACTION ARTHRODESIS","SUP-ITM-10203856","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3368.95","73","","4170.85","4170.85","4170.85","1 through 10","2051.37","4615","percent of total billed charges",""
"FOOT WEDGE 12MM SUBTALAR DISTRACTION ARTHRODESIS","SUP-ITM-10203856","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2051.37","44.45","","649.55","649.55","649.55","1 through 10","2051.37","4615","percent of total billed charges",""
"FOOT WEDGE 12MM SUBTALAR DISTRACTION ARTHRODESIS","SUP-ITM-10203856","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","WELLPOINT [1015]","HB CH WELLPOINT","3595.55","77.91","","8998.38","2542.37","8998.38","20","2051.37","4615","percent of total billed charges",""
"FOOT WEDGE 12MM SUBTALAR DISTRACTION ARTHRODESIS","SUP-ITM-10203856","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4615.00","3461.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2736.70","59.3","","1891.61","1609.14","3664.18","25","2307.5","3620.47","percent of total billed charges",""
"FOOT WEDGE 12MM SUBTALAR DISTRACTION ARTHRODESIS","SUP-ITM-10203856","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4615.00","3461.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3620.47","78.45","","1470.68","1310.06","2481.69","19","2307.5","3620.47","percent of total billed charges",""
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With McC","562","MS-DRG","","","","","","","","inpatient","","","30327.63","22745.72","MEDICARE [2001]","HB BWF MEDICARE","14712.31","","Case rate ($14,712.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,479.42, add-ons for qualifying new technology services are included. If operating cost exceeds $59,003.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,568.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $13,365.79 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,140.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,007.28. The transfer capital threshold is the transfer adjustment factor * $1,007.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","14803.43","1 through 10","13188.88","14712.31","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","22789.87","17092.40","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8842.06","","Case rate ($8,584.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,597.96, add-ons for qualifying new technology services are included. If operating cost exceeds $54,121.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,193.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,612.20 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,258.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.08. The transfer capital threshold is the transfer adjustment factor * $633.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","8676.56","8676.56","8676.56","1 through 10","8412.83","9372.84","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","22789.87","17092.40","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","9372.84","","Case rate ($9,372.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,597.96, add-ons for qualifying new technology services are included. If operating cost exceeds $54,121.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,193.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,400.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,258.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.08. The transfer capital threshold is the transfer adjustment factor * $633.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8992.41","8992.41","8992.41","1 through 10","8412.83","9372.84","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","22789.87","17092.40","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8412.83","","Case rate ($8,584.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,597.96, add-ons for qualifying new technology services are included. If operating cost exceeds $54,121.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,193.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,612.20 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,258.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.08. The transfer capital threshold is the transfer adjustment factor * $633.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8216.27","8216.27","8216.27","1 through 10","8412.83","9372.84","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","22789.87","17092.40","MEDICARE [2001]","HB BWF MEDICARE","9372.84","","Case rate ($9,372.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,597.96, add-ons for qualifying new technology services are included. If operating cost exceeds $54,121.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,193.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,400.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,258.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.08. The transfer capital threshold is the transfer adjustment factor * $633.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9078.72","0.03","9138.63","20","8412.83","9372.84","other","Inpatient DRG"
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC","563","MS-DRG","","","","","","","","inpatient","","","22789.87","17092.40","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8412.83","","Case rate ($8,584.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,597.96, add-ons for qualifying new technology services are included. If operating cost exceeds $54,121.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,193.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,612.20 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,258.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $633.08. The transfer capital threshold is the transfer adjustment factor * $633.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8227.13","8227.13","8227.13","1 through 10","8412.83","9372.84","other","Inpatient DRG"
"Fractures And Dislocations Except Femur, Pelvis And Back,MAJOR","342","DRG","","","","","","","","inpatient","","","31443.39","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24319.45","","Standard inlier is a Case rate ($24,319.45). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,874, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,452.04) for the length of stay and the standard reimbursement.","24319.44","24319.44","24319.44","1 through 10","4473.51","39079.73","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MINOR","342","DRG","","","","","","","","inpatient","","","9349.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12953.69","","Standard inlier is a Case rate ($12,953.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,020, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,838.72) for the length of stay and the standard reimbursement.","12953.69","12953.69","12953.69","1 through 10","4473.51","39079.73","case rate",""
"Fractures And Dislocations Except Femur, Pelvis And Back,MODERATE","342","DRG","","","","","","","","inpatient","","","35456.95","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5417.10","","Case rate ($5,989.53). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,419.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,584.53 and the sum of the standard inlier and any outlier amount.","5988.06","5988.06","5988.06","1 through 10","4473.51","39079.73","case rate",""
"Fractures Of Hip And Pelvis With McC","535","MS-DRG","","","","","","","","inpatient","","","27849.77","20887.33","MEDICARE [2001]","HB BWF MEDICARE","13271.77","","Case rate ($13,271.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,162.44, add-ons for qualifying new technology services are included. If operating cost exceeds $57,686.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,467.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,026.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,823.21 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $906.32. The transfer capital threshold is the transfer adjustment factor * $906.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13385.80","7032.35","13474.98","1 through 10","11900.35","13271.77","other","Inpatient DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","16399.42","12299.56","MEDICARE [2001]","HB BWF MEDICARE","8486.13","","Case rate ($8,486.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,787.31, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,131.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,575.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,448.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.94. The transfer capital threshold is the transfer adjustment factor * $570.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1449.56","728.09","8314.33","1 through 10","7619.69","8486.13","other","Inpatient DRG"
"Fractures Of Hip And Pelvis Without McC","536","MS-DRG","","","","","","","","inpatient","","","16399.42","12299.56","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7619.69","","Case rate ($7,775.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,787.31, add-ons for qualifying new technology services are included. If operating cost exceeds $53,311.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,131.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,865.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,448.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.94. The transfer capital threshold is the transfer adjustment factor * $570.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","5403.61","5403.61","5403.61","1 through 10","7619.69","8486.13","other","Inpatient DRG"
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","AETNA [1001]","HB CH AETNA HMO / PPO","1897.67","58.3","","554.95","91.85","1421.75","94","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2376.15","73","","2490.03","2490.03","2490.03","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1897.67","58.3","","750.00","750.00","750.00","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1725.15","53","","1192.50","120.84","4149.90","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2766.75","85","","750.00","75.00","750.00","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3255.00","100","","657.00","121.50","1971.00","14","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3255.00","100","","75.00","75.00","75.00","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3255.00","100","","366.00","144.00","1971.00","45","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2376.15","73","","667.50","667.50","667.50","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1446.85","44.45","","123.77","123.77","123.77","1 through 10","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","WELLPOINT [1015]","HB CH WELLPOINT","2535.97","77.91","","483.51","229.32","1316.08","96","1446.85","3255","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1930.22","59.3","","439.50","225.34","1872.27","197","1627.5","2553.55","percent of total billed charges",""
"FUSION LAPIDUS 3.5MM 0.0 4 HOLE PLATE BONE DARCO MRS LPS SS DISPLACEMENT STEP","SUP-ITM-10026192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2553.55","78.45","","385.32","55.36","1815.62","58","1627.5","2553.55","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","AETNA [1001]","HB CH AETNA HMO / PPO","2419.45","58.3","","554.95","91.85","1421.75","94","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3029.50","73","","2490.03","2490.03","2490.03","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2419.45","58.3","","750.00","750.00","750.00","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2199.50","53","","1192.50","120.84","4149.90","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3527.50","85","","750.00","75.00","750.00","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4150.00","100","","657.00","121.50","1971.00","14","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4150.00","100","","75.00","75.00","75.00","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4150.00","100","","366.00","144.00","1971.00","45","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3029.50","73","","667.50","667.50","667.50","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1844.68","44.45","","123.77","123.77","123.77","1 through 10","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","both","","","4150.00","3112.50","WELLPOINT [1015]","HB CH WELLPOINT","3233.27","77.91","","483.51","229.32","1316.08","96","1844.68","4150","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4150.00","3112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2460.95","59.3","","439.50","225.34","1872.27","197","2075","3255.68","percent of total billed charges",""
"FUSION TITANIUM 10 HOLE PLATE BONE ANKLE ANTERIOR RIGHT","SUP-ITM-10154448","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4150.00","3112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3255.68","78.45","","385.32","55.36","1815.62","58","2075","3255.68","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","both","","","6251.00","4688.25","AETNA [1001]","HB CH AETNA HMO / PPO","3644.33","58.3","","6252.88","2501.15","6252.88","1 through 10","2681.68","4870.15","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3067.37","49.07","","1842.24","1842.24","1842.24","1 through 10","2500.4","4903.91","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3131.75","50.1","","1806.52","1806.52","1844.79","12","2500.4","4903.91","percent of total billed charges",""
"Fx Inferior Turbinate Nasal Therap","PX-76000754","CDM","30930","CPT","0761","RC","","","","outpatient","","","6251.00","4688.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3706.84","59.3","","3095.84","3095.84","3095.84","1 through 10","2500.4","4903.91","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1258.00","943.50","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","427.19","427.19","15","405.83","1066.72","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","both","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","418.65","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","405.83","1066.72","other","OPPS APC"
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1258.00","943.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","745.99","59.3","","716.68","716.68","716.68","1 through 10","486.06","986.9","percent of total billed charges",""
"G&M Prostate Biopsy 10-20 Spec","PX-31000159","CDM","G0416","HCPCS","0312","RC","","","","outpatient","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","986.90","78.45","","940.24","940.24","940.24","1 through 10","486.06","986.9","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","AETNA [1001]","HB CH AETNA HMO / PPO","34980.00","58.3","","1830.28","315.58","1830.28","1 through 10","26670","60000","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43800.00","73","","4170.85","4170.85","4170.85","1 through 10","26670","60000","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26670.00","44.45","","649.55","649.55","649.55","1 through 10","26670","60000","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","both","","","60000.00","45000.00","WELLPOINT [1015]","HB CH WELLPOINT","46746.00","77.91","","8998.38","2542.37","8998.38","20","26670","60000","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35580.00","59.3","","1891.61","1609.14","3664.18","25","30000","47070","percent of total billed charges",""
"G220308 Elevate III Vad System for Hr-Pci 2025p001864","PX-62400333","CDM","C1889","HCPCS","0624","RC","","","","outpatient","","","60000.00","45000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47070.00","78.45","","1470.68","1310.06","2481.69","19","30000","47070","percent of total billed charges",""
"G6pd Enzyme Qn","PX-30000470","CDM","82955","CPT","0301","RC","","","","both","","","73.00","54.75","AETNA [1001]","HB CH AETNA HMO / PPO","42.56","58.3","","40.26","40.26","40.26","1 through 10","9.51","57.19","percent of total billed charges",""
"G6pd Enzyme Qn","PX-30000470","CDM","82955","CPT","0301","RC","","","","outpatient","","","73.00","54.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.29","59.3","","41.61","41.61","41.61","1 through 10","9.2","57.27","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","1 through 10","16.13","99.28","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","both","","","136.00","102.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","72.08","53","","69.96","69.96","69.96","1 through 10","16.13","99.28","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","77.35","1 through 10","16.98","106.69","percent of total billed charges",""
"Gammaglobulin Ige","PX-30000449","CDM","82785","CPT","0301","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","61.82","101.48","1 through 10","16.98","106.69","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","AETNA [1001]","HB CH AETNA HMO / PPO","37.90","58.3","","35.72","35.72","35.72","76","9.11","54.91","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","37.90","58.3","","35.72","35.72","35.72","1 through 10","9.11","54.91","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.45","53","","33.39","33.39","100.17","1 through 10","9.11","54.91","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","both","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.89","44.45","","28.29","28.29","28.29","1 through 10","9.11","54.91","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","65.00","48.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.55","59.3","","36.92","36.92","110.75","75","7.66","50.99","percent of total billed charges",""
"Gammaglobulin Igm Iga Igd or Igg","PX-30000447","CDM","82784","CPT","0301","RC","","","","outpatient","","","65.00","48.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","50.99","78.45","","48.43","28.70","48.44","88","7.66","50.99","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","both","","","2175.00","1631.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","2068.43","other","OPPS APC"
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","2175.00","1631.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1067.27","49.07","","2115.00","2115.00","2115.00","1 through 10","567.68","1706.29","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","2175.00","1631.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1089.68","50.1","","331.25","331.25","331.25","1 through 10","567.68","1706.29","percent of total billed charges",""
"Ganglion of Impar Block","PX-76001872","CDM","64999","CPT","0761","RC","","","","outpatient","","","2175.00","1631.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1706.29","78.45","","282.15","282.15","282.15","1 through 10","567.68","1706.29","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","AETNA [1001]","HB CH AETNA HMO / PPO","81.04","58.3","","76.55","76.55","76.55","11","11.3","101.47","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.79","44.45","","103.79","103.79","103.79","1 through 10","11.3","101.47","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","237.33","38","11.81","109.05","percent of total billed charges",""
"Ganglioside Antibody Panel, Serum","PX-30003549","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.05","78.45","","207.58","103.79","207.58","1 through 10","11.81","109.05","percent of total billed charges",""
"Gas Dilution/Washout Determine Lung","PX-46000044","CDM","94727","CPT","0460","RC","","","","outpatient","","","488.00","366.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","382.84","78.45","","365.18","365.18","365.18","1 through 10","191.73","382.84","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","406.32","469.56","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","MEDICARE [2001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","23","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","470.86","470.86","470.86","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.46","469.56","470.46","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","467.66","467.66","470.66","1 through 10","453.34","1388.46","other","OPPS APC"
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1127.89","59.3","","1083.51","1083.51","1083.51","1 through 10","626.57","1492.12","percent of total billed charges",""
"Gastric Emptying Imaging Study","PX-34000184","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1492.12","78.45","","1849.00","1421.51","1849.00","1 through 10","626.57","1492.12","percent of total billed charges",""
"Gastric Emptyng Imag Std W/Sm Bwl Transit","PX-34000182","CDM","78265","CPT","0341","RC","","","","both","","","2211.00","1658.25","MEDICARE [2001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","450.15","450.15","450.15","1 through 10","453.34","1722.59","other","OPPS APC"
"Gastric Emptyng Imag Std W/Sm Bwl Transit","PX-34000182","CDM","78265","CPT","0341","RC","","","","both","","","2211.00","1658.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","472.66","472.66","1 through 10","453.34","1722.59","other","OPPS APC"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","9650.07","","Case rate ($9,369). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,336.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","17283.67","17283.67","17283.67","1 through 10","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10232.32","","Case rate ($10,232.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,199.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9893.57","9893.57","9893.57","1 through 10","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9181.62","","Case rate ($9,369). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,336.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9071.06","9071.06","9071.06","1 through 10","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","10232.32","","Case rate ($10,232.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,199.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9057.74","9057.74","9057.74","1 through 10","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","MEDICARE [2001]","HB BWF MEDICARE","10232.32","","Case rate ($10,232.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,199.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9988.33","0.03","10054.44","34","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9181.62","","Case rate ($9,369). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,336.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9065.04","9065.04","9071.06","1 through 10","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With Cc","378","MS-DRG","","","","","","","","inpatient","","","28959.78","21719.83","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9181.62","","Case rate ($9,369). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,383.72, add-ons for qualifying new technology services are included. If operating cost exceeds $54,907.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,254.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,336.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,044.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $693.32. The transfer capital threshold is the transfer adjustment factor * $693.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9037.54","9037.54","9052.55","1 through 10","9181.62","10232.32","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41828.05","31371.04","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","16827.08","","Case rate ($17,170.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,197.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,721.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,853.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,538.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,858.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,292.32. The transfer capital threshold is the transfer adjustment factor * $1,292.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16492.76","16492.76","16492.76","1 through 10","16827.08","18779.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41828.05","31371.04","HUMANA [1012]","HB BWF MEDICARE","18779.70","","Case rate ($18,779.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,197.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,721.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,853.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $17,148.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,858.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,292.32. The transfer capital threshold is the transfer adjustment factor * $1,292.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16492.24","16492.24","16492.24","1 through 10","16827.08","18779.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41828.05","31371.04","MEDICARE [2001]","HB BWF MEDICARE","18779.70","","Case rate ($18,779.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,197.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,721.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,853.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $17,148.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,858.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,292.32. The transfer capital threshold is the transfer adjustment factor * $1,292.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18208.45","0.03","18330.37","29","16827.08","18779.7","other","Inpatient DRG"
"Gastrointestinal Hemorrhage With McC","377","MS-DRG","","","","","","","","inpatient","","","41828.05","31371.04","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16827.08","","Case rate ($17,170.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,197.92, add-ons for qualifying new technology services are included. If operating cost exceeds $62,721.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,853.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,538.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,858.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,292.32. The transfer capital threshold is the transfer adjustment factor * $1,292.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16420.49","16420.49","16496.24","1 through 10","16827.08","18779.7","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24618.33","18463.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7839.63","","Case rate ($7,611.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,623.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,146.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,119.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,713.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,283.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.36. The transfer capital threshold is the transfer adjustment factor * $558.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7783.61","7783.61","7783.61","1 through 10","7459.06","7875.5996","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24618.33","18463.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7611.29","","Case rate ($7,611.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,623.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,146.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,119.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,713.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,283.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.36. The transfer capital threshold is the transfer adjustment factor * $558.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7435.57","7435.57","8090.29","1 through 10","7459.06","7875.5996","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24618.33","18463.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7459.06","","Case rate ($7,611.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,623.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,146.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,119.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,713.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,283.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.36. The transfer capital threshold is the transfer adjustment factor * $558.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7429.89","7429.89","7429.89","1 through 10","7459.06","7875.5996","other","Inpatient DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24618.33","18463.75","MEDICARE [2001]","HB BWF MEDICARE","7611.29","","Case rate ($7,611.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,623.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,146.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,119.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,713.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,283.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.36. The transfer capital threshold is the transfer adjustment factor * $558.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8168.10","528.67","8221.84","32","7459.06","7875.5996","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24618.33","18463.75","MOLINA [1014]","HB BWF MEDICARE","7611.29","","Case rate ($7,611.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,623.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,146.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,119.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,713.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,283.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.36. The transfer capital threshold is the transfer adjustment factor * $558.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14972.64","14972.64","14972.64","1 through 10","7459.06","7875.5996","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction With Cc","389","MS-DRG","","","","","","","","inpatient","","","24618.33","18463.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7459.06","","Case rate ($7,611.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,623.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,146.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,119.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,713.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,283.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $558.36. The transfer capital threshold is the transfer adjustment factor * $558.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","5006.24","5006.24","5006.24","1 through 10","7459.06","7875.5996","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","33244.32","24933.24","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","15236.88","","Case rate ($15,236.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,958.99, add-ons for qualifying new technology services are included. If operating cost exceeds $59,482.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,604.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,853.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,619.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.04. The transfer capital threshold is the transfer adjustment factor * $1,044.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13429.59","13429.59","13429.59","1 through 10","13658.09","15236.88","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","33244.32","24933.24","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13658.09","","Case rate ($13,936.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,958.99, add-ons for qualifying new technology services are included. If operating cost exceeds $59,482.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,604.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,553.55 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,619.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.04. The transfer capital threshold is the transfer adjustment factor * $1,044.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13316.44","13316.44","13316.44","1 through 10","13658.09","15236.88","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","33244.32","24933.24","MEDICARE [2001]","HB BWF MEDICARE","15236.88","","Case rate ($15,236.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,958.99, add-ons for qualifying new technology services are included. If operating cost exceeds $59,482.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,604.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $13,853.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,619.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.04. The transfer capital threshold is the transfer adjustment factor * $1,044.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13155.62","0.03","14867.06","13","13658.09","15236.88","other","Inpatient DRG"
"Gastrointestinal Obstruction With McC","388","MS-DRG","","","","","","","","inpatient","","","33244.32","24933.24","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13658.09","","Case rate ($13,936.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,958.99, add-ons for qualifying new technology services are included. If operating cost exceeds $59,482.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,604.82, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,553.55 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,619.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,044.04. The transfer capital threshold is the transfer adjustment factor * $1,044.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13353.94","13353.94","13353.94","1 through 10","13658.09","15236.88","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","14942.44","11206.83","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","5508.53","","Case rate ($5,348.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,356.26, add-ons for qualifying new technology services are included. If operating cost exceeds $50,879.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,945.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,624.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,017.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.59. The transfer capital threshold is the transfer adjustment factor * $384.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7742.64","7742.64","7742.64","1 through 10","5241.13","5508.53","other","Inpatient DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","14942.44","11206.83","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","5348.09","","Case rate ($5,348.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,356.26, add-ons for qualifying new technology services are included. If operating cost exceeds $50,879.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,945.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,624.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,017.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.59. The transfer capital threshold is the transfer adjustment factor * $384.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","5154.21","5154.21","5154.21","1 through 10","5241.13","5508.53","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","14942.44","11206.83","MEDICARE [2001]","HB BWF MEDICARE","5348.09","","Case rate ($5,348.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,356.26, add-ons for qualifying new technology services are included. If operating cost exceeds $50,879.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,945.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,624.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,017.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.59. The transfer capital threshold is the transfer adjustment factor * $384.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","978.30","978.30","5655.54","1 through 10","5241.13","5508.53","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Obstruction Without Cc/McC","390","MS-DRG","","","","","","","","inpatient","","","14942.44","11206.83","WELLSENSE [1003]","HB BWF MEDICARE","5348.09","","Case rate ($5,348.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,356.26, add-ons for qualifying new technology services are included. If operating cost exceeds $50,879.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,945.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $4,624.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,017.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $384.59. The transfer capital threshold is the transfer adjustment factor * $384.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","5158.24","5158.24","5158.24","1 through 10","5241.13","5508.53","other","Inpatient Replacement Plans DRG"
"Gastrointestinal Vascular Insufficiency,MAJOR","246","DRG","","","","","","","","inpatient","","","152343.82","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8823.63","","Case rate ($9,756.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,186.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,427.93 and the sum of the standard inlier and any outlier amount.","16720.05","16720.05","16720.05","1 through 10","8823.63","90537.93","case rate",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","AETNA [1001]","HB CH AETNA HMO / PPO","307.26","58.3","","554.95","91.85","1421.75","94","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","384.74","73","","2490.03","2490.03","2490.03","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","307.26","58.3","","750.00","750.00","750.00","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","279.33","53","","1192.50","120.84","4149.90","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","447.98","85","","750.00","75.00","750.00","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","527.04","100","","657.00","121.50","1971.00","14","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","527.04","100","","75.00","75.00","75.00","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","527.04","100","","366.00","144.00","1971.00","45","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","384.74","73","","667.50","667.50","667.50","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","234.27","44.45","","123.77","123.77","123.77","1 through 10","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","both","","","527.04","395.28","WELLPOINT [1015]","HB CH WELLPOINT","410.62","77.91","","483.51","229.32","1316.08","96","234.27","527.04","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","527.04","395.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","312.53","59.3","","439.50","225.34","1872.27","197","263.52","413.46","percent of total billed charges",""
"GAUGE DEPTH 7.3MM SCREW CANNULATED","SUP-ITM-10005727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","527.04","395.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","413.46","78.45","","385.32","55.36","1815.62","58","263.52","413.46","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB CH AETNA HMO / PPO","163.82","58.3","","226.23","226.23","226.23","30","98.35","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.93","53","","211.47","211.47","211.47","1 through 10","98.35","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","205.13","73","","228.23","228.23","228.23","1 through 10","98.35","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","TRICARE [160005]","HB BWF TRICARE","266.95","95","","72.94","72.94","72.94","1 through 10","98.35","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","both","","","281.00","210.75","WELLPOINT [1015]","HB CH WELLPOINT","218.93","77.91","","314.25","314.25","713.25","30","98.35","266.95","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","281.00","210.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.63","59.3","","233.81","233.81","233.81","36","16.94","246.25","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.90","44.45","","306.75","306.75","306.75","1 through 10","16.94","246.25","percent of total billed charges",""
"General Health Panel","PX-30000007","CDM","80050","CPT","0301","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.44","78.45","","306.75","181.78","306.75","33","16.94","246.25","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR INTELLIS BATTERY - DISCONTINUED PER SUPPLIER","SUP-ITM-10194186","CDM","C1820","HCPCS","0278","RC","","","","both","","","32400.00","24300.00","WELLPOINT [1015]","HB CH WELLPOINT","25242.84","77.91","","17681.62","17681.62","17681.62","1 through 10","17172","32400","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR INTELLIS BATTERY - DISCONTINUED PER SUPPLIER","SUP-ITM-10194186","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","32400.00","24300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","19213.20","59.3","","74853.32","74853.32","74853.32","1 through 10","14401.8","25417.8","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR PRECISION MONTAGE SPINE CORD IMPLANTABLE PULSE MRI CONDITIONAL LEAD","SUP-ITM-10174951","CDM","C1820","HCPCS","0278","RC","","","","both","","","32600.00","24450.00","WELLPOINT [1015]","HB CH WELLPOINT","25398.66","77.91","","17681.62","17681.62","17681.62","1 through 10","17278","32600","percent of total billed charges",""
"GENERATOR NEUROSTIMULATOR PRECISION MONTAGE SPINE CORD IMPLANTABLE PULSE MRI CONDITIONAL LEAD","SUP-ITM-10174951","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","32600.00","24450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","19331.80","59.3","","74853.32","74853.32","74853.32","1 through 10","14490.7","25574.7","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","both","","","34000.00","25500.00","WELLPOINT [1015]","HB CH WELLPOINT","26489.40","77.91","","17681.62","17681.62","17681.62","1 through 10","18020","34000","percent of total billed charges",""
"GENERATOR SPECTRA WAVEWRITER SPINAL CORD","SUP-ITM-10232345","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","34000.00","25500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","20162.00","59.3","","74853.32","74853.32","74853.32","1 through 10","15113","26673","percent of total billed charges",""
"Genomic Seq Analys Dna&Rna Analys 5-50 Gene","PX-30002913","CDM","81450","CPT","0301","RC","","","","outpatient","","","3742.00","2806.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2219.01","59.3","","2132.45","2132.45","2132.45","1 through 10","1871","3047.3","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","1 through 10","7.06","47.21","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","33.99","1 through 10","7.42","47.07","percent of total billed charges",""
"Ggt/Ggtp","PX-30000476","CDM","82977","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","26.42","26.42","44.59","1 through 10","7.42","47.07","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","AETNA [1001]","HB CH AETNA HMO / PPO","3585.45","58.3","","1634.24","1004.95","1718.99","42","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4489.50","73","","2123.89","1900.92","2123.89","1 through 10","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3585.45","58.3","","3729.00","1254.19","3729.00","1 through 10","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3259.50","53","","939.37","939.37","5593.65","1 through 10","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5227.50","85","","2323.25","1864.50","2882.25","16","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6150.00","100","","2909.44","1772.40","10952.08","45","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6150.00","100","","2323.25","2323.25","2323.25","1 through 10","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6150.00","100","","2882.25","1772.40","10169.17","187","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4489.50","73","","1659.41","1659.41","1659.41","1 through 10","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","both","","","6150.00","4612.50","WELLPOINT [1015]","HB CH WELLPOINT","4791.47","77.91","","2050.91","1468.48","2902.83","52","2733.68","6150","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6150.00","4612.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3646.95","59.3","","1548.60","1092.60","3613.79","82","3075","4824.68","percent of total billed charges",""
"GLENOID AUGMENTED SM 15DEG UNIVERS VAULTROCK LT","SUP-ITM-10285904","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6150.00","4612.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4824.68","78.45","","2085.51","998.68","6202.11","56","3075","4824.68","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"GLENOID COMPONENT 15DEG SM CORTILOC RT","SUP-ITM-10205064","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"GLENOID COMPONENT 35DEG MED CORTILOC LT","SUP-ITM-10205059","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","AETNA [1001]","HB CH AETNA HMO / PPO","17162.24","58.3","","1634.24","1004.95","1718.99","42","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","21489.59","73","","2123.89","1900.92","2123.89","1 through 10","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","17162.24","58.3","","3729.00","1254.19","3729.00","1 through 10","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","15602.03","53","","939.37","939.37","5593.65","1 through 10","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","25022.13","85","","2323.25","1864.50","2882.25","16","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","29437.80","100","","2909.44","1772.40","10952.08","45","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","29437.80","100","","2323.25","2323.25","2323.25","1 through 10","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","29437.80","100","","2882.25","1772.40","10169.17","187","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","21489.59","73","","1659.41","1659.41","1659.41","1 through 10","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","both","","","29437.80","22078.35","WELLPOINT [1015]","HB CH WELLPOINT","22934.99","77.91","","2050.91","1468.48","2902.83","52","13085.1","29437.8","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","29437.80","22078.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","17456.62","59.3","","1548.60","1092.60","3613.79","82","14718.9","23093.95","percent of total billed charges",""
"GLENOID COMPREHENSIVE VRS WITH FAST GUIDES","SUP-ITM-10240114","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","29437.80","22078.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","23093.95","78.45","","2085.51","998.68","6202.11","56","14718.9","23093.95","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","AETNA [1001]","HB CH AETNA HMO / PPO","2006.06","58.3","","1634.24","1004.95","1718.99","42","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2511.88","73","","2123.89","1900.92","2123.89","1 through 10","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2006.06","58.3","","3729.00","1254.19","3729.00","1 through 10","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1823.69","53","","939.37","939.37","5593.65","1 through 10","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2924.79","85","","2323.25","1864.50","2882.25","16","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3440.93","100","","2909.44","1772.40","10952.08","45","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3440.93","100","","2323.25","2323.25","2323.25","1 through 10","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3440.93","100","","2882.25","1772.40","10169.17","187","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2511.88","73","","1659.41","1659.41","1659.41","1 through 10","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","WELLPOINT [1015]","HB CH WELLPOINT","2680.83","77.91","","2050.91","1468.48","2902.83","52","1529.49","3440.93","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1548.60","1092.60","3613.79","82","1720.47","2699.41","percent of total billed charges",""
"GLENOID PLATE 39MM MED SPHERE HEAD SHOULDER UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132820","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.41","78.45","","2085.51","998.68","6202.11","56","1720.47","2699.41","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM LATERALIZED","SUP-ITM-10215309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 36MM PERFORM REVERSE STANDARD","SUP-ITM-10211838","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE COMPONENT 39MM ECCENTRIC INTERIOR OFFSET","SUP-ITM-10215305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","AETNA [1001]","HB CH AETNA HMO / PPO","2218.43","58.3","","1634.24","1004.95","1718.99","42","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2777.80","73","","2123.89","1900.92","2123.89","1 through 10","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2218.43","58.3","","3729.00","1254.19","3729.00","1 through 10","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2016.76","53","","939.37","939.37","5593.65","1 through 10","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3234.42","85","","2323.25","1864.50","2882.25","16","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3805.20","100","","2909.44","1772.40","10952.08","45","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3805.20","100","","2323.25","2323.25","2323.25","1 through 10","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3805.20","100","","2882.25","1772.40","10169.17","187","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2777.80","73","","1659.41","1659.41","1659.41","1 through 10","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","WELLPOINT [1015]","HB CH WELLPOINT","2964.63","77.91","","2050.91","1468.48","2902.83","52","1691.41","3805.2","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1548.60","1092.60","3613.79","82","1902.6","2985.18","percent of total billed charges",""
"GLENOSPHERE GLENOID 36MM DIA 3 HUMERAL SHOULDER VERSA DIAL REVERSE COBALT ALLOY PLUS","SUP-ITM-10091556","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2985.18","78.45","","2085.51","998.68","6202.11","56","1902.6","2985.18","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","AETNA [1001]","HB CH AETNA HMO / PPO","2343.66","58.3","","1634.24","1004.95","1718.99","42","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2934.60","73","","2123.89","1900.92","2123.89","1 through 10","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2343.66","58.3","","3729.00","1254.19","3729.00","1 through 10","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2130.60","53","","939.37","939.37","5593.65","1 through 10","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3417.00","85","","2323.25","1864.50","2882.25","16","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4020.00","100","","2909.44","1772.40","10952.08","45","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4020.00","100","","2323.25","2323.25","2323.25","1 through 10","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4020.00","100","","2882.25","1772.40","10169.17","187","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2934.60","73","","1659.41","1659.41","1659.41","1 through 10","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","WELLPOINT [1015]","HB CH WELLPOINT","3131.98","77.91","","2050.91","1468.48","2902.83","52","1786.89","4020","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4020.00","3015.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2383.86","59.3","","1548.60","1092.60","3613.79","82","2010","3153.69","percent of total billed charges",""
"GLENOSPHERE REVERSE 36MM EXPANDED SMALL","SUP-ITM-10288115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3153.69","78.45","","2085.51","998.68","6202.11","56","2010","3153.69","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","1 through 10","11.81","93.2","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","both","","","98.00","73.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","62.13","63.4","","62.99","62.99","62.99","1 through 10","11.81","93.2","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","98.00","73.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.11","59.3","","55.67","55.67","55.67","1 through 10","17.87","76.88","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","56.55","57.7","","57.29","55.10","57.29","11","17.87","76.88","percent of total billed charges",""
"Gliadin Antibody Each Immunoglobulin Class","PX-30003768","CDM","86258","CPT","0302","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","43.28","146.07","1 through 10","17.87","76.88","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","both","","","619.00","464.25","AETNA [1001]","HB CH AETNA HMO / PPO","360.88","58.3","","229.07","229.07","229.07","1 through 10","265.55","619","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","both","","","619.00","464.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","619.00","100","","146.35","146.35","146.35","1 through 10","265.55","619","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","both","","","619.00","464.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","619.00","100","","479.79","159.93","479.79","1 through 10","265.55","619","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","both","","","619.00","464.25","WELLPOINT [1015]","HB CH WELLPOINT","482.26","77.91","","611.65","611.65","611.65","1 through 10","265.55","619","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","outpatient","","","619.00","464.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","303.74","49.07","","153.61","153.61","153.61","20","247.6","485.61","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","outpatient","","","619.00","464.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","310.12","50.1","","153.61","153.61","153.61","35","247.6","485.61","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","outpatient","","","619.00","464.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","367.07","59.3","","710.22","236.74","710.22","1 through 10","247.6","485.61","percent of total billed charges",""
"Glucagon Tolerance Panel Pheochrom","PX-30000053","CDM","80424","CPT","0300","RC","","","","outpatient","","","619.00","464.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","485.61","78.45","","310.60","184.06","310.60","11","247.6","485.61","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","1 through 10","3.85","30.66","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","both","","","42.00","31.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","30.66","73","","5.50","5.50","5.50","1 through 10","3.85","30.66","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","24.03","1 through 10","4.05","32.95","percent of total billed charges",""
"Glucose Blood","PX-30000463","CDM","82947","CPT","0301","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","31.52","31.52","1 through 10","4.05","32.95","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","27.00","20.25","AETNA [1001]","HB CH AETNA HMO / PPO","15.74","58.3","","14.74","14.74","29.48","20","3.21","19.71","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","27.00","20.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","14.31","53","","13.78","13.78","13.78","1 through 10","3.21","19.71","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","both","","","27.00","20.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","12.00","44.45","","11.85","11.85","11.85","1 through 10","3.21","19.71","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","27.00","20.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","16.01","59.3","","15.24","15.24","15.24","14","2.42","21.18","percent of total billed charges",""
"Glucose by Device","PX-30000472","CDM","82962","CPT","0301","RC","","","","outpatient","","","27.00","20.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","21.18","78.45","","19.99","11.85","19.99","18","2.42","21.18","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","both","","","36.00","27.00","AETNA [1001]","HB CH AETNA HMO / PPO","20.99","58.3","","19.85","19.85","19.85","1 through 10","3.85","26.28","percent of total billed charges",""
"Glucose Fluid Not Blood","PX-30000461","CDM","82945","CPT","0301","RC","","","","outpatient","","","36.00","27.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.35","59.3","","20.51","20.51","20.51","1 through 10","4.05","28.24","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","both","","","39.00","29.25","AETNA [1001]","HB CH AETNA HMO / PPO","22.74","58.3","","21.55","21.55","21.55","11","4.66","31.12","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","23.13","59.3","","22.27","22.27","22.27","15","4.89","30.6","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","17.34","44.45","","29.21","29.21","29.21","1 through 10","4.89","30.6","percent of total billed charges",""
"Glucose Post Dose","PX-30000465","CDM","82950","CPT","0301","RC","","","","outpatient","","","39.00","29.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","30.60","78.45","","29.21","29.21","29.22","1 through 10","4.89","30.6","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","1 through 10","12.61","84.38","percent of total billed charges",""
"Glucose Tolerance 1st 3 Specimen","PX-30000466","CDM","82951","CPT","0301","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","79.19","79.19","79.19","1 through 10","13.27","83.16","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","16.42","98.82","percent of total billed charges",""
"Glycated Protein (Fructosamine)","PX-30000480","CDM","82985","CPT","0301","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","53.76","90.72","1 through 10","15.54","95.03","percent of total billed charges",""
"GRAFT ALLO 12X14.5 5MM BONE PARALLEL PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2889.45","2167.09","AETNA [1001]","HB CH AETNA HMO / PPO","1684.55","58.3","","1830.28","315.58","1830.28","1 through 10","1284.36","2889.45","percent of total billed charges",""
"GRAFT ALLO 12X14.5 5MM BONE PARALLEL PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2889.45","2167.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2109.30","73","","4170.85","4170.85","4170.85","1 through 10","1284.36","2889.45","percent of total billed charges",""
"GRAFT ALLO 12X14.5 5MM BONE PARALLEL PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2889.45","2167.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.36","44.45","","649.55","649.55","649.55","1 through 10","1284.36","2889.45","percent of total billed charges",""
"GRAFT ALLO 12X14.5 5MM BONE PARALLEL PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124317","CDM","C1889","HCPCS","0278","RC","","","","both","","","2889.45","2167.09","WELLPOINT [1015]","HB CH WELLPOINT","2251.17","77.91","","8998.38","2542.37","8998.38","20","1284.36","2889.45","percent of total billed charges",""
"GRAFT ALLO 12X14.5 5MM BONE PARALLEL PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124317","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2889.45","2167.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1713.44","59.3","","1891.61","1609.14","3664.18","25","1444.73","2266.77","percent of total billed charges",""
"GRAFT ALLO 12X14.5 5MM BONE PARALLEL PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124317","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2889.45","2167.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2266.77","78.45","","1470.68","1310.06","2481.69","19","1444.73","2266.77","percent of total billed charges",""
"GRAFT ALLO 1IN MATRIX DURAL DURAGEN COLLAGEN SUTURABLE CA/1EA","SUP-ITM-10024786","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","723.00","542.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.19","78.45","","555.84","555.84","555.84","1 through 10","361.5","567.19","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","7234.74","5426.05","AETNA [1001]","HB CH AETNA HMO / PPO","4217.85","58.3","","585.96","347.85","5016.82","1 through 10","3215.84","7234.74","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","7234.74","5426.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6149.53","85","","1295.16","1295.16","1295.16","1 through 10","3215.84","7234.74","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","7234.74","5426.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7234.74","100","","2700.00","1008.69","2700.00","1 through 10","3215.84","7234.74","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","7234.74","5426.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7234.74","100","","2520.00","797.10","5898.60","1 through 10","3215.84","7234.74","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","7234.74","5426.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3215.84","44.45","","1953.42","1953.42","1953.42","1 through 10","3215.84","7234.74","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","both","","","7234.74","5426.05","WELLPOINT [1015]","HB CH WELLPOINT","5636.59","77.91","","1490.36","627.80","7327.37","1 through 10","3215.84","7234.74","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7234.74","5426.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","4290.20","59.3","","536.35","188.54","1772.63","17","3617.37","5675.65","percent of total billed charges",""
"GRAFT ALLO 8CMX16 TISSUE ALLOMAX COLLAGEN ACELLULAR DERMAL MATRIX RECTANGLE BX/1","SUP-ITM-10072526","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","7234.74","5426.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5675.65","78.45","","562.30","246.20","3344.28","1 through 10","3617.37","5675.65","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","4240.00","3180.00","AETNA [1001]","HB CH AETNA HMO / PPO","2471.92","58.3","","1830.28","315.58","1830.28","1 through 10","1884.68","4240","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","4240.00","3180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3095.20","73","","4170.85","4170.85","4170.85","1 through 10","1884.68","4240","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","4240.00","3180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1884.68","44.45","","649.55","649.55","649.55","1 through 10","1884.68","4240","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","both","","","4240.00","3180.00","WELLPOINT [1015]","HB CH WELLPOINT","3303.38","77.91","","8998.38","2542.37","8998.38","20","1884.68","4240","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4240.00","3180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2514.32","59.3","","1891.61","1609.14","3664.18","25","2120","3326.28","percent of total billed charges",""
"GRAFT ALLO AVANCE 15X2.0 3.0MM NERVE DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100507","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4240.00","3180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3326.28","78.45","","1470.68","1310.06","2481.69","19","2120","3326.28","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","AETNA [1001]","HB CH AETNA HMO / PPO","5830.00","58.3","","1830.28","315.58","1830.28","1 through 10","4445","10000","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","4170.85","4170.85","4170.85","1 through 10","4445","10000","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4445.00","44.45","","649.55","649.55","649.55","1 through 10","4445","10000","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB CH WELLPOINT","7791.00","77.91","","8998.38","2542.37","8998.38","20","4445","10000","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5930.00","59.3","","1891.61","1609.14","3664.18","25","5000","7845","percent of total billed charges",""
"GRAFT ALLO BONE TIBIA LATERAL WITH MENISCUS BLOCK ASEPTIC FRESH FROZEN RIGHT","SUP-ITM-10065841","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7845.00","78.45","","1470.68","1310.06","2481.69","19","5000","7845","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","AETNA [1001]","HB CH AETNA HMO / PPO","13992.00","58.3","","1830.28","315.58","1830.28","1 through 10","10668","24000","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17520.00","73","","4170.85","4170.85","4170.85","1 through 10","10668","24000","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10668.00","44.45","","649.55","649.55","649.55","1 through 10","10668","24000","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","both","","","24000.00","18000.00","WELLPOINT [1015]","HB CH WELLPOINT","18698.40","77.91","","8998.38","2542.37","8998.38","20","10668","24000","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24000.00","18000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","14232.00","59.3","","1891.61","1609.14","3664.18","25","12000","18828","percent of total billed charges",""
"GRAFT ALLO TISSUE FEMUR HEMI CONDYLE OSTEOARTICULAR LATERAL RT FRESH","SUP-ITM-10050433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24000.00","18000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18828.00","78.45","","1470.68","1310.06","2481.69","19","12000","18828","percent of total billed charges",""
"GRAFT ALLO TROCHLEA OSTEOCHONDRAL LT FEMORAL FRESH","SUP-ITM-10080613","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","AETNA [1001]","HB CH AETNA HMO / PPO","14283.50","58.3","","1830.28","315.58","1830.28","1 through 10","10890.25","24500","percent of total billed charges",""
"GRAFT ALLO TROCHLEA OSTEOCHONDRAL LT FEMORAL FRESH","SUP-ITM-10080613","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17885.00","73","","4170.85","4170.85","4170.85","1 through 10","10890.25","24500","percent of total billed charges",""
"GRAFT ALLO TROCHLEA OSTEOCHONDRAL LT FEMORAL FRESH","SUP-ITM-10080613","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10890.25","44.45","","649.55","649.55","649.55","1 through 10","10890.25","24500","percent of total billed charges",""
"GRAFT ALLO TROCHLEA OSTEOCHONDRAL LT FEMORAL FRESH","SUP-ITM-10080613","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","WELLPOINT [1015]","HB CH WELLPOINT","19087.95","77.91","","8998.38","2542.37","8998.38","20","10890.25","24500","percent of total billed charges",""
"GRAFT ALLO TROCHLEA OSTEOCHONDRAL LT FEMORAL FRESH","SUP-ITM-10080613","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24500.00","18375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","14528.50","59.3","","1891.61","1609.14","3664.18","25","12250","19220.25","percent of total billed charges",""
"GRAFT ALLO TROCHLEA OSTEOCHONDRAL LT FEMORAL FRESH","SUP-ITM-10080613","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24500.00","18375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19220.25","78.45","","1470.68","1310.06","2481.69","19","12250","19220.25","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","AETNA [1001]","HB CH AETNA HMO / PPO","2397.59","58.3","","554.95","91.85","1421.75","94","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3002.13","73","","2490.03","2490.03","2490.03","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2397.59","58.3","","750.00","750.00","750.00","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2179.63","53","","1192.50","120.84","4149.90","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3495.63","85","","750.00","75.00","750.00","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4112.50","100","","657.00","121.50","1971.00","14","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4112.50","100","","75.00","75.00","75.00","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4112.50","100","","366.00","144.00","1971.00","45","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3002.13","73","","667.50","667.50","667.50","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1828.01","44.45","","123.77","123.77","123.77","1 through 10","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","both","","","4112.50","3084.37","WELLPOINT [1015]","HB CH WELLPOINT","3204.05","77.91","","483.51","229.32","1316.08","96","1828.01","4112.5","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2438.71","59.3","","439.50","225.34","1872.27","197","2056.25","3226.26","percent of total billed charges",""
"GRAFT BONE 1 2MM ACTIFUSE ABX SYNTHETIC PUTTY GRANULE","SUP-ITM-10029111","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4112.50","3084.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3226.26","78.45","","385.32","55.36","1815.62","58","2056.25","3226.26","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","AETNA [1001]","HB CH AETNA HMO / PPO","281.38","58.3","","1830.28","315.58","1830.28","1 through 10","214.53","482.64","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","352.33","73","","4170.85","4170.85","4170.85","1 through 10","214.53","482.64","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.53","44.45","","649.55","649.55","649.55","1 through 10","214.53","482.64","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","both","","","482.64","361.98","WELLPOINT [1015]","HB CH WELLPOINT","376.02","77.91","","8998.38","2542.37","8998.38","20","214.53","482.64","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","482.64","361.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","286.21","59.3","","1891.61","1609.14","3664.18","25","241.32","378.63","percent of total billed charges",""
"GRAFT BONE 1 8MM 10 CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","482.64","361.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","378.63","78.45","","1470.68","1310.06","2481.69","19","241.32","378.63","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","AETNA [1001]","HB CH AETNA HMO / PPO","210.68","58.3","","1830.28","315.58","1830.28","1 through 10","160.63","361.38","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","263.81","73","","4170.85","4170.85","4170.85","1 through 10","160.63","361.38","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.63","44.45","","649.55","649.55","649.55","1 through 10","160.63","361.38","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","both","","","361.38","271.03","WELLPOINT [1015]","HB CH WELLPOINT","281.55","77.91","","8998.38","2542.37","8998.38","20","160.63","361.38","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.38","271.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.30","59.3","","1891.61","1609.14","3664.18","25","180.69","283.5","percent of total billed charges",""
"GRAFT BONE 1 8MM 5 READI CANCELLOUS CRUSHED FREEZE DRIED CHIPS BIORESORBABLE SUBSTITUTE","SUP-ITM-10010237","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","361.38","271.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.50","78.45","","1470.68","1310.06","2481.69","19","180.69","283.5","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","979.20","734.40","AETNA [1001]","HB CH AETNA HMO / PPO","570.87","58.3","","1830.28","315.58","1830.28","1 through 10","435.25","979.2","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","979.20","734.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","714.82","73","","4170.85","4170.85","4170.85","1 through 10","435.25","979.2","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","979.20","734.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","435.25","44.45","","649.55","649.55","649.55","1 through 10","435.25","979.2","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","both","","","979.20","734.40","WELLPOINT [1015]","HB CH WELLPOINT","762.89","77.91","","8998.38","2542.37","8998.38","20","435.25","979.2","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","979.20","734.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","580.67","59.3","","1891.61","1609.14","3664.18","25","489.6","768.18","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CHIPS CRUSHED BIORESORBABLE SUBSTITUTE FREEZE DRIED","SUP-ITM-10008886","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","979.20","734.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","768.18","78.45","","1470.68","1310.06","2481.69","19","489.6","768.18","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","AETNA [1001]","HB CH AETNA HMO / PPO","428.47","58.3","","1830.28","315.58","1830.28","1 through 10","326.68","734.94","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","536.51","73","","4170.85","4170.85","4170.85","1 through 10","326.68","734.94","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.68","44.45","","649.55","649.55","649.55","1 through 10","326.68","734.94","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","both","","","734.94","551.20","WELLPOINT [1015]","HB CH WELLPOINT","572.59","77.91","","8998.38","2542.37","8998.38","20","326.68","734.94","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","734.94","551.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.82","59.3","","1891.61","1609.14","3664.18","25","367.47","576.56","percent of total billed charges",""
"GRAFT BONE 1 8MM READI CANCELLOUS CRUSHED FREEZE DRIED","SUP-ITM-10010234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","734.94","551.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","576.56","78.45","","1470.68","1310.06","2481.69","19","367.47","576.56","percent of total billed charges",""
"GRAFT BONE 1.0CC VIVIGEN ALLO DBM CELLULAR MATRIX FROZEN","SUP-ITM-10168489","CDM","C1889","HCPCS","0278","RC","","","","both","","","1339.26","1004.44","AETNA [1001]","HB CH AETNA HMO / PPO","780.79","58.3","","1830.28","315.58","1830.28","1 through 10","595.3","1339.26","percent of total billed charges",""
"GRAFT BONE 1.0CC VIVIGEN ALLO DBM CELLULAR MATRIX FROZEN","SUP-ITM-10168489","CDM","C1889","HCPCS","0278","RC","","","","both","","","1339.26","1004.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","977.66","73","","4170.85","4170.85","4170.85","1 through 10","595.3","1339.26","percent of total billed charges",""
"GRAFT BONE 1.0CC VIVIGEN ALLO DBM CELLULAR MATRIX FROZEN","SUP-ITM-10168489","CDM","C1889","HCPCS","0278","RC","","","","both","","","1339.26","1004.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","595.30","44.45","","649.55","649.55","649.55","1 through 10","595.3","1339.26","percent of total billed charges",""
"GRAFT BONE 1.0CC VIVIGEN ALLO DBM CELLULAR MATRIX FROZEN","SUP-ITM-10168489","CDM","C1889","HCPCS","0278","RC","","","","both","","","1339.26","1004.44","WELLPOINT [1015]","HB CH WELLPOINT","1043.42","77.91","","8998.38","2542.37","8998.38","20","595.3","1339.26","percent of total billed charges",""
"GRAFT BONE 1.0CC VIVIGEN ALLO DBM CELLULAR MATRIX FROZEN","SUP-ITM-10168489","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1339.26","1004.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","794.18","59.3","","1891.61","1609.14","3664.18","25","669.63","1050.65","percent of total billed charges",""
"GRAFT BONE 1.0CC VIVIGEN ALLO DBM CELLULAR MATRIX FROZEN","SUP-ITM-10168489","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1339.26","1004.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1050.65","78.45","","1470.68","1310.06","2481.69","19","669.63","1050.65","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","AETNA [1001]","HB CH AETNA HMO / PPO","870.39","58.3","","554.95","91.85","1421.75","94","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1089.85","73","","2490.03","2490.03","2490.03","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","870.39","58.3","","750.00","750.00","750.00","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","791.26","53","","1192.50","120.84","4149.90","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1269.01","85","","750.00","75.00","750.00","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1492.95","100","","657.00","121.50","1971.00","14","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1492.95","100","","75.00","75.00","75.00","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1492.95","100","","366.00","144.00","1971.00","45","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1089.85","73","","667.50","667.50","667.50","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","663.62","44.45","","123.77","123.77","123.77","1 through 10","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","both","","","1492.95","1119.71","WELLPOINT [1015]","HB CH WELLPOINT","1163.16","77.91","","483.51","229.32","1316.08","96","663.62","1492.95","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1492.95","1119.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","885.32","59.3","","439.50","225.34","1872.27","197","746.48","1171.22","percent of total billed charges",""
"GRAFT BONE 1.4 2.8MM 10 MED CHRONOS BETA TRICALCIUM PHOSPHATE GRANULE VOID FILLER","SUP-ITM-10041310","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1492.95","1119.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1171.22","78.45","","385.32","55.36","1815.62","58","746.48","1171.22","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","AETNA [1001]","HB CH AETNA HMO / PPO","4054.01","58.3","","1830.28","315.58","1830.28","1 through 10","3090.92","6953.7","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5076.20","73","","4170.85","4170.85","4170.85","1 through 10","3090.92","6953.7","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3090.92","44.45","","649.55","649.55","649.55","1 through 10","3090.92","6953.7","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","WELLPOINT [1015]","HB CH WELLPOINT","5417.63","77.91","","8998.38","2542.37","8998.38","20","3090.92","6953.7","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","4123.54","59.3","","1891.61","1609.14","3664.18","25","3476.85","5455.18","percent of total billed charges",""
"GRAFT BONE 10CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282976","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5455.18","78.45","","1470.68","1310.06","2481.69","19","3476.85","5455.18","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","2656.68","1992.51","AETNA [1001]","HB CH AETNA HMO / PPO","1548.84","58.3","","1830.28","315.58","1830.28","1 through 10","1180.89","2656.68","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","2656.68","1992.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1939.38","73","","4170.85","4170.85","4170.85","1 through 10","1180.89","2656.68","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","2656.68","1992.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1180.89","44.45","","649.55","649.55","649.55","1 through 10","1180.89","2656.68","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","both","","","2656.68","1992.51","WELLPOINT [1015]","HB CH WELLPOINT","2069.82","77.91","","8998.38","2542.37","8998.38","20","1180.89","2656.68","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2656.68","1992.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","1575.41","59.3","","1891.61","1609.14","3664.18","25","1328.34","2084.17","percent of total billed charges",""
"GRAFT BONE 10CC ALLO DBX DEMINERALIZED MATRIX FREEZE DRIED PUTTY SYRINGE","SUP-ITM-10008199","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2656.68","1992.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2084.17","78.45","","1470.68","1310.06","2481.69","19","1328.34","2084.17","percent of total billed charges",""
"GRAFT BONE 10CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168491","CDM","C1889","HCPCS","0278","RC","","","","both","","","6787.20","5090.40","AETNA [1001]","HB CH AETNA HMO / PPO","3956.94","58.3","","1830.28","315.58","1830.28","1 through 10","3016.91","6787.2","percent of total billed charges",""
"GRAFT BONE 10CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168491","CDM","C1889","HCPCS","0278","RC","","","","both","","","6787.20","5090.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4954.66","73","","4170.85","4170.85","4170.85","1 through 10","3016.91","6787.2","percent of total billed charges",""
"GRAFT BONE 10CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168491","CDM","C1889","HCPCS","0278","RC","","","","both","","","6787.20","5090.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3016.91","44.45","","649.55","649.55","649.55","1 through 10","3016.91","6787.2","percent of total billed charges",""
"GRAFT BONE 10CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168491","CDM","C1889","HCPCS","0278","RC","","","","both","","","6787.20","5090.40","WELLPOINT [1015]","HB CH WELLPOINT","5287.91","77.91","","8998.38","2542.37","8998.38","20","3016.91","6787.2","percent of total billed charges",""
"GRAFT BONE 10CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168491","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6787.20","5090.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","4024.81","59.3","","1891.61","1609.14","3664.18","25","3393.6","5324.56","percent of total billed charges",""
"GRAFT BONE 10CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168491","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6787.20","5090.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5324.56","78.45","","1470.68","1310.06","2481.69","19","3393.6","5324.56","percent of total billed charges",""
"GRAFT BONE 10MM SHORT LIGAMENT BISECTED PATELLAR BLOCK FROZEN MINIMUM","SUP-ITM-10010260","CDM","C1889","HCPCS","0278","RC","","","","both","","","4604.56","3453.42","AETNA [1001]","HB CH AETNA HMO / PPO","2684.46","58.3","","1830.28","315.58","1830.28","1 through 10","2046.73","4604.56","percent of total billed charges",""
"GRAFT BONE 10MM SHORT LIGAMENT BISECTED PATELLAR BLOCK FROZEN MINIMUM","SUP-ITM-10010260","CDM","C1889","HCPCS","0278","RC","","","","both","","","4604.56","3453.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3361.33","73","","4170.85","4170.85","4170.85","1 through 10","2046.73","4604.56","percent of total billed charges",""
"GRAFT BONE 10MM SHORT LIGAMENT BISECTED PATELLAR BLOCK FROZEN MINIMUM","SUP-ITM-10010260","CDM","C1889","HCPCS","0278","RC","","","","both","","","4604.56","3453.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2046.73","44.45","","649.55","649.55","649.55","1 through 10","2046.73","4604.56","percent of total billed charges",""
"GRAFT BONE 10MM SHORT LIGAMENT BISECTED PATELLAR BLOCK FROZEN MINIMUM","SUP-ITM-10010260","CDM","C1889","HCPCS","0278","RC","","","","both","","","4604.56","3453.42","WELLPOINT [1015]","HB CH WELLPOINT","3587.41","77.91","","8998.38","2542.37","8998.38","20","2046.73","4604.56","percent of total billed charges",""
"GRAFT BONE 10MM SHORT LIGAMENT BISECTED PATELLAR BLOCK FROZEN MINIMUM","SUP-ITM-10010260","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4604.56","3453.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","2730.50","59.3","","1891.61","1609.14","3664.18","25","2302.28","3612.28","percent of total billed charges",""
"GRAFT BONE 10MM SHORT LIGAMENT BISECTED PATELLAR BLOCK FROZEN MINIMUM","SUP-ITM-10010260","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4604.56","3453.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3612.28","78.45","","1470.68","1310.06","2481.69","19","2302.28","3612.28","percent of total billed charges",""
"GRAFT BONE 11MM ALLO FLEXI PATELLAR LIGAMENT PRESHAPED FROZEN","SUP-ITM-10056532","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.64","4631.73","AETNA [1001]","HB CH AETNA HMO / PPO","3600.40","58.3","","1830.28","315.58","1830.28","1 through 10","2745.07","6175.64","percent of total billed charges",""
"GRAFT BONE 11MM ALLO FLEXI PATELLAR LIGAMENT PRESHAPED FROZEN","SUP-ITM-10056532","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.64","4631.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4508.22","73","","4170.85","4170.85","4170.85","1 through 10","2745.07","6175.64","percent of total billed charges",""
"GRAFT BONE 11MM ALLO FLEXI PATELLAR LIGAMENT PRESHAPED FROZEN","SUP-ITM-10056532","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.64","4631.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2745.07","44.45","","649.55","649.55","649.55","1 through 10","2745.07","6175.64","percent of total billed charges",""
"GRAFT BONE 11MM ALLO FLEXI PATELLAR LIGAMENT PRESHAPED FROZEN","SUP-ITM-10056532","CDM","C1889","HCPCS","0278","RC","","","","both","","","6175.64","4631.73","WELLPOINT [1015]","HB CH WELLPOINT","4811.44","77.91","","8998.38","2542.37","8998.38","20","2745.07","6175.64","percent of total billed charges",""
"GRAFT BONE 11MM ALLO FLEXI PATELLAR LIGAMENT PRESHAPED FROZEN","SUP-ITM-10056532","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6175.64","4631.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","3662.15","59.3","","1891.61","1609.14","3664.18","25","3087.82","4844.79","percent of total billed charges",""
"GRAFT BONE 11MM ALLO FLEXI PATELLAR LIGAMENT PRESHAPED FROZEN","SUP-ITM-10056532","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6175.64","4631.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4844.79","78.45","","1470.68","1310.06","2481.69","19","3087.82","4844.79","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","AETNA [1001]","HB CH AETNA HMO / PPO","1651.30","58.3","","1830.28","315.58","1830.28","1 through 10","1259.01","2832.42","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2067.67","73","","4170.85","4170.85","4170.85","1 through 10","1259.01","2832.42","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1259.01","44.45","","649.55","649.55","649.55","1 through 10","1259.01","2832.42","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","both","","","2832.42","2124.31","WELLPOINT [1015]","HB CH WELLPOINT","2206.74","77.91","","8998.38","2542.37","8998.38","20","1259.01","2832.42","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2832.42","2124.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","1679.63","59.3","","1891.61","1609.14","3664.18","25","1416.21","2222.03","percent of total billed charges",""
"GRAFT BONE 12X14.5 6.0MM 7.0DEG LORDOTIC PRESERVON VERTI2 CERVICAL IMPLANTABLE","SUP-ITM-10124323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2832.42","2124.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2222.03","78.45","","1470.68","1310.06","2481.69","19","1416.21","2222.03","percent of total billed charges",""
"GRAFT BONE 12X14.5 7MM 7DEG LORDOTIC PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124313","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","AETNA [1001]","HB CH AETNA HMO / PPO","1560.98","58.3","","1830.28","315.58","1830.28","1 through 10","1190.15","2677.5","percent of total billed charges",""
"GRAFT BONE 12X14.5 7MM 7DEG LORDOTIC PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124313","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1954.58","73","","4170.85","4170.85","4170.85","1 through 10","1190.15","2677.5","percent of total billed charges",""
"GRAFT BONE 12X14.5 7MM 7DEG LORDOTIC PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124313","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1190.15","44.45","","649.55","649.55","649.55","1 through 10","1190.15","2677.5","percent of total billed charges",""
"GRAFT BONE 12X14.5 7MM 7DEG LORDOTIC PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124313","CDM","C1889","HCPCS","0278","RC","","","","both","","","2677.50","2008.12","WELLPOINT [1015]","HB CH WELLPOINT","2086.04","77.91","","8998.38","2542.37","8998.38","20","1190.15","2677.5","percent of total billed charges",""
"GRAFT BONE 12X14.5 7MM 7DEG LORDOTIC PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124313","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2677.50","2008.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1587.76","59.3","","1891.61","1609.14","3664.18","25","1338.75","2100.5","percent of total billed charges",""
"GRAFT BONE 12X14.5 7MM 7DEG LORDOTIC PRESERVON VERTI1 CERVICAL IMPLANTABLE","SUP-ITM-10124313","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2677.50","2008.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2100.50","78.45","","1470.68","1310.06","2481.69","19","1338.75","2100.5","percent of total billed charges",""
"GRAFT BONE 15CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168492","CDM","C1889","HCPCS","0278","RC","","","","both","","","8544.60","6408.45","AETNA [1001]","HB CH AETNA HMO / PPO","4981.50","58.3","","1830.28","315.58","1830.28","1 through 10","3798.07","8544.6","percent of total billed charges",""
"GRAFT BONE 15CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168492","CDM","C1889","HCPCS","0278","RC","","","","both","","","8544.60","6408.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6237.56","73","","4170.85","4170.85","4170.85","1 through 10","3798.07","8544.6","percent of total billed charges",""
"GRAFT BONE 15CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168492","CDM","C1889","HCPCS","0278","RC","","","","both","","","8544.60","6408.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3798.07","44.45","","649.55","649.55","649.55","1 through 10","3798.07","8544.6","percent of total billed charges",""
"GRAFT BONE 15CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168492","CDM","C1889","HCPCS","0278","RC","","","","both","","","8544.60","6408.45","WELLPOINT [1015]","HB CH WELLPOINT","6657.10","77.91","","8998.38","2542.37","8998.38","20","3798.07","8544.6","percent of total billed charges",""
"GRAFT BONE 15CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168492","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8544.60","6408.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","5066.95","59.3","","1891.61","1609.14","3664.18","25","4272.3","6703.24","percent of total billed charges",""
"GRAFT BONE 15CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168492","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8544.60","6408.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6703.24","78.45","","1470.68","1310.06","2481.69","19","4272.3","6703.24","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","AETNA [1001]","HB CH AETNA HMO / PPO","708.80","58.3","","1830.28","315.58","1830.28","1 through 10","540.41","1215.78","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","887.52","73","","4170.85","4170.85","4170.85","1 through 10","540.41","1215.78","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.41","44.45","","649.55","649.55","649.55","1 through 10","540.41","1215.78","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","both","","","1215.78","911.83","WELLPOINT [1015]","HB CH WELLPOINT","947.21","77.91","","8998.38","2542.37","8998.38","20","540.41","1215.78","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1215.78","911.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.96","59.3","","1891.61","1609.14","3664.18","25","607.89","953.78","percent of total billed charges",""
"GRAFT BONE 15X120MM 200 XW FROZEN STRUT MATRI CORTICAL IMPLANTABLE","SUP-ITM-10010269","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1215.78","911.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.78","78.45","","1470.68","1310.06","2481.69","19","607.89","953.78","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1694.61","1270.96","AETNA [1001]","HB CH AETNA HMO / PPO","987.96","58.3","","1830.28","315.58","1830.28","1 through 10","753.25","1694.61","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1694.61","1270.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1237.07","73","","4170.85","4170.85","4170.85","1 through 10","753.25","1694.61","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1694.61","1270.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.25","44.45","","649.55","649.55","649.55","1 through 10","753.25","1694.61","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","both","","","1694.61","1270.96","WELLPOINT [1015]","HB CH WELLPOINT","1320.27","77.91","","8998.38","2542.37","8998.38","20","753.25","1694.61","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1694.61","1270.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","1004.90","59.3","","1891.61","1609.14","3664.18","25","847.31","1329.42","percent of total billed charges",""
"GRAFT BONE 16MM MATRI DOWEL CLOWARD","SUP-ITM-10010250","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1694.61","1270.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1329.42","78.45","","1470.68","1310.06","2481.69","19","847.31","1329.42","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","AETNA [1001]","HB CH AETNA HMO / PPO","605.15","58.3","","554.95","91.85","1421.75","94","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","757.74","73","","2490.03","2490.03","2490.03","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","605.15","58.3","","750.00","750.00","750.00","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","550.14","53","","1192.50","120.84","4149.90","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","882.30","85","","750.00","75.00","750.00","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1038.00","100","","657.00","121.50","1971.00","14","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1038.00","100","","75.00","75.00","75.00","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1038.00","100","","366.00","144.00","1971.00","45","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","757.74","73","","667.50","667.50","667.50","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","461.39","44.45","","123.77","123.77","123.77","1 through 10","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","both","","","1038.00","778.50","WELLPOINT [1015]","HB CH WELLPOINT","808.71","77.91","","483.51","229.32","1316.08","96","461.39","1038","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.00","778.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","615.53","59.3","","439.50","225.34","1872.27","197","519","814.31","percent of total billed charges",""
"GRAFT BONE 1CC 1 TO 2MM GRANULE PUTTY MAGNETOS","SUP-ITM-10280395","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1038.00","778.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","814.31","78.45","","385.32","55.36","1815.62","58","519","814.31","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","AETNA [1001]","HB CH AETNA HMO / PPO","1484.76","58.3","","1830.28","315.58","1830.28","1 through 10","1132.03","2546.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1859.13","73","","4170.85","4170.85","4170.85","1 through 10","1132.03","2546.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1132.03","44.45","","649.55","649.55","649.55","1 through 10","1132.03","2546.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","both","","","2546.76","1910.07","WELLPOINT [1015]","HB CH WELLPOINT","1984.18","77.91","","8998.38","2542.37","8998.38","20","1132.03","2546.76","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2546.76","1910.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","1510.23","59.3","","1891.61","1609.14","3664.18","25","1273.38","1997.93","percent of total billed charges",""
"GRAFT BONE 200MM MATRI FEMORAL SHAFT BISECTED FROZEN GREATER THAN OR EQUAL","SUP-ITM-10010258","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2546.76","1910.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1997.93","78.45","","1470.68","1310.06","2481.69","19","1273.38","1997.93","percent of total billed charges",""
"GRAFT BONE 25.0X100.0 4.0MM SUBSTITUTE VITOSS BIOACTIVE FOAM STRIP","SUP-ITM-10029649","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4206.68","3155.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3300.14","78.45","","555.84","555.84","555.84","1 through 10","2103.34","3300.14","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2866.68","2150.01","AETNA [1001]","HB CH AETNA HMO / PPO","1671.27","58.3","","1830.28","315.58","1830.28","1 through 10","1274.24","2866.68","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2866.68","2150.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2092.68","73","","4170.85","4170.85","4170.85","1 through 10","1274.24","2866.68","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2866.68","2150.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1274.24","44.45","","649.55","649.55","649.55","1 through 10","1274.24","2866.68","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","both","","","2866.68","2150.01","WELLPOINT [1015]","HB CH WELLPOINT","2233.43","77.91","","8998.38","2542.37","8998.38","20","1274.24","2866.68","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2866.68","2150.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","1699.94","59.3","","1891.61","1609.14","3664.18","25","1433.34","2248.91","percent of total billed charges",""
"GRAFT BONE 43MM FROZEN MATRI HUMERUS HEAD IMPLANTABLE","SUP-ITM-10010281","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2866.68","2150.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2248.91","78.45","","1470.68","1310.06","2481.69","19","1433.34","2248.91","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","AETNA [1001]","HB CH AETNA HMO / PPO","1694.78","58.3","","1830.28","315.58","1830.28","1 through 10","1292.16","2907","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2122.11","73","","4170.85","4170.85","4170.85","1 through 10","1292.16","2907","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1292.16","44.45","","649.55","649.55","649.55","1 through 10","1292.16","2907","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","both","","","2907.00","2180.25","WELLPOINT [1015]","HB CH WELLPOINT","2264.84","77.91","","8998.38","2542.37","8998.38","20","1292.16","2907","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2907.00","2180.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1723.85","59.3","","1891.61","1609.14","3664.18","25","1453.5","2280.54","percent of total billed charges",""
"GRAFT BONE 43MM MATRI ALLO FEMORAL HEAD REPAIR STRUCTURAL FROZEN IS GREATER THAN OR EQUAL","SUP-ITM-10010273","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2907.00","2180.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2280.54","78.45","","1470.68","1310.06","2481.69","19","1453.5","2280.54","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","AETNA [1001]","HB CH AETNA HMO / PPO","1685.16","58.3","","554.95","91.85","1421.75","94","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2110.07","73","","2490.03","2490.03","2490.03","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1685.16","58.3","","750.00","750.00","750.00","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1531.97","53","","1192.50","120.84","4149.90","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2456.93","85","","750.00","75.00","750.00","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2890.50","100","","657.00","121.50","1971.00","14","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2890.50","100","","75.00","75.00","75.00","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2890.50","100","","366.00","144.00","1971.00","45","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2110.07","73","","667.50","667.50","667.50","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1284.83","44.45","","123.77","123.77","123.77","1 through 10","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","both","","","2890.50","2167.87","WELLPOINT [1015]","HB CH WELLPOINT","2251.99","77.91","","483.51","229.32","1316.08","96","1284.83","2890.5","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.50","2167.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","1714.07","59.3","","439.50","225.34","1872.27","197","1445.25","2267.6","percent of total billed charges",""
"GRAFT BONE 5 1 2MM ACTIFUSE ABX SYNTHETIC GRANULE VOID FILLER SUBSTITUTE","SUP-ITM-10029110","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2890.50","2167.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2267.60","78.45","","385.32","55.36","1815.62","58","1445.25","2267.6","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","AETNA [1001]","HB CH AETNA HMO / PPO","2159.26","58.3","","1830.28","315.58","1830.28","1 through 10","1646.29","3703.7","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2703.70","73","","4170.85","4170.85","4170.85","1 through 10","1646.29","3703.7","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1646.29","44.45","","649.55","649.55","649.55","1 through 10","1646.29","3703.7","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","WELLPOINT [1015]","HB CH WELLPOINT","2885.55","77.91","","8998.38","2542.37","8998.38","20","1646.29","3703.7","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2196.29","59.3","","1891.61","1609.14","3664.18","25","1851.85","2905.55","percent of total billed charges",""
"GRAFT BONE 5CC 1 TO 2MM GRANULE MOLDABLE PUTTY MAGNETOS","SUP-ITM-10282975","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2905.55","78.45","","1470.68","1310.06","2481.69","19","1851.85","2905.55","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","AETNA [1001]","HB CH AETNA HMO / PPO","3572.92","58.3","","554.95","91.85","1421.75","94","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4473.81","73","","2490.03","2490.03","2490.03","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3572.92","58.3","","750.00","750.00","750.00","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3248.11","53","","1192.50","120.84","4149.90","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5209.23","85","","750.00","75.00","750.00","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6128.50","100","","657.00","121.50","1971.00","14","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6128.50","100","","75.00","75.00","75.00","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6128.50","100","","366.00","144.00","1971.00","45","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4473.81","73","","667.50","667.50","667.50","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2724.12","44.45","","123.77","123.77","123.77","1 through 10","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","both","","","6128.50","4596.37","WELLPOINT [1015]","HB CH WELLPOINT","4774.71","77.91","","483.51","229.32","1316.08","96","2724.12","6128.5","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6128.50","4596.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","3634.20","59.3","","439.50","225.34","1872.27","197","3064.25","4807.81","percent of total billed charges",""
"GRAFT BONE 5CC ACCUFILL CALCIUM COMPOUND VOID FILLER","SUP-ITM-10107416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6128.50","4596.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4807.81","78.45","","385.32","55.36","1815.62","58","3064.25","4807.81","percent of total billed charges",""
"GRAFT BONE 5CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168490","CDM","C1889","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","AETNA [1001]","HB CH AETNA HMO / PPO","2237.55","58.3","","1830.28","315.58","1830.28","1 through 10","1705.99","3838","percent of total billed charges",""
"GRAFT BONE 5CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168490","CDM","C1889","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2801.74","73","","4170.85","4170.85","4170.85","1 through 10","1705.99","3838","percent of total billed charges",""
"GRAFT BONE 5CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168490","CDM","C1889","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.99","44.45","","649.55","649.55","649.55","1 through 10","1705.99","3838","percent of total billed charges",""
"GRAFT BONE 5CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168490","CDM","C1889","HCPCS","0278","RC","","","","both","","","3838.00","2878.50","WELLPOINT [1015]","HB CH WELLPOINT","2990.19","77.91","","8998.38","2542.37","8998.38","20","1705.99","3838","percent of total billed charges",""
"GRAFT BONE 5CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3838.00","2878.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2275.93","59.3","","1891.61","1609.14","3664.18","25","1919","3010.91","percent of total billed charges",""
"GRAFT BONE 5CC VIVIGEN CELLULAR MATRIX","SUP-ITM-10168490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3838.00","2878.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3010.91","78.45","","1470.68","1310.06","2481.69","19","1919","3010.91","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL RIGHT","SUP-ITM-10079413","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","AETNA [1001]","HB CH AETNA HMO / PPO","6723.74","58.3","","1830.28","315.58","1830.28","1 through 10","5126.42","11533","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL RIGHT","SUP-ITM-10079413","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8419.09","73","","4170.85","4170.85","4170.85","1 through 10","5126.42","11533","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL RIGHT","SUP-ITM-10079413","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5126.42","44.45","","649.55","649.55","649.55","1 through 10","5126.42","11533","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL RIGHT","SUP-ITM-10079413","CDM","C1889","HCPCS","0278","RC","","","","both","","","11533.00","8649.75","WELLPOINT [1015]","HB CH WELLPOINT","8985.36","77.91","","8998.38","2542.37","8998.38","20","5126.42","11533","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL RIGHT","SUP-ITM-10079413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11533.00","8649.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","6839.07","59.3","","1891.61","1609.14","3664.18","25","5766.5","9047.64","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS HEMI PLATEAU FROZEN LATERAL RIGHT","SUP-ITM-10079413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","11533.00","8649.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9047.64","78.45","","1470.68","1310.06","2481.69","19","5766.5","9047.64","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","AETNA [1001]","HB CH AETNA HMO / PPO","5760.03","58.3","","1830.28","315.58","1830.28","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7212.39","73","","4170.85","4170.85","4170.85","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4391.65","44.45","","649.55","649.55","649.55","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","WELLPOINT [1015]","HB CH WELLPOINT","7697.49","77.91","","8998.38","2542.37","8998.38","20","4391.65","9879.98","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9879.98","7409.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","5858.83","59.3","","1891.61","1609.14","3664.18","25","4939.99","7750.84","percent of total billed charges",""
"GRAFT BONE ALLO MENISCUS LT LATERAL","SUP-ITM-10124418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9879.98","7409.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7750.84","78.45","","1470.68","1310.06","2481.69","19","4939.99","7750.84","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","AETNA [1001]","HB CH AETNA HMO / PPO","2411.29","58.3","","554.95","91.85","1421.75","94","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3019.28","73","","2490.03","2490.03","2490.03","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2411.29","58.3","","750.00","750.00","750.00","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2192.08","53","","1192.50","120.84","4149.90","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3515.60","85","","750.00","75.00","750.00","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4136.00","100","","657.00","121.50","1971.00","14","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4136.00","100","","75.00","75.00","75.00","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4136.00","100","","366.00","144.00","1971.00","45","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3019.28","73","","667.50","667.50","667.50","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1838.45","44.45","","123.77","123.77","123.77","1 through 10","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","both","","","4136.00","3102.00","WELLPOINT [1015]","HB CH WELLPOINT","3222.36","77.91","","483.51","229.32","1316.08","96","1838.45","4136","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.00","3102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2452.65","59.3","","439.50","225.34","1872.27","197","2068","3244.69","percent of total billed charges",""
"GRAFT BONE ALLO TIBIA FROZEN DISTAL RIGHT","SUP-ITM-10010793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4136.00","3102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3244.69","78.45","","385.32","55.36","1815.62","58","2068","3244.69","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","AETNA [1001]","HB CH AETNA HMO / PPO","5830.00","58.3","","1830.28","315.58","1830.28","1 through 10","4445","10000","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","4170.85","4170.85","4170.85","1 through 10","4445","10000","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4445.00","44.45","","649.55","649.55","649.55","1 through 10","4445","10000","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB CH WELLPOINT","7791.00","77.91","","8998.38","2542.37","8998.38","20","4445","10000","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5930.00","59.3","","1891.61","1609.14","3664.18","25","5000","7845","percent of total billed charges",""
"GRAFT BONE RT MEDIAL BLOCK FROZEN FRESH TIBIAL MENISCUS IMPLANTABLE","SUP-ITM-10135341","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7845.00","78.45","","1470.68","1310.06","2481.69","19","5000","7845","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","AETNA [1001]","HB CH AETNA HMO / PPO","14283.50","58.3","","1830.28","315.58","1830.28","1 through 10","10890.25","24500","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17885.00","73","","4170.85","4170.85","4170.85","1 through 10","10890.25","24500","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10890.25","44.45","","649.55","649.55","649.55","1 through 10","10890.25","24500","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","both","","","24500.00","18375.00","WELLPOINT [1015]","HB CH WELLPOINT","19087.95","77.91","","8998.38","2542.37","8998.38","20","10890.25","24500","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24500.00","18375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","14528.50","59.3","","1891.61","1609.14","3664.18","25","12250","19220.25","percent of total billed charges",""
"GRAFT BONE RT PATELLA","SUP-ITM-10114049","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24500.00","18375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19220.25","78.45","","1470.68","1310.06","2481.69","19","12250","19220.25","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2295.00","1721.25","AETNA [1001]","HB CH AETNA HMO / PPO","1337.99","58.3","","1830.28","315.58","1830.28","1 through 10","1020.13","2295","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2295.00","1721.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1675.35","73","","4170.85","4170.85","4170.85","1 through 10","1020.13","2295","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2295.00","1721.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1020.13","44.45","","649.55","649.55","649.55","1 through 10","1020.13","2295","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","both","","","2295.00","1721.25","WELLPOINT [1015]","HB CH WELLPOINT","1788.03","77.91","","8998.38","2542.37","8998.38","20","1020.13","2295","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2295.00","1721.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1360.94","59.3","","1891.61","1609.14","3664.18","25","1147.5","1800.43","percent of total billed charges",""
"GRAFT BONE SM ON ORTHOBLEND DEMINERALIZED MATRIX DEFECT JAR","SUP-ITM-10041859","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2295.00","1721.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1800.43","78.45","","1470.68","1310.06","2481.69","19","1147.5","1800.43","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","AETNA [1001]","HB CH AETNA HMO / PPO","13454.94","58.3","","1830.28","315.58","1830.28","1 through 10","10258.53","23078.8","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16847.52","73","","4170.85","4170.85","4170.85","1 through 10","10258.53","23078.8","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10258.53","44.45","","649.55","649.55","649.55","1 through 10","10258.53","23078.8","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","both","","","23078.80","17309.10","WELLPOINT [1015]","HB CH WELLPOINT","17980.69","77.91","","8998.38","2542.37","8998.38","20","10258.53","23078.8","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","23078.80","17309.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","13685.73","59.3","","1891.61","1609.14","3664.18","25","11539.4","18105.32","percent of total billed charges",""
"GRAFT CONDYLE FEMORAL LT LATERAL ID","SUP-ITM-10124417","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","23078.80","17309.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18105.32","78.45","","1470.68","1310.06","2481.69","19","11539.4","18105.32","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","24600.00","18450.00","AETNA [1001]","HB CH AETNA HMO / PPO","14341.80","58.3","","1830.28","315.58","1830.28","1 through 10","10934.7","24600","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","24600.00","18450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17958.00","73","","4170.85","4170.85","4170.85","1 through 10","10934.7","24600","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","24600.00","18450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10934.70","44.45","","649.55","649.55","649.55","1 through 10","10934.7","24600","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","both","","","24600.00","18450.00","WELLPOINT [1015]","HB CH WELLPOINT","19165.86","77.91","","8998.38","2542.37","8998.38","20","10934.7","24600","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24600.00","18450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","14587.80","59.3","","1891.61","1609.14","3664.18","25","12300","19298.7","percent of total billed charges",""
"GRAFT FEMORAL HEMI CONDYLE OSTEOARTICULAR MEDIAL LT FROZEN","SUP-ITM-10029611","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","24600.00","18450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","19298.70","78.45","","1470.68","1310.06","2481.69","19","12300","19298.7","percent of total billed charges",""
"Graft Full Forehd/Chin/Mth <20cm","PX-76000173","CDM","15240","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1254.10","1254.10","1254.10","1 through 10","1548.96","7178","other","ASC "
"Graft Full Trunk <20cm","PX-76000169","CDM","15200","CPT","0761","RC","","","","outpatient","","","8008.00","6006.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1254.10","1254.10","1254.10","1 through 10","1548.96","7178","other","ASC "
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","both","","","1335.59","1001.69","AETNA [1001]","HB CH AETNA HMO / PPO","778.65","58.3","","1786.05","1786.05","1786.05","1 through 10","707.86","1040.56","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","both","","","1335.59","1001.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","778.65","58.3","","3150.00","3150.00","3150.00","1 through 10","707.86","1040.56","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","both","","","1335.59","1001.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","707.86","53","","1669.50","1669.50","1669.50","1 through 10","707.86","1040.56","percent of total billed charges",""
"GRAFT IMPLANT 1OZ 21GA SYNTHETIC TISSUE INJECTABLE CALCIUM HYDROXYLAPATITE SODIUM CMC RESORBABLE COAPTITE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10020071","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","1335.59","1001.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","792.00","59.3","","1845.90","1845.90","1845.90","1 through 10","593.67","1047.77","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","AETNA [1001]","HB CH AETNA HMO / PPO","3458.65","58.3","","554.95","91.85","1421.75","94","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4330.73","73","","2490.03","2490.03","2490.03","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3458.65","58.3","","750.00","750.00","750.00","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3144.23","53","","1192.50","120.84","4149.90","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5042.63","85","","750.00","75.00","750.00","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5932.50","100","","657.00","121.50","1971.00","14","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5932.50","100","","75.00","75.00","75.00","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5932.50","100","","366.00","144.00","1971.00","45","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4330.73","73","","667.50","667.50","667.50","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2637.00","44.45","","123.77","123.77","123.77","1 through 10","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","both","","","5932.50","4449.37","WELLPOINT [1015]","HB CH WELLPOINT","4622.01","77.91","","483.51","229.32","1316.08","96","2637","5932.5","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","3517.97","59.3","","439.50","225.34","1872.27","197","2966.25","4654.05","percent of total billed charges",""
"GRAFT LIGAMENT 10MM PATELLAR PRESHAPED FROZEN","SUP-ITM-10056531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5932.50","4449.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4654.05","78.45","","385.32","55.36","1815.62","58","2966.25","4654.05","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","both","","","636.00","477.00","AETNA [1001]","HB CH AETNA HMO / PPO","370.79","58.3","","585.96","347.85","5016.82","1 through 10","282.7","636","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","both","","","636.00","477.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","540.60","85","","1295.16","1295.16","1295.16","1 through 10","282.7","636","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","both","","","636.00","477.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","636.00","100","","2700.00","1008.69","2700.00","1 through 10","282.7","636","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","both","","","636.00","477.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","636.00","100","","2520.00","797.10","5898.60","1 through 10","282.7","636","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","both","","","636.00","477.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.70","44.45","","1953.42","1953.42","1953.42","1 through 10","282.7","636","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","both","","","636.00","477.00","WELLPOINT [1015]","HB CH WELLPOINT","495.51","77.91","","1490.36","627.80","7327.37","1 through 10","282.7","636","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","636.00","477.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","377.15","59.3","","536.35","188.54","1772.63","17","318","498.94","percent of total billed charges",""
"GRAFT MESH 1.3IN 1.55IN 3.3CM 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10188639","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","636.00","477.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","498.94","78.45","","562.30","246.20","3344.28","1 through 10","318","498.94","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","AETNA [1001]","HB CH AETNA HMO / PPO","376.04","58.3","","585.96","347.85","5016.82","1 through 10","286.7","645","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","548.25","85","","1295.16","1295.16","1295.16","1 through 10","286.7","645","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","645.00","100","","2700.00","1008.69","2700.00","1 through 10","286.7","645","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","645.00","100","","2520.00","797.10","5898.60","1 through 10","286.7","645","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.70","44.45","","1953.42","1953.42","1953.42","1 through 10","286.7","645","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","both","","","645.00","483.75","WELLPOINT [1015]","HB CH WELLPOINT","502.52","77.91","","1490.36","627.80","7327.37","1 through 10","286.7","645","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","382.49","59.3","","536.35","188.54","1772.63","17","322.5","506","percent of total billed charges",""
"GRAFT MESH 1.6IN 1.9IN 4.1CM 4.8CM LARGE PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10026982","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","506.00","78.45","","562.30","246.20","3344.28","1 through 10","322.5","506","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","both","","","711.00","533.25","AETNA [1001]","HB CH AETNA HMO / PPO","414.51","58.3","","585.96","347.85","5016.82","1 through 10","316.04","711","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","604.35","85","","1295.16","1295.16","1295.16","1 through 10","316.04","711","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","711.00","100","","2700.00","1008.69","2700.00","1 through 10","316.04","711","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","711.00","100","","2520.00","797.10","5898.60","1 through 10","316.04","711","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.04","44.45","","1953.42","1953.42","1953.42","1 through 10","316.04","711","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","both","","","711.00","533.25","WELLPOINT [1015]","HB CH WELLPOINT","553.94","77.91","","1490.36","627.80","7327.37","1 through 10","316.04","711","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.62","59.3","","536.35","188.54","1772.63","17","355.5","557.78","percent of total billed charges",""
"GRAFT MESH 1.6IN 2IN 4.1CM 5CM XL PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR BX/6EA","SUP-ITM-10188628","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","562.30","246.20","3344.28","1 through 10","355.5","557.78","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB CH AETNA HMO / PPO","454.74","58.3","","585.96","347.85","5016.82","1 through 10","346.71","780","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","663.00","85","","1295.16","1295.16","1295.16","1 through 10","346.71","780","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","780.00","100","","2700.00","1008.69","2700.00","1 through 10","346.71","780","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","780.00","100","","2520.00","797.10","5898.60","1 through 10","346.71","780","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.71","44.45","","1953.42","1953.42","1953.42","1 through 10","346.71","780","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB CH WELLPOINT","607.70","77.91","","1490.36","627.80","7327.37","1 through 10","346.71","780","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.54","59.3","","536.35","188.54","1772.63","17","390","611.91","percent of total billed charges",""
"GRAFT MESH 10.5CM 16CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR RIGHT CS/1EA","SUP-ITM-10018259","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","562.30","246.20","3344.28","1 through 10","390","611.91","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","34194.00","25645.50","AETNA [1001]","HB CH AETNA HMO / PPO","19935.10","58.3","","585.96","347.85","5016.82","1 through 10","15199.23","34194","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","34194.00","25645.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","29064.90","85","","1295.16","1295.16","1295.16","1 through 10","15199.23","34194","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","34194.00","25645.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","34194.00","100","","2700.00","1008.69","2700.00","1 through 10","15199.23","34194","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","34194.00","25645.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","34194.00","100","","2520.00","797.10","5898.60","1 through 10","15199.23","34194","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","34194.00","25645.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15199.23","44.45","","1953.42","1953.42","1953.42","1 through 10","15199.23","34194","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","both","","","34194.00","25645.50","WELLPOINT [1015]","HB CH WELLPOINT","26640.55","77.91","","1490.36","627.80","7327.37","1 through 10","15199.23","34194","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34194.00","25645.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20277.04","59.3","","536.35","188.54","1772.63","17","17097","26825.19","percent of total billed charges",""
"GRAFT MESH 10X12IN PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159299","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","34194.00","25645.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26825.19","78.45","","562.30","246.20","3344.28","1 through 10","17097","26825.19","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","9471.80","7103.85","AETNA [1001]","HB CH AETNA HMO / PPO","5522.06","58.3","","585.96","347.85","5016.82","1 through 10","4210.22","9471.8","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","9471.80","7103.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8051.03","85","","1295.16","1295.16","1295.16","1 through 10","4210.22","9471.8","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","9471.80","7103.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9471.80","100","","2700.00","1008.69","2700.00","1 through 10","4210.22","9471.8","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","9471.80","7103.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9471.80","100","","2520.00","797.10","5898.60","1 through 10","4210.22","9471.8","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","9471.80","7103.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4210.22","44.45","","1953.42","1953.42","1953.42","1 through 10","4210.22","9471.8","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","both","","","9471.80","7103.85","WELLPOINT [1015]","HB CH WELLPOINT","7379.48","77.91","","1490.36","627.80","7327.37","1 through 10","4210.22","9471.8","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9471.80","7103.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","5616.78","59.3","","536.35","188.54","1772.63","17","4735.9","7430.63","percent of total billed charges",""
"GRAFT MESH 10X15CM PHASIX SYNTHETIC MONOFILAMENT WOVEN RESORBABLE RECTANGULAR CS/1EA","SUP-ITM-10159306","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","9471.80","7103.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7430.63","78.45","","562.30","246.20","3344.28","1 through 10","4735.9","7430.63","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","AETNA [1001]","HB CH AETNA HMO / PPO","1294.26","58.3","","585.96","347.85","5016.82","1 through 10","986.79","2220","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1887.00","85","","1295.16","1295.16","1295.16","1 through 10","986.79","2220","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2220.00","100","","2700.00","1008.69","2700.00","1 through 10","986.79","2220","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2220.00","100","","2520.00","797.10","5898.60","1 through 10","986.79","2220","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","986.79","44.45","","1953.42","1953.42","1953.42","1 through 10","986.79","2220","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","both","","","2220.00","1665.00","WELLPOINT [1015]","HB CH WELLPOINT","1729.60","77.91","","1490.36","627.80","7327.37","1 through 10","986.79","2220","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1316.46","59.3","","536.35","188.54","1772.63","17","1110","1741.59","percent of total billed charges",""
"GRAFT MESH 15CMX10 SYNTHETIC ABDOMINAL ABSORBABLE COATED ELLIPSE POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082652","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2220.00","1665.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1741.59","78.45","","562.30","246.20","3344.28","1 through 10","1110","1741.59","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","585.96","347.85","5016.82","1 through 10","280.04","630","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","535.50","85","","1295.16","1295.16","1295.16","1 through 10","280.04","630","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","630.00","100","","2700.00","1008.69","2700.00","1 through 10","280.04","630","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","630.00","100","","2520.00","797.10","5898.60","1 through 10","280.04","630","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","1953.42","1953.42","1953.42","1 through 10","280.04","630","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB CH WELLPOINT","490.83","77.91","","1490.36","627.80","7327.37","1 through 10","280.04","630","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","373.59","59.3","","536.35","188.54","1772.63","17","315","494.24","percent of total billed charges",""
"GRAFT MESH 1IN 1.35IN PLUG MONOFILAMENT SM PERFIX POLYPROPYLENE INGUINAL HERNIA SOFT TISSUE REPAIR CS/6EA","SUP-ITM-10061802","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","562.30","246.20","3344.28","1 through 10","315","494.24","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","3812.50","2859.37","AETNA [1001]","HB CH AETNA HMO / PPO","2222.69","58.3","","585.96","347.85","5016.82","1 through 10","1694.66","3812.5","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","3812.50","2859.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3240.63","85","","1295.16","1295.16","1295.16","1 through 10","1694.66","3812.5","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","3812.50","2859.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3812.50","100","","2700.00","1008.69","2700.00","1 through 10","1694.66","3812.5","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","3812.50","2859.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3812.50","100","","2520.00","797.10","5898.60","1 through 10","1694.66","3812.5","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","3812.50","2859.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1694.66","44.45","","1953.42","1953.42","1953.42","1 through 10","1694.66","3812.5","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","both","","","3812.50","2859.37","WELLPOINT [1015]","HB CH WELLPOINT","2970.32","77.91","","1490.36","627.80","7327.37","1 through 10","1694.66","3812.5","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3812.50","2859.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2260.81","59.3","","536.35","188.54","1772.63","17","1906.25","2990.91","percent of total billed charges",""
"GRAFT MESH 25.4CMX15.2 SYNTHETIC ABDOMINAL ABSORBABLE COATED OVAL POLYPROPYLENE SEPRA VENTRALIGHT ST CS/1EA","SUP-ITM-10082653","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3812.50","2859.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2990.91","78.45","","562.30","246.20","3344.28","1 through 10","1906.25","2990.91","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","585.96","347.85","5016.82","1 through 10","320.04","720","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","1295.16","1295.16","1295.16","1 through 10","320.04","720","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","2700.00","1008.69","2700.00","1 through 10","320.04","720","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","2520.00","797.10","5898.60","1 through 10","320.04","720","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","1953.42","1953.42","1953.42","1 through 10","320.04","720","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","1490.36","627.80","7327.37","1 through 10","320.04","720","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","536.35","188.54","1772.63","17","360","564.84","percent of total billed charges",""
"GRAFT MESH 8.5CM 13.5CM 3DMAX POLYPROPYLENE MONOFILAMENT PATCH LAPAROSCOPY HERNIA REPAIR LEFT CS/1EA","SUP-ITM-10013931","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","562.30","246.20","3344.28","1 through 10","360","564.84","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","both","","","303.54","227.65","AETNA [1001]","HB CH AETNA HMO / PPO","176.96","58.3","","585.96","347.85","5016.82","1 through 10","134.92","303.54","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","both","","","303.54","227.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","258.01","85","","1295.16","1295.16","1295.16","1 through 10","134.92","303.54","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","both","","","303.54","227.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","303.54","100","","2700.00","1008.69","2700.00","1 through 10","134.92","303.54","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","both","","","303.54","227.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","303.54","100","","2520.00","797.10","5898.60","1 through 10","134.92","303.54","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","both","","","303.54","227.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.92","44.45","","1953.42","1953.42","1953.42","1 through 10","134.92","303.54","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","both","","","303.54","227.65","WELLPOINT [1015]","HB CH WELLPOINT","236.49","77.91","","1490.36","627.80","7327.37","1 through 10","134.92","303.54","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","303.54","227.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","180.00","59.3","","536.35","188.54","1772.63","17","151.77","238.13","percent of total billed charges",""
"GRAFT MESH 9X13CM PARIETEX MACROPOROUS POLYESTER CONVENTIONAL FLAT SHEET","SUP-ITM-10267142","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","303.54","227.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","238.13","78.45","","562.30","246.20","3344.28","1 through 10","151.77","238.13","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","13594.00","10195.50","AETNA [1001]","HB CH AETNA HMO / PPO","7925.30","58.3","","1830.28","315.58","1830.28","1 through 10","6042.53","13594","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","13594.00","10195.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9923.62","73","","4170.85","4170.85","4170.85","1 through 10","6042.53","13594","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","13594.00","10195.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6042.53","44.45","","649.55","649.55","649.55","1 through 10","6042.53","13594","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","both","","","13594.00","10195.50","WELLPOINT [1015]","HB CH WELLPOINT","10591.09","77.91","","8998.38","2542.37","8998.38","20","6042.53","13594","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13594.00","10195.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","8061.24","59.3","","1891.61","1609.14","3664.18","25","6797","10664.49","percent of total billed charges",""
"GRAFT NERVE 2 TO 3X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10124156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13594.00","10195.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10664.49","78.45","","1470.68","1310.06","2481.69","19","6797","10664.49","percent of total billed charges",""
"GRAFT NERVE 30X4.0 5.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100509","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","AETNA [1001]","HB CH AETNA HMO / PPO","4021.53","58.3","","1830.28","315.58","1830.28","1 through 10","3066.16","6898","percent of total billed charges",""
"GRAFT NERVE 30X4.0 5.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100509","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5035.54","73","","4170.85","4170.85","4170.85","1 through 10","3066.16","6898","percent of total billed charges",""
"GRAFT NERVE 30X4.0 5.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100509","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3066.16","44.45","","649.55","649.55","649.55","1 through 10","3066.16","6898","percent of total billed charges",""
"GRAFT NERVE 30X4.0 5.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100509","CDM","C1889","HCPCS","0278","RC","","","","both","","","6898.00","5173.50","WELLPOINT [1015]","HB CH WELLPOINT","5374.23","77.91","","8998.38","2542.37","8998.38","20","3066.16","6898","percent of total billed charges",""
"GRAFT NERVE 30X4.0 5.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6898.00","5173.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4090.51","59.3","","1891.61","1609.14","3664.18","25","3449","5411.48","percent of total billed charges",""
"GRAFT NERVE 30X4.0 5.0MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10100509","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6898.00","5173.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5411.48","78.45","","1470.68","1310.06","2481.69","19","3449","5411.48","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","AETNA [1001]","HB CH AETNA HMO / PPO","8683.20","58.3","","1830.28","315.58","1830.28","1 through 10","6620.38","14894","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10872.62","73","","4170.85","4170.85","4170.85","1 through 10","6620.38","14894","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6620.38","44.45","","649.55","649.55","649.55","1 through 10","6620.38","14894","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","both","","","14894.00","11170.50","WELLPOINT [1015]","HB CH WELLPOINT","11603.92","77.91","","8998.38","2542.37","8998.38","20","6620.38","14894","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14894.00","11170.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","8832.14","59.3","","1891.61","1609.14","3664.18","25","7447","11684.34","percent of total billed charges",""
"GRAFT NERVE 4 5X70MM AVANCE ALLO DECELLULARIZED EXTRACELLULAR MATRIX PERIPHERAL","SUP-ITM-10101013","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","14894.00","11170.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11684.34","78.45","","1470.68","1310.06","2481.69","19","7447","11684.34","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 10MM FEMORAL PRECUT HYALINE CARTILAGE FRESH CORE","SUP-ITM-10147050","CDM","C1889","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","AETNA [1001]","HB CH AETNA HMO / PPO","3381.40","58.3","","1830.28","315.58","1830.28","1 through 10","2578.1","5800","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 10MM FEMORAL PRECUT HYALINE CARTILAGE FRESH CORE","SUP-ITM-10147050","CDM","C1889","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4234.00","73","","4170.85","4170.85","4170.85","1 through 10","2578.1","5800","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 10MM FEMORAL PRECUT HYALINE CARTILAGE FRESH CORE","SUP-ITM-10147050","CDM","C1889","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2578.10","44.45","","649.55","649.55","649.55","1 through 10","2578.1","5800","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 10MM FEMORAL PRECUT HYALINE CARTILAGE FRESH CORE","SUP-ITM-10147050","CDM","C1889","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","WELLPOINT [1015]","HB CH WELLPOINT","4518.78","77.91","","8998.38","2542.37","8998.38","20","2578.1","5800","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 10MM FEMORAL PRECUT HYALINE CARTILAGE FRESH CORE","SUP-ITM-10147050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5800.00","4350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3439.40","59.3","","1891.61","1609.14","3664.18","25","2900","4550.1","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 10MM FEMORAL PRECUT HYALINE CARTILAGE FRESH CORE","SUP-ITM-10147050","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5800.00","4350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4550.10","78.45","","1470.68","1310.06","2481.69","19","2900","4550.1","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 16MM CORE FS/A","SUP-ITM-10235760","CDM","C1889","HCPCS","0278","RC","","","","both","","","10400.00","7800.00","AETNA [1001]","HB CH AETNA HMO / PPO","6063.20","58.3","","1830.28","315.58","1830.28","1 through 10","4622.8","10400","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 16MM CORE FS/A","SUP-ITM-10235760","CDM","C1889","HCPCS","0278","RC","","","","both","","","10400.00","7800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7592.00","73","","4170.85","4170.85","4170.85","1 through 10","4622.8","10400","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 16MM CORE FS/A","SUP-ITM-10235760","CDM","C1889","HCPCS","0278","RC","","","","both","","","10400.00","7800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4622.80","44.45","","649.55","649.55","649.55","1 through 10","4622.8","10400","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 16MM CORE FS/A","SUP-ITM-10235760","CDM","C1889","HCPCS","0278","RC","","","","both","","","10400.00","7800.00","WELLPOINT [1015]","HB CH WELLPOINT","8102.64","77.91","","8998.38","2542.37","8998.38","20","4622.8","10400","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 16MM CORE FS/A","SUP-ITM-10235760","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10400.00","7800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6167.20","59.3","","1891.61","1609.14","3664.18","25","5200","8158.8","percent of total billed charges",""
"GRAFT OSTEOCHONDRAL 16MM CORE FS/A","SUP-ITM-10235760","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","10400.00","7800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8158.80","78.45","","1470.68","1310.06","2481.69","19","5200","8158.8","percent of total billed charges",""
"GRAFT SOFT TISSUE FROZEN FLEXI LT MEDIAL MENISCUS IMPLANTABLE","SUP-ITM-10124419","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","AETNA [1001]","HB CH AETNA HMO / PPO","5760.03","58.3","","1830.28","315.58","1830.28","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT SOFT TISSUE FROZEN FLEXI LT MEDIAL MENISCUS IMPLANTABLE","SUP-ITM-10124419","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7212.39","73","","4170.85","4170.85","4170.85","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT SOFT TISSUE FROZEN FLEXI LT MEDIAL MENISCUS IMPLANTABLE","SUP-ITM-10124419","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4391.65","44.45","","649.55","649.55","649.55","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT SOFT TISSUE FROZEN FLEXI LT MEDIAL MENISCUS IMPLANTABLE","SUP-ITM-10124419","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","WELLPOINT [1015]","HB CH WELLPOINT","7697.49","77.91","","8998.38","2542.37","8998.38","20","4391.65","9879.98","percent of total billed charges",""
"GRAFT SOFT TISSUE FROZEN FLEXI LT MEDIAL MENISCUS IMPLANTABLE","SUP-ITM-10124419","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9879.98","7409.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","5858.83","59.3","","1891.61","1609.14","3664.18","25","4939.99","7750.84","percent of total billed charges",""
"GRAFT SOFT TISSUE FROZEN FLEXI LT MEDIAL MENISCUS IMPLANTABLE","SUP-ITM-10124419","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9879.98","7409.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7750.84","78.45","","1470.68","1310.06","2481.69","19","4939.99","7750.84","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","AETNA [1001]","HB CH AETNA HMO / PPO","1530.95","58.3","","1830.28","315.58","1830.28","1 through 10","1167.25","2625.99","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1916.97","73","","4170.85","4170.85","4170.85","1 through 10","1167.25","2625.99","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1167.25","44.45","","649.55","649.55","649.55","1 through 10","1167.25","2625.99","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","WELLPOINT [1015]","HB CH WELLPOINT","2045.91","77.91","","8998.38","2542.37","8998.38","20","1167.25","2625.99","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1557.21","59.3","","1891.61","1609.14","3664.18","25","1313","2060.09","percent of total billed charges",""
"GRAFT SPINE 6MMX9 SPACER ALLO ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048804","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2060.09","78.45","","1470.68","1310.06","2481.69","19","1313","2060.09","percent of total billed charges",""
"GRAFT TALUS RT FRESH TISSUE ALLO","SUP-ITM-10124407","CDM","C1889","HCPCS","0278","RC","","","","both","","","13700.00","10275.00","AETNA [1001]","HB CH AETNA HMO / PPO","7987.10","58.3","","1830.28","315.58","1830.28","1 through 10","6089.65","13700","percent of total billed charges",""
"GRAFT TALUS RT FRESH TISSUE ALLO","SUP-ITM-10124407","CDM","C1889","HCPCS","0278","RC","","","","both","","","13700.00","10275.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10001.00","73","","4170.85","4170.85","4170.85","1 through 10","6089.65","13700","percent of total billed charges",""
"GRAFT TALUS RT FRESH TISSUE ALLO","SUP-ITM-10124407","CDM","C1889","HCPCS","0278","RC","","","","both","","","13700.00","10275.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6089.65","44.45","","649.55","649.55","649.55","1 through 10","6089.65","13700","percent of total billed charges",""
"GRAFT TALUS RT FRESH TISSUE ALLO","SUP-ITM-10124407","CDM","C1889","HCPCS","0278","RC","","","","both","","","13700.00","10275.00","WELLPOINT [1015]","HB CH WELLPOINT","10673.67","77.91","","8998.38","2542.37","8998.38","20","6089.65","13700","percent of total billed charges",""
"GRAFT TALUS RT FRESH TISSUE ALLO","SUP-ITM-10124407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13700.00","10275.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","8124.10","59.3","","1891.61","1609.14","3664.18","25","6850","10747.65","percent of total billed charges",""
"GRAFT TALUS RT FRESH TISSUE ALLO","SUP-ITM-10124407","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","13700.00","10275.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10747.65","78.45","","1470.68","1310.06","2481.69","19","6850","10747.65","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","AETNA [1001]","HB CH AETNA HMO / PPO","1974.18","58.3","","1830.28","315.58","1830.28","1 through 10","1505.19","3386.25","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2471.96","73","","4170.85","4170.85","4170.85","1 through 10","1505.19","3386.25","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1505.19","44.45","","649.55","649.55","649.55","1 through 10","1505.19","3386.25","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","both","","","3386.25","2539.69","WELLPOINT [1015]","HB CH WELLPOINT","2638.23","77.91","","8998.38","2542.37","8998.38","20","1505.19","3386.25","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3386.25","2539.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2008.05","59.3","","1891.61","1609.14","3664.18","25","1693.13","2656.51","percent of total billed charges",""
"GRAFT TENDON GTE 230X4.0MM FLEXI ALLO GRACILIS HAMSTRING FROZEN MINIMUM","SUP-ITM-10010279","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3386.25","2539.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2656.51","78.45","","1470.68","1310.06","2481.69","19","1693.13","2656.51","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.86","1373.89","AETNA [1001]","HB CH AETNA HMO / PPO","1067.97","58.3","","1830.28","315.58","1830.28","1 through 10","814.26","1831.86","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.86","1373.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1337.26","73","","4170.85","4170.85","4170.85","1 through 10","814.26","1831.86","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.86","1373.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","814.26","44.45","","649.55","649.55","649.55","1 through 10","814.26","1831.86","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","both","","","1831.86","1373.89","WELLPOINT [1015]","HB CH WELLPOINT","1427.20","77.91","","8998.38","2542.37","8998.38","20","814.26","1831.86","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1831.86","1373.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","1086.29","59.3","","1891.61","1609.14","3664.18","25","915.93","1437.09","percent of total billed charges",""
"GRAFT TISSUE 1 TO 8MMX60 HUMAN FREEZE ALLO DRIED CANCELLOUS CRUSHED","SUP-ITM-10002480","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1831.86","1373.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1437.09","78.45","","1470.68","1310.06","2481.69","19","915.93","1437.09","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","both","","","4912.00","3684.00","AETNA [1001]","HB CH AETNA HMO / PPO","2863.70","58.3","","585.96","347.85","5016.82","1 through 10","2183.38","4912","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","both","","","4912.00","3684.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4175.20","85","","1295.16","1295.16","1295.16","1 through 10","2183.38","4912","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","both","","","4912.00","3684.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4912.00","100","","2700.00","1008.69","2700.00","1 through 10","2183.38","4912","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","both","","","4912.00","3684.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4912.00","100","","2520.00","797.10","5898.60","1 through 10","2183.38","4912","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","both","","","4912.00","3684.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2183.38","44.45","","1953.42","1953.42","1953.42","1 through 10","2183.38","4912","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","both","","","4912.00","3684.00","WELLPOINT [1015]","HB CH WELLPOINT","3826.94","77.91","","1490.36","627.80","7327.37","1 through 10","2183.38","4912","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4912.00","3684.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2912.82","59.3","","536.35","188.54","1772.63","17","2456","3853.46","percent of total billed charges",""
"GRAFT TISSUE 1.0MMX20 30CM GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10005038","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4912.00","3684.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3853.46","78.45","","562.30","246.20","3344.28","1 through 10","2456","3853.46","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","AETNA [1001]","HB CH AETNA HMO / PPO","1194.57","58.3","","585.96","347.85","5016.82","1 through 10","910.78","2049","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1741.65","85","","1295.16","1295.16","1295.16","1 through 10","910.78","2049","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2049.00","100","","2700.00","1008.69","2700.00","1 through 10","910.78","2049","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2049.00","100","","2520.00","797.10","5898.60","1 through 10","910.78","2049","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","910.78","44.45","","1953.42","1953.42","1953.42","1 through 10","910.78","2049","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","both","","","2049.00","1536.75","WELLPOINT [1015]","HB CH WELLPOINT","1596.38","77.91","","1490.36","627.80","7327.37","1 through 10","910.78","2049","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2049.00","1536.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1215.06","59.3","","536.35","188.54","1772.63","17","1024.5","1607.44","percent of total billed charges",""
"GRAFT TISSUE 1.0X10CM 15 4 6IN GORE TEX PATCH SOFT KEYHOLE","SUP-ITM-10001470","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2049.00","1536.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1607.44","78.45","","562.30","246.20","3344.28","1 through 10","1024.5","1607.44","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9666.00","7249.50","AETNA [1001]","HB CH AETNA HMO / PPO","5635.28","58.3","","66.84","33.42","66.84","3696","92.01","7530.78","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9666.00","7249.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5122.98","53","","16493.60","16493.60","16493.60","1 through 10","92.01","7530.78","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9666.00","7249.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7056.18","73","","10382.90","10382.90","10382.90","1 through 10","92.01","7530.78","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9666.00","7249.50","WELLPOINT [1015]","HB CH WELLPOINT","7530.78","77.91","","31178.94","77.77","31197.77","2412","92.01","7530.78","percent of total billed charges",""
"GRAFT TISSUE 1.6 PLUS/MINUS .4MM MED HUMAN ALLODERM LG PERFORATED REGENERATIVE MATRIX IMPLANTABLE","SUP-ITM-10132978","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9666.00","7249.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5045.65","52.2","","67.43","30.35","93.27","9212","4833","5045.65","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7780.00","5835.00","AETNA [1001]","HB CH AETNA HMO / PPO","4535.74","58.3","","66.84","33.42","66.84","3696","92.01","6061.4","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7780.00","5835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4123.40","53","","16493.60","16493.60","16493.60","1 through 10","92.01","6061.4","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7780.00","5835.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5679.40","73","","10382.90","10382.90","10382.90","1 through 10","92.01","6061.4","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7780.00","5835.00","WELLPOINT [1015]","HB CH WELLPOINT","6061.40","77.91","","31178.94","77.77","31197.77","2412","92.01","6061.4","percent of total billed charges",""
"GRAFT TISSUE 1.6 SELECT DUO MED THICK HUMAN ALLODERM CONTOURED MED PERFORATED REGENERATIVE MATRIX","SUP-ITM-10132981","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7780.00","5835.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4061.16","52.2","","67.43","30.35","93.27","9212","3890","4061.16","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","807.00","605.25","AETNA [1001]","HB CH AETNA HMO / PPO","470.48","58.3","","585.96","347.85","5016.82","1 through 10","358.71","807","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","685.95","85","","1295.16","1295.16","1295.16","1 through 10","358.71","807","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","807.00","100","","2700.00","1008.69","2700.00","1 through 10","358.71","807","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","807.00","605.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","807.00","100","","2520.00","797.10","5898.60","1 through 10","358.71","807","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","807.00","605.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","358.71","44.45","","1953.42","1953.42","1953.42","1 through 10","358.71","807","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","both","","","807.00","605.25","WELLPOINT [1015]","HB CH WELLPOINT","628.73","77.91","","1490.36","627.80","7327.37","1 through 10","358.71","807","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","807.00","605.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","478.55","59.3","","536.35","188.54","1772.63","17","403.5","633.09","percent of total billed charges",""
"GRAFT TISSUE 10X5CM 1MM GORE TEX EPTFE BIOMATERIAL PATCH SOFT KEYHOLE","SUP-ITM-10005040","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","807.00","605.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","633.09","78.45","","562.30","246.20","3344.28","1 through 10","403.5","633.09","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","9980.00","7485.00","AETNA [1001]","HB CH AETNA HMO / PPO","5818.34","58.3","","1830.28","315.58","1830.28","1 through 10","4436.11","9980","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","9980.00","7485.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7285.40","73","","4170.85","4170.85","4170.85","1 through 10","4436.11","9980","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","9980.00","7485.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4436.11","44.45","","649.55","649.55","649.55","1 through 10","4436.11","9980","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","both","","","9980.00","7485.00","WELLPOINT [1015]","HB CH WELLPOINT","7775.42","77.91","","8998.38","2542.37","8998.38","20","4436.11","9980","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9980.00","7485.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5918.14","59.3","","1891.61","1609.14","3664.18","25","4990","7829.31","percent of total billed charges",""
"GRAFT TISSUE 110MG DENOVO NT ALLO CARTILAGE ARTICULAR PARTICULATED NATURAL","SUP-ITM-10029541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9980.00","7485.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7829.31","78.45","","1470.68","1310.06","2481.69","19","4990","7829.31","percent of total billed charges",""
"GRAFT TISSUE 12X4CM XTHICK READY TO USE ALLODERM SKIN REGENERATIVE MATRIX","SUP-ITM-10125999","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3897.00","2922.75","AETNA [1001]","HB CH AETNA HMO / PPO","2271.95","58.3","","66.84","33.42","66.84","3696","92.01","3036.15","percent of total billed charges",""
"GRAFT TISSUE 12X4CM XTHICK READY TO USE ALLODERM SKIN REGENERATIVE MATRIX","SUP-ITM-10125999","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3897.00","2922.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2065.41","53","","16493.60","16493.60","16493.60","1 through 10","92.01","3036.15","percent of total billed charges",""
"GRAFT TISSUE 12X4CM XTHICK READY TO USE ALLODERM SKIN REGENERATIVE MATRIX","SUP-ITM-10125999","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3897.00","2922.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2844.81","73","","10382.90","10382.90","10382.90","1 through 10","92.01","3036.15","percent of total billed charges",""
"GRAFT TISSUE 12X4CM XTHICK READY TO USE ALLODERM SKIN REGENERATIVE MATRIX","SUP-ITM-10125999","CDM","Q4116","HCPCS","0636","RC","","","","both","","","3897.00","2922.75","WELLPOINT [1015]","HB CH WELLPOINT","3036.15","77.91","","31178.94","77.77","31197.77","2412","92.01","3036.15","percent of total billed charges",""
"GRAFT TISSUE 12X4CM XTHICK READY TO USE ALLODERM SKIN REGENERATIVE MATRIX","SUP-ITM-10125999","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","3897.00","2922.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2034.23","52.2","","67.43","30.35","93.27","9212","1948.5","2034.23","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","3869.78","2902.33","AETNA [1001]","HB CH AETNA HMO / PPO","2256.08","58.3","","1830.28","315.58","1830.28","1 through 10","1720.12","3869.78","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","3869.78","2902.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2824.94","73","","4170.85","4170.85","4170.85","1 through 10","1720.12","3869.78","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","3869.78","2902.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.12","44.45","","649.55","649.55","649.55","1 through 10","1720.12","3869.78","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","both","","","3869.78","2902.33","WELLPOINT [1015]","HB CH WELLPOINT","3014.95","77.91","","8998.38","2542.37","8998.38","20","1720.12","3869.78","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3869.78","2902.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","2294.78","59.3","","1891.61","1609.14","3664.18","25","1934.89","3035.84","percent of total billed charges",""
"GRAFT TISSUE 160MM FLEXI ALLO TENDON ACHILLES BONE BLOCK FROZEN","SUP-ITM-10010256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3869.78","2902.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3035.84","78.45","","1470.68","1310.06","2481.69","19","1934.89","3035.84","percent of total billed charges",""
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","AETNA [1001]","HB CH AETNA HMO / PPO","3203.00","58.3","","66.84","33.42","66.84","3696","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2911.82","53","","16493.60","16493.60","16493.60","1 through 10","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4010.62","73","","10382.90","10382.90","10382.90","1 through 10","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","WELLPOINT [1015]","HB CH WELLPOINT","4280.38","77.91","","31178.94","77.77","31197.77","2412","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 16X6CM ALLODERM REHYDRATED REGENERATIVE THIN","SUP-ITM-10100897","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5494.00","4120.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2867.87","52.2","","67.43","30.35","93.27","9212","2747","2867.87","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","8132.00","6099.00","AETNA [1001]","HB CH AETNA HMO / PPO","4740.96","58.3","","585.96","347.85","5016.82","1 through 10","3614.67","8132","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","8132.00","6099.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6912.20","85","","1295.16","1295.16","1295.16","1 through 10","3614.67","8132","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","8132.00","6099.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8132.00","100","","2700.00","1008.69","2700.00","1 through 10","3614.67","8132","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","8132.00","6099.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8132.00","100","","2520.00","797.10","5898.60","1 through 10","3614.67","8132","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","8132.00","6099.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3614.67","44.45","","1953.42","1953.42","1953.42","1 through 10","3614.67","8132","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","both","","","8132.00","6099.00","WELLPOINT [1015]","HB CH WELLPOINT","6335.64","77.91","","1490.36","627.80","7327.37","1 through 10","3614.67","8132","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8132.00","6099.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4822.28","59.3","","536.35","188.54","1772.63","17","4066","6379.55","percent of total billed charges",""
"GRAFT TISSUE 2.0MMX20 30CM GORE TEX EPTFE PATCH","SUP-ITM-10005039","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8132.00","6099.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6379.55","78.45","","562.30","246.20","3344.28","1 through 10","4066","6379.55","percent of total billed charges",""
"GRAFT TISSUE 3X3IN DURAGEN PLUS ULTRA PURE COLLAGEN REGENERATION MATRIX DURAL PK/5EA","SUP-ITM-10215594","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1390.86","1043.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1091.13","78.45","","555.84","555.84","555.84","1 through 10","695.43","1091.13","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","AETNA [1001]","HB CH AETNA HMO / PPO","3203.00","58.3","","66.84","33.42","66.84","3696","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2911.82","53","","16493.60","16493.60","16493.60","1 through 10","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4010.62","73","","10382.90","10382.90","10382.90","1 through 10","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","both","","","5494.00","4120.50","WELLPOINT [1015]","HB CH WELLPOINT","4280.38","77.91","","31178.94","77.77","31197.77","2412","92.01","4280.38","percent of total billed charges",""
"GRAFT TISSUE 6X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132967","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","5494.00","4120.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2867.87","52.2","","67.43","30.35","93.27","9212","2747","2867.87","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132973","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7326.00","5494.50","AETNA [1001]","HB CH AETNA HMO / PPO","4271.06","58.3","","66.84","33.42","66.84","3696","92.01","5707.69","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132973","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7326.00","5494.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3882.78","53","","16493.60","16493.60","16493.60","1 through 10","92.01","5707.69","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132973","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7326.00","5494.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5347.98","73","","10382.90","10382.90","10382.90","1 through 10","92.01","5707.69","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132973","CDM","Q4116","HCPCS","0636","RC","","","","both","","","7326.00","5494.50","WELLPOINT [1015]","HB CH WELLPOINT","5707.69","77.91","","31178.94","77.77","31197.77","2412","92.01","5707.69","percent of total billed charges",""
"GRAFT TISSUE 8X16CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132973","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","7326.00","5494.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3824.17","52.2","","67.43","30.35","93.27","9212","3663","3824.17","percent of total billed charges",""
"GRAFT TISSUE 8X20CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132975","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9156.00","6867.00","AETNA [1001]","HB CH AETNA HMO / PPO","5337.95","58.3","","66.84","33.42","66.84","3696","92.01","7133.44","percent of total billed charges",""
"GRAFT TISSUE 8X20CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132975","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9156.00","6867.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4852.68","53","","16493.60","16493.60","16493.60","1 through 10","92.01","7133.44","percent of total billed charges",""
"GRAFT TISSUE 8X20CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132975","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9156.00","6867.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6683.88","73","","10382.90","10382.90","10382.90","1 through 10","92.01","7133.44","percent of total billed charges",""
"GRAFT TISSUE 8X20CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132975","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9156.00","6867.00","WELLPOINT [1015]","HB CH WELLPOINT","7133.44","77.91","","31178.94","77.77","31197.77","2412","92.01","7133.44","percent of total billed charges",""
"GRAFT TISSUE 8X20CM ALLODERM READY TO USE REGENERATIVE MATRIX MED","SUP-ITM-10132975","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9156.00","6867.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4779.43","52.2","","67.43","30.35","93.27","9212","4578","4779.43","percent of total billed charges",""
"GRAFT TISSUE FROZEN FLEXI RT LATERAL MENISCUS IMPLANTABLE","SUP-ITM-10124420","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","AETNA [1001]","HB CH AETNA HMO / PPO","5760.03","58.3","","1830.28","315.58","1830.28","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT TISSUE FROZEN FLEXI RT LATERAL MENISCUS IMPLANTABLE","SUP-ITM-10124420","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7212.39","73","","4170.85","4170.85","4170.85","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT TISSUE FROZEN FLEXI RT LATERAL MENISCUS IMPLANTABLE","SUP-ITM-10124420","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4391.65","44.45","","649.55","649.55","649.55","1 through 10","4391.65","9879.98","percent of total billed charges",""
"GRAFT TISSUE FROZEN FLEXI RT LATERAL MENISCUS IMPLANTABLE","SUP-ITM-10124420","CDM","C1889","HCPCS","0278","RC","","","","both","","","9879.98","7409.98","WELLPOINT [1015]","HB CH WELLPOINT","7697.49","77.91","","8998.38","2542.37","8998.38","20","4391.65","9879.98","percent of total billed charges",""
"GRAFT TISSUE FROZEN FLEXI RT LATERAL MENISCUS IMPLANTABLE","SUP-ITM-10124420","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9879.98","7409.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","5858.83","59.3","","1891.61","1609.14","3664.18","25","4939.99","7750.84","percent of total billed charges",""
"GRAFT TISSUE FROZEN FLEXI RT LATERAL MENISCUS IMPLANTABLE","SUP-ITM-10124420","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9879.98","7409.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7750.84","78.45","","1470.68","1310.06","2481.69","19","4939.99","7750.84","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","AETNA [1001]","HB CH AETNA HMO / PPO","2062.07","58.3","","585.96","347.85","5016.82","1 through 10","1572.2","3537","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3006.45","85","","1295.16","1295.16","1295.16","1 through 10","1572.2","3537","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3537.00","100","","2700.00","1008.69","2700.00","1 through 10","1572.2","3537","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3537.00","100","","2520.00","797.10","5898.60","1 through 10","1572.2","3537","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1572.20","44.45","","1953.42","1953.42","1953.42","1 through 10","1572.2","3537","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","both","","","3537.00","2652.75","WELLPOINT [1015]","HB CH WELLPOINT","2755.68","77.91","","1490.36","627.80","7327.37","1 through 10","1572.2","3537","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3537.00","2652.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2097.44","59.3","","536.35","188.54","1772.63","17","1768.5","2774.78","percent of total billed charges",""
"GRAFT VASCULAR 2.0MMX10 15CM GORE TEX EPTFE SOFT TISSUE HERNIA PATCH","SUP-ITM-10013874","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3537.00","2652.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2774.78","78.45","","562.30","246.20","3344.28","1 through 10","1768.5","2774.78","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","both","","","522.00","391.50","AETNA [1001]","HB CH AETNA HMO / PPO","304.33","58.3","","585.96","347.85","5016.82","1 through 10","232.03","522","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","443.70","85","","1295.16","1295.16","1295.16","1 through 10","232.03","522","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","522.00","100","","2700.00","1008.69","2700.00","1 through 10","232.03","522","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","522.00","100","","2520.00","797.10","5898.60","1 through 10","232.03","522","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","1953.42","1953.42","1953.42","1 through 10","232.03","522","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","both","","","522.00","391.50","WELLPOINT [1015]","HB CH WELLPOINT","406.69","77.91","","1490.36","627.80","7327.37","1 through 10","232.03","522","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","309.55","59.3","","536.35","188.54","1772.63","17","261","409.51","percent of total billed charges",""
"GRAFT VASCULAR 8MMX75MM STRAIGHT THIN WALL NON RINGED","SUP-ITM-10100264","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","562.30","246.20","3344.28","1 through 10","261","409.51","percent of total billed charges",""
"GRAFT WHOLE CONDYLE RT FEMORAL FRESH ALLO","SUP-ITM-10088563","CDM","C1889","HCPCS","0278","RC","","","","both","","","42700.00","32025.00","AETNA [1001]","HB CH AETNA HMO / PPO","24894.10","58.3","","1830.28","315.58","1830.28","1 through 10","18980.15","42700","percent of total billed charges",""
"GRAFT WHOLE CONDYLE RT FEMORAL FRESH ALLO","SUP-ITM-10088563","CDM","C1889","HCPCS","0278","RC","","","","both","","","42700.00","32025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","31171.00","73","","4170.85","4170.85","4170.85","1 through 10","18980.15","42700","percent of total billed charges",""
"GRAFT WHOLE CONDYLE RT FEMORAL FRESH ALLO","SUP-ITM-10088563","CDM","C1889","HCPCS","0278","RC","","","","both","","","42700.00","32025.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","18980.15","44.45","","649.55","649.55","649.55","1 through 10","18980.15","42700","percent of total billed charges",""
"GRAFT WHOLE CONDYLE RT FEMORAL FRESH ALLO","SUP-ITM-10088563","CDM","C1889","HCPCS","0278","RC","","","","both","","","42700.00","32025.00","WELLPOINT [1015]","HB CH WELLPOINT","33267.57","77.91","","8998.38","2542.37","8998.38","20","18980.15","42700","percent of total billed charges",""
"GRAFT WHOLE CONDYLE RT FEMORAL FRESH ALLO","SUP-ITM-10088563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","42700.00","32025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","25321.10","59.3","","1891.61","1609.14","3664.18","25","21350","33498.15","percent of total billed charges",""
"GRAFT WHOLE CONDYLE RT FEMORAL FRESH ALLO","SUP-ITM-10088563","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","42700.00","32025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33498.15","78.45","","1470.68","1310.06","2481.69","19","21350","33498.15","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo 25 Cc or Less","PX-76002657","CDM","15773","CPT","0761","RC","","","","outpatient","","","2629.00","1971.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1778.43","","Case rate ($1,778.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1259.13","1259.13","2571.61","1 through 10","1314.5","4472.66","other","ASC "
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","AETNA [1001]","HB CH AETNA HMO / PPO","1515.80","58.3","","3299.94","1823.47","5601.39","1 through 10","1115.4","4795.51","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","8132.42","3914.08","8132.42","1 through 10","1115.4","4795.51","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","4615.73","3582.14","5920.48","1 through 10","1115.4","4795.51","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","MEDICARE [2001]","HB BWF MEDICARE","4655.83","","APC Price ($4,655.83). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4347.62","4347.62","4347.62","1 through 10","1115.4","4795.51","other","OPPS APC"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,477). Procedure 2, Per diem ($1,738.50). Procedures 3 - 9999, Per diem ($869.25).","2955.45","2955.45","2955.45","1 through 10","1115.4","4795.51","per diem",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,797). Procedure 2, Per diem ($1,898.50). Procedures 3 - 9999, Per diem ($949.25).","3797.00","3686.00","3797.00","1 through 10","1115.4","4795.51","per diem",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","both","","","2600.00","1950.00","WELLPOINT [1015]","HB CH WELLPOINT","2025.66","77.91","","5970.80","2985.40","7802.87","1 through 10","1115.4","4795.51","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3262.95","","Case rate ($3,262.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2355.85","2306.91","4613.81","34","1300","7178","other","ASC "
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3262.95","","Case rate ($3,262.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2359.12","2310.17","4718.23","51","1300","7178","other","ASC "
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","16251.05","3250.21","19501.23","20","1300","7178","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6583.39","3416.17","7164.28","1 through 10","1300","7178","other","Multiple Surgery"
"Grafting of Autologous Fat by Lipo 50 Cc or Less","PX-76002655","CDM","15771","CPT","0761","RC","","","","outpatient","","","2600.00","1950.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2039.70","78.45","","4411.20","3178.22","8007.82","1 through 10","1300","7178","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","AETNA [1001]","HB CH AETNA HMO / PPO","438.42","58.3","","3299.94","1823.47","3299.94","1 through 10","322.61","585.88","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","268.85","268.85","268.85","1 through 10","322.61","585.88","per diem",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","316.20","316.20","316.20","1 through 10","322.61","585.88","per diem",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","345.55","345.55","345.55","1 through 10","322.61","585.88","per diem",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","both","","","752.00","564.00","WELLPOINT [1015]","HB CH WELLPOINT","585.88","77.91","","3449.15","2985.40","5790.44","1 through 10","322.61","585.88","percent of total billed charges",""
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","outpatient","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","238.29","","Case rate ($238.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","6663.00","6663.00","6663.00","1 through 10","238.29","589.94","other","ASC "
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","outpatient","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","238.29","","Case rate ($238.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","10386.00","7959.08","10386.00","1 through 10","238.29","589.94","other","ASC "
"Grafting of Autologous Fat by Lipo Ea Addl 50 Cc","PX-76002656","CDM","15772","CPT","0761","RC","","","","outpatient","","","752.00","564.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","589.94","78.45","","3797.49","3178.22","8007.82","1 through 10","238.29","589.94","percent of total billed charges",""
"Grafting of Autologous Soft Tiss by Direct Exc","PX-76002654","CDM","15769","CPT","0761","RC","","","","outpatient","","","2623.00","1967.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3262.95","","Case rate ($3,262.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2355.85","2355.85","2355.85","1 through 10","1311.5","7178","other","ASC "
"Grafting of Autologous Soft Tiss by Direct Exc","PX-76002654","CDM","15769","CPT","0761","RC","","","","outpatient","","","2623.00","1967.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3262.95","","Case rate ($3,262.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2359.12","2310.17","4718.23","1 through 10","1311.5","7178","other","ASC "
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","554.95","91.85","1421.75","94","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2490.03","2490.03","2490.03","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","750.00","750.00","750.00","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","1192.50","120.84","4149.90","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","750.00","75.00","750.00","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","657.00","121.50","1971.00","14","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","75.00","75.00","75.00","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","366.00","144.00","1971.00","45","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","667.50","667.50","667.50","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1600.20","44.45","","123.77","123.77","123.77","1 through 10","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","483.51","229.32","1316.08","96","1600.2","3600","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","439.50","225.34","1872.27","197","1800","2824.2","percent of total billed charges",""
"GRIP PLATE 2.0X4.0MM MD TROCHANTERIC DALL MILES VITALLIUM CABLES LOW PROFILE PROXIMALIMAL HOOK DISTAL SPIKE","SUP-ITM-10076769","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","385.32","55.36","1815.62","58","1800","2824.2","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","34.16","34.16","34.16","1 through 10","44.28","170.56","other","OPPS APC"
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","134.62","134.62","134.62","1 through 10","44.28","170.56","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","74.27","74.27","74.27","1 through 10","44.28","170.56","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","234.18","206.36","468.36","17","44.28","170.56","percent of total billed charges",""
"Gross & Micro Level II","PX-31000148","CDM","88302","CPT","0312","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","119.36","59.68","393.00","15","56.93","125.76","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.43","62.43","62.43","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","62.18","62.18","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","262.07","73","","248.93","248.93","248.93","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.27","53","","184.97","184.97","184.97","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","MEDICARE [2001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","59.09","63.45","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","TRICARE [160005]","HB BWF TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","60.28","60.28","60.28","1 through 10","60.28","279.7","other","Tricare OPPS"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.58","44.45","","268.31","268.31","268.31","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.18","58.56","62.19","1 through 10","60.28","279.7","other","OPPS APC"
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.58","44.45","","159.00","159.00","159.00","1 through 10","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","both","","","359.00","269.25","WELLPOINT [1015]","HB CH WELLPOINT","279.70","77.91","","623.87","274.87","1247.74","24","60.28","279.7","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","359.00","269.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.89","59.3","","409.02","204.51","3069.00","37","90.37","281.64","percent of total billed charges",""
"Gross & Micro Level III","PX-31000149","CDM","88304","CPT","0312","RC","","","","outpatient","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.64","78.45","","268.31","258.58","804.93","24","90.37","281.64","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","AETNA [1001]","HB CH AETNA HMO / PPO","205.22","58.3","","581.73","387.82","775.64","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.06","168.82","285.98","1 through 10","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","ELDER SERVICES [1037]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","79.97","79.97","79.97","1 through 10","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","FALLON HEALTH [1008]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","62.18","62.18","62.18","1 through 10","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","256.96","73","","249.66","249.66","249.66","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","205.22","58.3","","387.82","171.00","775.64","19","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH GMMI INTERNATIONAL","186.56","53","","181.26","181.26","181.26","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.56","53","","181.26","128.26","181.26","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","MEDICARE [2001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63.45","59.14","63.45","29","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","256.96","73","","193.92","193.92","193.92","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","TRICARE [160005]","HB BWF TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","60.28","60.28","60.28","1 through 10","60.28","274.24","other","Tricare OPPS"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.92","54.92","54.92","1 through 10","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.45","63.45","63.45","1 through 10","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.46","44.45","","3155.16","262.93","3155.16","19","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","62.19","57.96","63.45","1 through 10","60.28","274.24","other","OPPS APC"
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","156.46","44.45","","311.64","311.64","311.64","1 through 10","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","both","","","352.00","264.00","WELLPOINT [1015]","HB CH WELLPOINT","274.24","77.91","","611.36","269.36","1222.72","59","60.28","274.24","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.74","59.3","","601.23","200.41","1202.16","334","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","276.14","78.45","","262.93","262.65","262.93","1 through 10","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level IV","PX-31000150","CDM","88305","CPT","0312","RC","","","","outpatient","","","352.00","264.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.14","78.45","","525.86","262.93","1051.72","268","90.37","276.14","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","AETNA [1001]","HB CH AETNA HMO / PPO","473.40","58.3","","447.93","447.93","447.93","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","341.96","341.96","341.96","1 through 10","360.93","1456.11","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","592.76","73","","559.91","559.91","559.91","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","473.40","58.3","","1580.00","395.00","3135.51","23","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","INTERNATIONAL COMMERCIAL [140001]","HB CH GMMI INTERNATIONAL","430.36","53","","418.70","418.70","418.70","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","430.36","53","","418.70","418.70","813.02","1 through 10","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","427.19","427.19","1 through 10","360.93","1456.11","other","OPPS APC"
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.93","44.45","","2879.36","719.84","4858.80","26","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","both","","","812.00","609.00","WELLPOINT [1015]","HB CH WELLPOINT","632.63","77.91","","11297.60","2370.00","14122.00","251","360.93","1456.11","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","812.00","609.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","481.52","59.3","","3703.52","903.76","7230.08","187","324.26","926.86","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","812.00","609.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","637.01","78.45","","5466.15","1213.44","5466.15","11","324.26","926.86","percent of total billed charges",""
"Gross & Micro Level V","PX-31000151","CDM","88307","CPT","0312","RC","","","","outpatient","","","812.00","609.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","637.01","78.45","","4251.45","607.35","4858.80","196","324.26","926.86","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1215.00","911.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","886.95","73","","837.31","837.31","837.31","1 through 10","540.07","2963.62","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","540.07","44.45","","538.06","538.06","538.06","1 through 10","540.07","2963.62","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","2111.16","2111.16","2111.16","1 through 10","540.07","2963.62","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","692.07","578.33","692.07","1 through 10","607.5","1886.45","percent of total billed charges",""
"Gross & Micro Level VI","PX-31000152","CDM","88309","CPT","0312","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","907.95","538.06","1815.90","1 through 10","607.5","1886.45","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","125.00","93.75","MEDICARE [2001]","HB BWF MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","97.39","other","OPPS APC"
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","125.00","93.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","25.08","25.08","25.08","1 through 10","27.63","97.39","other","OPPS APC"
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","both","","","125.00","93.75","WELLPOINT [1015]","HB CH WELLPOINT","97.39","77.91","","96.09","96.09","218.09","1 through 10","27.63","97.39","percent of total billed charges",""
"Gross Only Level I","PX-31000147","CDM","88300","CPT","0312","RC","","","","outpatient","","","125.00","93.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.06","78.45","","93.79","93.79","93.79","1 through 10","30.43","98.06","percent of total billed charges",""
"Group Psychotherapy","PX-90000125","CDM","90853","CPT","0914","RC","","","","both","","","133.00","99.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.36","119.36","159.14","80","70.49","222.51","other","OPPS APC"
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","73.32","75.98","1 through 10","16.34","100.74","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","235.56","78.52","235.56","1 through 10","17.2","108.26","percent of total billed charges",""
"Growth Hormone (Hgh)","PX-30000483","CDM","83003","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","17.2","108.26","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","AETNA [1001]","HB CH AETNA HMO / PPO","347.32","58.3","","554.95","91.85","1421.75","94","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","434.89","73","","2490.03","2490.03","2490.03","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","347.32","58.3","","750.00","750.00","750.00","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","315.74","53","","1192.50","120.84","4149.90","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","506.38","85","","750.00","75.00","750.00","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","595.74","100","","657.00","121.50","1971.00","14","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","595.74","100","","75.00","75.00","75.00","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","595.74","100","","366.00","144.00","1971.00","45","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","434.89","73","","667.50","667.50","667.50","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.81","44.45","","123.77","123.77","123.77","1 through 10","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","both","","","595.74","446.80","WELLPOINT [1015]","HB CH WELLPOINT","464.14","77.91","","483.51","229.32","1316.08","96","264.81","595.74","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.74","446.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","353.27","59.3","","439.50","225.34","1872.27","197","297.87","467.36","percent of total billed charges",""
"GUIDE PIN 2.8X300MM DRILL TIP","SUP-ITM-10178626","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","595.74","446.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","467.36","78.45","","385.32","55.36","1815.62","58","297.87","467.36","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","AETNA [1001]","HB CH AETNA HMO / PPO","1754.25","58.3","","1634.24","1004.95","1718.99","42","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2196.57","73","","2123.89","1900.92","2123.89","1 through 10","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1754.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1594.77","53","","939.37","939.37","5593.65","1 through 10","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2557.65","85","","2323.25","1864.50","2882.25","16","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3009.00","100","","2909.44","1772.40","10952.08","45","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3009.00","100","","2323.25","2323.25","2323.25","1 through 10","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3009.00","100","","2882.25","1772.40","10169.17","187","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2196.57","73","","1659.41","1659.41","1659.41","1 through 10","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","both","","","3009.00","2256.75","WELLPOINT [1015]","HB CH WELLPOINT","2344.31","77.91","","2050.91","1468.48","2902.83","52","1337.5","3009","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3009.00","2256.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1784.34","59.3","","1548.60","1092.60","3613.79","82","1504.5","2360.56","percent of total billed charges",""
"GUIDE TIBIAL ALIGNMENT PROPHECY PREOPERATIVE IN BONE HIGH RESOLUTION NYLON PATIENT SPECIFIC","SUP-ITM-10146376","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3009.00","2256.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2360.56","78.45","","2085.51","998.68","6202.11","56","1504.5","2360.56","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","161.55","62.25","161.55","1 through 10","60.01","135","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","52.44","22.90","505.57","1 through 10","60.01","135","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.75","85","","68.52","68.52","68.52","1 through 10","60.01","135","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.00","100","","62.20","62.19","81.17","14","60.01","135","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.00","100","","43.22","31.95","953.91","1 through 10","60.01","135","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","63.92","25.16","245.73","18","60.01","135","percent of total billed charges",""
"GUIDE WIRE .062 X 12IN LONG","SUP-ITM-10115630","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","97.25","24.56","207.80","18","67.5","105.91","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","AETNA [1001]","HB CH AETNA HMO / PPO","245.17","58.3","","161.55","62.25","161.55","1 through 10","186.93","420.54","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.89","53","","52.44","22.90","505.57","1 through 10","186.93","420.54","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.46","85","","68.52","68.52","68.52","1 through 10","186.93","420.54","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.54","100","","62.20","62.19","81.17","14","186.93","420.54","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.54","100","","43.22","31.95","953.91","1 through 10","186.93","420.54","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","both","","","420.54","315.40","WELLPOINT [1015]","HB CH WELLPOINT","327.64","77.91","","63.92","25.16","245.73","18","186.93","420.54","percent of total billed charges",""
"Guide/Glide Wire T1","PX-27000084","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","420.54","315.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.91","78.45","","97.25","24.56","207.80","18","210.27","329.91","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","AETNA [1001]","HB CH AETNA HMO / PPO","2331.99","58.3","","161.55","62.25","161.55","1 through 10","1777.99","3999.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2119.99","53","","52.44","22.90","505.57","1 through 10","1777.99","3999.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3399.98","85","","68.52","68.52","68.52","1 through 10","1777.99","3999.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3999.98","100","","62.20","62.19","81.17","14","1777.99","3999.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3999.98","100","","43.22","31.95","953.91","1 through 10","1777.99","3999.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","both","","","3999.98","2999.98","WELLPOINT [1015]","HB CH WELLPOINT","3116.38","77.91","","63.92","25.16","245.73","18","1777.99","3999.98","percent of total billed charges",""
"Guide/Glide Wire T2","PX-27000085","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","3999.98","2999.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3137.98","78.45","","97.25","24.56","207.80","18","1999.99","3137.98","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","161.55","62.25","161.55","1 through 10","138.68","312","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","52.44","22.90","505.57","1 through 10","138.68","312","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.20","85","","68.52","68.52","68.52","1 through 10","138.68","312","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","312.00","100","","62.20","62.19","81.17","14","138.68","312","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","312.00","100","","43.22","31.95","953.91","1 through 10","138.68","312","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","63.92","25.16","245.73","18","138.68","312","percent of total billed charges",""
"GUIDEWIRE BILIARY 450CM 0.035IN JAGWIRE NITINOL ENDOGLIDE COATED ANGLED TIP TRIM BX/2EA","SUP-ITM-10028797","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","97.25","24.56","207.80","18","156","244.76","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","386.25","289.69","AETNA [1001]","HB CH AETNA HMO / PPO","225.18","58.3","","161.55","62.25","161.55","1 through 10","171.69","386.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","386.25","289.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","204.71","53","","52.44","22.90","505.57","1 through 10","171.69","386.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","386.25","289.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","328.31","85","","68.52","68.52","68.52","1 through 10","171.69","386.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","386.25","289.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","386.25","100","","62.20","62.19","81.17","14","171.69","386.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","386.25","289.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","386.25","100","","43.22","31.95","953.91","1 through 10","171.69","386.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","both","","","386.25","289.69","WELLPOINT [1015]","HB CH WELLPOINT","300.93","77.91","","63.92","25.16","245.73","18","171.69","386.25","percent of total billed charges",""
"GUIDEWIRE BILIARY 5CM HYDROPHILIC TIP SPYGLASS DISCOVER JAGWIRE BX/2EA","SUP-ITM-10295683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","386.25","289.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.01","78.45","","97.25","24.56","207.80","18","193.13","303.01","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","AETNA [1001]","HB CH AETNA HMO / PPO","52.47","58.3","","161.55","62.25","161.55","1 through 10","40.01","90","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","47.70","53","","52.44","22.90","505.57","1 through 10","40.01","90","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","76.50","85","","68.52","68.52","68.52","1 through 10","40.01","90","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","90.00","100","","62.20","62.19","81.17","14","40.01","90","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","90.00","100","","43.22","31.95","953.91","1 through 10","40.01","90","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","both","","","90.00","67.50","WELLPOINT [1015]","HB CH WELLPOINT","70.12","77.91","","63.92","25.16","245.73","18","40.01","90","percent of total billed charges",""
"GUIDEWIRE BONE .86MM DOUBLE ENDED TROCAR TIP BX/6EA","SUP-ITM-10154670","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","97.25","24.56","207.80","18","45","70.61","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","161.55","62.25","161.55","1 through 10","49.34","111","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","both","","","111.00","83.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","58.83","53","","52.44","22.90","505.57","1 through 10","49.34","111","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","94.35","85","","68.52","68.52","68.52","1 through 10","49.34","111","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","111.00","100","","62.20","62.19","81.17","14","49.34","111","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","111.00","100","","43.22","31.95","953.91","1 through 10","49.34","111","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","both","","","111.00","83.25","WELLPOINT [1015]","HB CH WELLPOINT","86.48","77.91","","63.92","25.16","245.73","18","49.34","111","percent of total billed charges",""
"GUIDEWIRE BONE 1.2MMX18IN BIOSURE HA SS SMOOTH TROCAR POINT BX/5EA","SUP-ITM-10049473","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","97.25","24.56","207.80","18","55.5","87.08","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","161.55","62.25","161.55","1 through 10","26.67","60","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","52.44","22.90","505.57","1 through 10","26.67","60","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","51.00","85","","68.52","68.52","68.52","1 through 10","26.67","60","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","60.00","100","","62.20","62.19","81.17","14","26.67","60","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","60.00","100","","43.22","31.95","953.91","1 through 10","26.67","60","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","63.92","25.16","245.73","18","26.67","60","percent of total billed charges",""
"GUIDEWIRE BONE 1.35MM 130 SS TROCAR TIP BX/6EA","SUP-ITM-10124493","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","97.25","24.56","207.80","18","30","47.07","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.59","226.19","AETNA [1001]","HB CH AETNA HMO / PPO","175.83","58.3","","161.55","62.25","161.55","1 through 10","134.06","301.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.59","226.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.84","53","","52.44","22.90","505.57","1 through 10","134.06","301.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.59","226.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","256.35","85","","68.52","68.52","68.52","1 through 10","134.06","301.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.59","226.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","301.59","100","","62.20","62.19","81.17","14","134.06","301.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.59","226.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","301.59","100","","43.22","31.95","953.91","1 through 10","134.06","301.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","both","","","301.59","226.19","WELLPOINT [1015]","HB CH WELLPOINT","234.97","77.91","","63.92","25.16","245.73","18","134.06","301.59","percent of total billed charges",""
"GUIDEWIRE BONE 2.4MMX10IN PCL SAFETY SS FLEXIBLE DRILL TIP","SUP-ITM-10014494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","301.59","226.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.60","78.45","","97.25","24.56","207.80","18","150.8","236.6","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","AETNA [1001]","HB CH AETNA HMO / PPO","53.17","58.3","","161.55","62.25","161.55","1 through 10","40.54","91.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","48.34","53","","52.44","22.90","505.57","1 through 10","40.54","91.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","77.52","85","","68.52","68.52","68.52","1 through 10","40.54","91.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","91.20","100","","62.20","62.19","81.17","14","40.54","91.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","91.20","100","","43.22","31.95","953.91","1 through 10","40.54","91.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","both","","","91.20","68.40","WELLPOINT [1015]","HB CH WELLPOINT","71.05","77.91","","63.92","25.16","245.73","18","40.54","91.2","percent of total billed charges",""
"GUIDEWIRE BONE 2.8MM 350 NAIL FEMORAL PROXIMAL","SUP-ITM-10039410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","91.20","68.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","71.55","78.45","","97.25","24.56","207.80","18","45.6","71.55","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","AETNA [1001]","HB CH AETNA HMO / PPO","62.77","58.3","","161.55","62.25","161.55","1 through 10","47.86","107.67","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.07","53","","52.44","22.90","505.57","1 through 10","47.86","107.67","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","91.52","85","","68.52","68.52","68.52","1 through 10","47.86","107.67","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","107.67","100","","62.20","62.19","81.17","14","47.86","107.67","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","107.67","100","","43.22","31.95","953.91","1 through 10","47.86","107.67","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","both","","","107.67","80.75","WELLPOINT [1015]","HB CH WELLPOINT","83.89","77.91","","63.92","25.16","245.73","18","47.86","107.67","percent of total billed charges",""
"GUIDEWIRE BONE 230X2.5MM COBALT ALLOY SPADE POINT THREADED BX/10EA","SUP-ITM-10007555","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.47","78.45","","97.25","24.56","207.80","18","53.84","84.47","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","AETNA [1001]","HB CH AETNA HMO / PPO","27.98","58.3","","161.55","62.25","161.55","1 through 10","21.34","48","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","25.44","53","","52.44","22.90","505.57","1 through 10","21.34","48","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","40.80","85","","68.52","68.52","68.52","1 through 10","21.34","48","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","48.00","100","","62.20","62.19","81.17","14","21.34","48","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","48.00","100","","43.22","31.95","953.91","1 through 10","21.34","48","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","both","","","48.00","36.00","WELLPOINT [1015]","HB CH WELLPOINT","37.40","77.91","","63.92","25.16","245.73","18","21.34","48","percent of total billed charges",""
"GUIDEWIRE BONE 6.0IN 0.045 KIRSCHNER ACUTRAK 2 SS SINGLE TROCAR","SUP-ITM-10010190","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","48.00","36.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","37.66","78.45","","97.25","24.56","207.80","18","24","37.66","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","161.55","62.25","161.55","1 through 10","20","45","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","23.85","53","","52.44","22.90","505.57","1 through 10","20","45","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","38.25","85","","68.52","68.52","68.52","1 through 10","20","45","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","45.00","100","","62.20","62.19","81.17","14","20","45","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","45.00","100","","43.22","31.95","953.91","1 through 10","20","45","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","both","","","45.00","33.75","WELLPOINT [1015]","HB CH WELLPOINT","35.06","77.91","","63.92","25.16","245.73","18","20","45","percent of total billed charges",""
"GUIDEWIRE BONE 8X0.092IN SS TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10156092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","97.25","24.56","207.80","18","22.5","35.3","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.71","32.78","AETNA [1001]","HB CH AETNA HMO / PPO","25.48","58.3","","161.55","62.25","161.55","1 through 10","19.43","43.71","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.71","32.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","23.17","53","","52.44","22.90","505.57","1 through 10","19.43","43.71","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.71","32.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","37.15","85","","68.52","68.52","68.52","1 through 10","19.43","43.71","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.71","32.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","43.71","100","","62.20","62.19","81.17","14","19.43","43.71","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.71","32.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","43.71","100","","43.22","31.95","953.91","1 through 10","19.43","43.71","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.71","32.78","WELLPOINT [1015]","HB CH WELLPOINT","34.05","77.91","","63.92","25.16","245.73","18","19.43","43.71","percent of total billed charges",""
"GUIDEWIRE CORE FIXED 3CM 150 0.035IN UROLOGY PTFE COATED FLEXIBLE STRAIGHT TIP","SUP-ITM-10155648","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.71","32.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.29","78.45","","97.25","24.56","207.80","18","21.86","34.29","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","161.55","62.25","161.55","1 through 10","220.03","495","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","52.44","22.90","505.57","1 through 10","220.03","495","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","420.75","85","","68.52","68.52","68.52","1 through 10","220.03","495","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","495.00","100","","62.20","62.19","81.17","14","220.03","495","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","495.00","100","","43.22","31.95","953.91","1 through 10","220.03","495","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","63.92","25.16","245.73","18","220.03","495","percent of total billed charges",""
"GUIDEWIRE DREAMWIRE 450CM .035IN RX BILIARY NITINOL COATED STRAIGHT ROUND HIGH PERFORMANCE STANDARD BX/2EA","SUP-ITM-10092410","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","97.25","24.56","207.80","18","247.5","388.33","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.13","137.35","AETNA [1001]","HB CH AETNA HMO / PPO","106.76","58.3","","161.55","62.25","161.55","1 through 10","81.4","183.13","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.13","137.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.06","53","","52.44","22.90","505.57","1 through 10","81.4","183.13","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.13","137.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","155.66","85","","68.52","68.52","68.52","1 through 10","81.4","183.13","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.13","137.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","183.13","100","","62.20","62.19","81.17","14","81.4","183.13","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.13","137.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","183.13","100","","43.22","31.95","953.91","1 through 10","81.4","183.13","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","both","","","183.13","137.35","WELLPOINT [1015]","HB CH WELLPOINT","142.68","77.91","","63.92","25.16","245.73","18","81.4","183.13","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPIC 3CM 150 0.035IN WIREX ANGLED TIP TORQUABLE HYDROPHILIC RADIOPAQUE NITINOL SENSOR BX/5EA","SUP-ITM-10028861","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","183.13","137.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.67","78.45","","97.25","24.56","207.80","18","91.57","143.67","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","540.75","405.56","AETNA [1001]","HB CH AETNA HMO / PPO","315.26","58.3","","161.55","62.25","161.55","1 through 10","240.36","540.75","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","540.75","405.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","286.60","53","","52.44","22.90","505.57","1 through 10","240.36","540.75","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","540.75","405.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","459.64","85","","68.52","68.52","68.52","1 through 10","240.36","540.75","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","540.75","405.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","540.75","100","","62.20","62.19","81.17","14","240.36","540.75","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","540.75","405.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","540.75","100","","43.22","31.95","953.91","1 through 10","240.36","540.75","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","both","","","540.75","405.56","WELLPOINT [1015]","HB CH WELLPOINT","421.30","77.91","","63.92","25.16","245.73","18","240.36","540.75","percent of total billed charges",""
"GUIDEWIRE ENDOSCOPY 480CM BILIARY DUCT BX/2EA","SUP-ITM-10210614","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","540.75","405.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","424.22","78.45","","97.25","24.56","207.80","18","270.38","424.22","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","both","","","97.50","73.12","AETNA [1001]","HB CH AETNA HMO / PPO","56.84","58.3","","161.55","62.25","161.55","1 through 10","43.34","97.5","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","both","","","97.50","73.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.68","53","","52.44","22.90","505.57","1 through 10","43.34","97.5","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","both","","","97.50","73.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","82.88","85","","68.52","68.52","68.52","1 through 10","43.34","97.5","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","both","","","97.50","73.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","97.50","100","","62.20","62.19","81.17","14","43.34","97.5","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","both","","","97.50","73.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","97.50","100","","43.22","31.95","953.91","1 through 10","43.34","97.5","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","both","","","97.50","73.12","WELLPOINT [1015]","HB CH WELLPOINT","75.96","77.91","","63.92","25.16","245.73","18","43.34","97.5","percent of total billed charges",""
"GUIDEWIRE FIXED 5CM 0.035INX145 CORE AMPLATZCORE EXTRA STIFF BODY PTFE COATING DOUBLE FLEXIBLE TIP","SUP-ITM-10158597","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","97.50","73.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.49","78.45","","97.25","24.56","207.80","18","48.75","76.49","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.00","128.25","AETNA [1001]","HB CH AETNA HMO / PPO","99.69","58.3","","161.55","62.25","161.55","1 through 10","76.01","171","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.00","128.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.63","53","","52.44","22.90","505.57","1 through 10","76.01","171","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","145.35","85","","68.52","68.52","68.52","1 through 10","76.01","171","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","171.00","100","","62.20","62.19","81.17","14","76.01","171","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.00","128.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","171.00","100","","43.22","31.95","953.91","1 through 10","76.01","171","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","both","","","171.00","128.25","WELLPOINT [1015]","HB CH WELLPOINT","133.23","77.91","","63.92","25.16","245.73","18","76.01","171","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 150CM .018IN 3CM STANDARD STRAIGHT FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000142","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","171.00","128.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.15","78.45","","97.25","24.56","207.80","18","85.5","134.15","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","AETNA [1001]","HB CH AETNA HMO / PPO","72.58","58.3","","161.55","62.25","161.55","1 through 10","55.34","124.5","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","65.99","53","","52.44","22.90","505.57","1 through 10","55.34","124.5","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","105.83","85","","68.52","68.52","68.52","1 through 10","55.34","124.5","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","124.50","100","","62.20","62.19","81.17","14","55.34","124.5","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","124.50","100","","43.22","31.95","953.91","1 through 10","55.34","124.5","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","both","","","124.50","93.37","WELLPOINT [1015]","HB CH WELLPOINT","97.00","77.91","","63.92","25.16","245.73","18","55.34","124.5","percent of total billed charges",""
"GUIDEWIRE GLIDEWIRE 180CM .035IN 3CM STANDARD ANGLE FLEXIBLE TIP HYDROPHILIC COATED REGULAR PERIPHERAL VASCULAR BX/5EA","SUP-ITM-10000200","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","124.50","93.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.67","78.45","","97.25","24.56","207.80","18","62.25","97.67","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","161.55","62.25","161.55","1 through 10","29.34","66","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.98","53","","52.44","22.90","505.57","1 through 10","29.34","66","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","56.10","85","","68.52","68.52","68.52","1 through 10","29.34","66","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","66.00","100","","62.20","62.19","81.17","14","29.34","66","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","66.00","100","","43.22","31.95","953.91","1 through 10","29.34","66","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","both","","","66.00","49.50","WELLPOINT [1015]","HB CH WELLPOINT","51.42","77.91","","63.92","25.16","245.73","18","29.34","66","percent of total billed charges",""
"GUIDEWIRE GUIDE 2.4 M 12 LONG .094 WIRE W/TROCAR TIP NONTHREADED BX/6EA","SUP-ITM-10154686","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","97.25","24.56","207.80","18","33","51.78","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","161.55","62.25","161.55","1 through 10","33.34","75","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","52.44","22.90","505.57","1 through 10","33.34","75","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","68.52","68.52","68.52","1 through 10","33.34","75","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","62.20","62.19","81.17","14","33.34","75","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","43.22","31.95","953.91","1 through 10","33.34","75","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","63.92","25.16","245.73","18","33.34","75","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.1MM ANKLE ARTHOSCOPY SS BX/6EA","SUP-ITM-10154664","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","97.25","24.56","207.80","18","37.5","58.84","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","AETNA [1001]","HB CH AETNA HMO / PPO","31.34","58.3","","161.55","62.25","161.55","1 through 10","23.9","53.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.49","53","","52.44","22.90","505.57","1 through 10","23.9","53.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","45.70","85","","68.52","68.52","68.52","1 through 10","23.9","53.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","53.76","100","","62.20","62.19","81.17","14","23.9","53.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","53.76","100","","43.22","31.95","953.91","1 through 10","23.9","53.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","both","","","53.76","40.32","WELLPOINT [1015]","HB CH WELLPOINT","41.88","77.91","","63.92","25.16","245.73","18","23.9","53.76","percent of total billed charges",""
"GUIDEWIRE KIRSCHNER 1.25X150MM NON THREADED","SUP-ITM-10043023","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.17","78.45","","97.25","24.56","207.80","18","26.88","42.17","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","both","","","308.38","231.28","AETNA [1001]","HB CH AETNA HMO / PPO","179.79","58.3","","161.55","62.25","161.55","1 through 10","137.07","308.38","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","both","","","308.38","231.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","163.44","53","","52.44","22.90","505.57","1 through 10","137.07","308.38","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","both","","","308.38","231.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","262.12","85","","68.52","68.52","68.52","1 through 10","137.07","308.38","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","both","","","308.38","231.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","308.38","100","","62.20","62.19","81.17","14","137.07","308.38","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","both","","","308.38","231.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","308.38","100","","43.22","31.95","953.91","1 through 10","137.07","308.38","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","both","","","308.38","231.28","WELLPOINT [1015]","HB CH WELLPOINT","240.26","77.91","","63.92","25.16","245.73","18","137.07","308.38","percent of total billed charges",""
"GUIDEWIRE NAVIPRO 260CM .035IN BILIARY HYDROPHILIC STANDARD STRAIGHT BX/5EA","SUP-ITM-10134601","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","308.38","231.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","241.92","78.45","","97.25","24.56","207.80","18","154.19","241.92","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","194.79","146.09","AETNA [1001]","HB CH AETNA HMO / PPO","113.56","58.3","","161.55","62.25","161.55","1 through 10","86.58","194.79","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","194.79","146.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","103.24","53","","52.44","22.90","505.57","1 through 10","86.58","194.79","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","194.79","146.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","165.57","85","","68.52","68.52","68.52","1 through 10","86.58","194.79","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","194.79","146.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","194.79","100","","62.20","62.19","81.17","14","86.58","194.79","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","194.79","146.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","194.79","100","","43.22","31.95","953.91","1 through 10","86.58","194.79","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","both","","","194.79","146.09","WELLPOINT [1015]","HB CH WELLPOINT","151.76","77.91","","63.92","25.16","245.73","18","86.58","194.79","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 1.6X220MM TROCAR TIP","SUP-ITM-10276386","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","194.79","146.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","152.81","78.45","","97.25","24.56","207.80","18","97.4","152.81","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","AETNA [1001]","HB CH AETNA HMO / PPO","228.79","58.3","","161.55","62.25","161.55","1 through 10","174.44","392.43","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","207.99","53","","52.44","22.90","505.57","1 through 10","174.44","392.43","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","333.57","85","","68.52","68.52","68.52","1 through 10","174.44","392.43","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","392.43","100","","62.20","62.19","81.17","14","174.44","392.43","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","392.43","100","","43.22","31.95","953.91","1 through 10","174.44","392.43","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","WELLPOINT [1015]","HB CH WELLPOINT","305.74","77.91","","63.92","25.16","245.73","18","174.44","392.43","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2MM 28IN SS INTRAMEDULLARY BALL NOSE","SUP-ITM-10065092","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","392.43","294.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.86","78.45","","97.25","24.56","207.80","18","196.22","307.86","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","AETNA [1001]","HB CH AETNA HMO / PPO","100.74","58.3","","161.55","62.25","161.55","1 through 10","76.81","172.8","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.58","53","","52.44","22.90","505.57","1 through 10","76.81","172.8","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","146.88","85","","68.52","68.52","68.52","1 through 10","76.81","172.8","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","172.80","100","","62.20","62.19","81.17","14","76.81","172.8","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","172.80","100","","43.22","31.95","953.91","1 through 10","76.81","172.8","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","both","","","172.80","129.60","WELLPOINT [1015]","HB CH WELLPOINT","134.63","77.91","","63.92","25.16","245.73","18","76.81","172.8","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.2X800MM T2 SMOOTH TIP SS SHAFT","SUP-ITM-10028280","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","172.80","129.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.56","78.45","","97.25","24.56","207.80","18","86.4","135.56","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","AETNA [1001]","HB CH AETNA HMO / PPO","83.48","58.3","","161.55","62.25","161.55","1 through 10","63.65","143.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","75.89","53","","52.44","22.90","505.57","1 through 10","63.65","143.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","121.71","85","","68.52","68.52","68.52","1 through 10","63.65","143.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","143.19","100","","62.20","62.19","81.17","14","63.65","143.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","143.19","100","","43.22","31.95","953.91","1 through 10","63.65","143.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","both","","","143.19","107.39","WELLPOINT [1015]","HB CH WELLPOINT","111.56","77.91","","63.92","25.16","245.73","18","63.65","143.19","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X200MM LCP PERIARTICULAR TI THREADED DRILL TIP EA/1EA","SUP-ITM-10012494","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","143.19","107.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.33","78.45","","97.25","24.56","207.80","18","71.6","112.33","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","AETNA [1001]","HB CH AETNA HMO / PPO","516.81","58.3","","161.55","62.25","161.55","1 through 10","394.04","886.47","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.83","53","","52.44","22.90","505.57","1 through 10","394.04","886.47","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","753.50","85","","68.52","68.52","68.52","1 through 10","394.04","886.47","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","886.47","100","","62.20","62.19","81.17","14","394.04","886.47","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","886.47","100","","43.22","31.95","953.91","1 through 10","394.04","886.47","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","both","","","886.47","664.85","WELLPOINT [1015]","HB CH WELLPOINT","690.65","77.91","","63.92","25.16","245.73","18","394.04","886.47","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.5X800MM T2 BALL TIP SS SHAFT","SUP-ITM-10033476","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","886.47","664.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","695.44","78.45","","97.25","24.56","207.80","18","443.24","695.44","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","161.55","62.25","161.55","1 through 10","114.68","258","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","136.74","53","","52.44","22.90","505.57","1 through 10","114.68","258","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","219.30","85","","68.52","68.52","68.52","1 through 10","114.68","258","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","258.00","100","","62.20","62.19","81.17","14","114.68","258","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","258.00","100","","43.22","31.95","953.91","1 through 10","114.68","258","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB CH WELLPOINT","201.01","77.91","","63.92","25.16","245.73","18","114.68","258","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 2.8X220MM FLUTED TIP","SUP-ITM-10276385","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","97.25","24.56","207.80","18","129","202.4","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","AETNA [1001]","HB CH AETNA HMO / PPO","380.11","58.3","","161.55","62.25","161.55","1 through 10","289.81","651.99","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.55","53","","52.44","22.90","505.57","1 through 10","289.81","651.99","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","554.19","85","","68.52","68.52","68.52","1 through 10","289.81","651.99","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.99","100","","62.20","62.19","81.17","14","289.81","651.99","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.99","100","","43.22","31.95","953.91","1 through 10","289.81","651.99","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","both","","","651.99","488.99","WELLPOINT [1015]","HB CH WELLPOINT","507.97","77.91","","63.92","25.16","245.73","18","289.81","651.99","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3.2X300MM ASNIS III SS THREADED 702462S","SUP-ITM-10145111","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","97.25","24.56","207.80","18","326","511.49","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","AETNA [1001]","HB CH AETNA HMO / PPO","556.13","58.3","","161.55","62.25","161.55","1 through 10","424.01","953.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.57","53","","52.44","22.90","505.57","1 through 10","424.01","953.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","810.82","85","","68.52","68.52","68.52","1 through 10","424.01","953.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","953.91","100","","62.20","62.19","81.17","14","424.01","953.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","953.91","100","","43.22","31.95","953.91","1 through 10","424.01","953.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","both","","","953.91","715.43","WELLPOINT [1015]","HB CH WELLPOINT","743.19","77.91","","63.92","25.16","245.73","18","424.01","953.91","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 3X1000MM T2 SS BALL TIP","SUP-ITM-10017925","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","953.91","715.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","748.34","78.45","","97.25","24.56","207.80","18","476.96","748.34","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","AETNA [1001]","HB CH AETNA HMO / PPO","124.90","58.3","","161.55","62.25","161.55","1 through 10","95.23","214.23","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","113.54","53","","52.44","22.90","505.57","1 through 10","95.23","214.23","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","182.10","85","","68.52","68.52","68.52","1 through 10","95.23","214.23","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","214.23","100","","62.20","62.19","81.17","14","95.23","214.23","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","214.23","100","","43.22","31.95","953.91","1 through 10","95.23","214.23","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","both","","","214.23","160.67","WELLPOINT [1015]","HB CH WELLPOINT","166.91","77.91","","63.92","25.16","245.73","18","95.23","214.23","percent of total billed charges",""
"GUIDEWIRE ORTHOPEDIC 400X3.2MM TI THREADED BX/3EA BX/3EA","SUP-ITM-10009825","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","214.23","160.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","168.06","78.45","","97.25","24.56","207.80","18","107.12","168.06","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","554.95","91.85","1421.75","94","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2490.03","2490.03","2490.03","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","750.00","750.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","1192.50","120.84","4149.90","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","750.00","75.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","657.00","121.50","1971.00","14","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","75.00","75.00","75.00","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","366.00","144.00","1971.00","45","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","667.50","667.50","667.50","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","123.77","123.77","123.77","1 through 10","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","483.51","229.32","1316.08","96","133.35","300","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","439.50","225.34","1872.27","197","150","235.35","percent of total billed charges",""
"GUIDEWIRE PIN 2.5X220MM AEQUALIS","SUP-ITM-10188861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","385.32","55.36","1815.62","58","150","235.35","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","AETNA [1001]","HB CH AETNA HMO / PPO","111.79","58.3","","161.55","62.25","161.55","1 through 10","85.23","191.75","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","101.63","53","","52.44","22.90","505.57","1 through 10","85.23","191.75","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","162.99","85","","68.52","68.52","68.52","1 through 10","85.23","191.75","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","191.75","100","","62.20","62.19","81.17","14","85.23","191.75","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","191.75","100","","43.22","31.95","953.91","1 through 10","85.23","191.75","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","both","","","191.75","143.81","WELLPOINT [1015]","HB CH WELLPOINT","149.39","77.91","","63.92","25.16","245.73","18","85.23","191.75","percent of total billed charges",""
"GUIDEWIRE SENSOR 3CM 150CM .035IN STRAIGHT ENDOSCOPIC MOVEABLE CORE HYDROPHILIC RADIOPAQUE NITINOL DISP SENSOR BX/5EA","SUP-ITM-10015940","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","191.75","143.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.43","78.45","","97.25","24.56","207.80","18","95.88","150.43","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.22","32.41","AETNA [1001]","HB CH AETNA HMO / PPO","25.20","58.3","","161.55","62.25","161.55","1 through 10","19.21","43.22","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.22","32.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","22.91","53","","52.44","22.90","505.57","1 through 10","19.21","43.22","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.22","32.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","36.74","85","","68.52","68.52","68.52","1 through 10","19.21","43.22","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.22","32.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","43.22","100","","62.20","62.19","81.17","14","19.21","43.22","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.22","32.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","43.22","100","","43.22","31.95","953.91","1 through 10","19.21","43.22","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","both","","","43.22","32.41","WELLPOINT [1015]","HB CH WELLPOINT","33.67","77.91","","63.92","25.16","245.73","18","19.21","43.22","percent of total billed charges",""
"GUIDEWIRE STARTER 15CM 180CM .035IN STRAIGHT BENTSON PTFE COATED BX/5EA","SUP-ITM-10041429","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","43.22","32.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","33.91","78.45","","97.25","24.56","207.80","18","21.61","33.91","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","AETNA [1001]","HB CH AETNA HMO / PPO","90.25","58.3","","161.55","62.25","161.55","1 through 10","68.81","154.8","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.04","53","","52.44","22.90","505.57","1 through 10","68.81","154.8","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","131.58","85","","68.52","68.52","68.52","1 through 10","68.81","154.8","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","154.80","100","","62.20","62.19","81.17","14","68.81","154.8","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","154.80","100","","43.22","31.95","953.91","1 through 10","68.81","154.8","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","both","","","154.80","116.10","WELLPOINT [1015]","HB CH WELLPOINT","120.60","77.91","","63.92","25.16","245.73","18","68.81","154.8","percent of total billed charges",""
"GUIDEWIRE TROCAR TIP 1.1MM 150MM","SUP-ITM-10267942","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","154.80","116.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.44","78.45","","97.25","24.56","207.80","18","77.4","121.44","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","AETNA [1001]","HB CH AETNA HMO / PPO","87.54","58.3","","161.55","62.25","161.55","1 through 10","66.75","150.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.58","53","","52.44","22.90","505.57","1 through 10","66.75","150.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.64","85","","68.52","68.52","68.52","1 through 10","66.75","150.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.16","100","","62.20","62.19","81.17","14","66.75","150.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.16","100","","43.22","31.95","953.91","1 through 10","66.75","150.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","both","","","150.16","112.62","WELLPOINT [1015]","HB CH WELLPOINT","116.99","77.91","","63.92","25.16","245.73","18","66.75","150.16","percent of total billed charges",""
"GUIDEWIRE UROLOGICAL .035INX150CM 3CM TAPER ZIPWIRE NITINOL HYDROPHILIC STRAIGHT TIP STANDARD SHAFT BX/5EA","SUP-ITM-10116063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","150.16","112.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.80","78.45","","97.25","24.56","207.80","18","75.08","117.8","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","AETNA [1001]","HB CH AETNA HMO / PPO","208.59","58.3","","161.55","62.25","161.55","1 through 10","159.03","357.78","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","189.62","53","","52.44","22.90","505.57","1 through 10","159.03","357.78","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","304.11","85","","68.52","68.52","68.52","1 through 10","159.03","357.78","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","357.78","100","","62.20","62.19","81.17","14","159.03","357.78","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","357.78","100","","43.22","31.95","953.91","1 through 10","159.03","357.78","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","both","","","357.78","268.33","WELLPOINT [1015]","HB CH WELLPOINT","278.75","77.91","","63.92","25.16","245.73","18","159.03","357.78","percent of total billed charges",""
"GUIDEWIRE UROLOGY .035IN 260CM GLIDEWIRE NITINOL HYDROPHILIC COATED ANGLED TIP BX/5EA","SUP-ITM-10118217","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","357.78","268.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","280.68","78.45","","97.25","24.56","207.80","18","178.89","280.68","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","AETNA [1001]","HB CH AETNA HMO / PPO","60.90","58.3","","161.55","62.25","161.55","1 through 10","46.43","104.46","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.36","53","","52.44","22.90","505.57","1 through 10","46.43","104.46","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","88.79","85","","68.52","68.52","68.52","1 through 10","46.43","104.46","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","104.46","100","","62.20","62.19","81.17","14","46.43","104.46","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","104.46","100","","43.22","31.95","953.91","1 through 10","46.43","104.46","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","both","","","104.46","78.34","WELLPOINT [1015]","HB CH WELLPOINT","81.38","77.91","","63.92","25.16","245.73","18","46.43","104.46","percent of total billed charges",""
"GUIDEWIRE UROLOGY 3.5X145CM 0.035IN NEPHROLITHOTOMY AMPLATZ SUPER STIFF FIXED CORE STRAIGHT FLEXIBLE TIP BX/5EA","SUP-ITM-10155672","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","104.46","78.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.95","78.45","","97.25","24.56","207.80","18","52.23","81.95","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.97","92.23","AETNA [1001]","HB CH AETNA HMO / PPO","71.69","58.3","","161.55","62.25","161.55","1 through 10","54.66","122.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.97","92.23","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","65.17","53","","52.44","22.90","505.57","1 through 10","54.66","122.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.97","92.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","104.52","85","","68.52","68.52","68.52","1 through 10","54.66","122.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.97","92.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","122.97","100","","62.20","62.19","81.17","14","54.66","122.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.97","92.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","122.97","100","","43.22","31.95","953.91","1 through 10","54.66","122.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","both","","","122.97","92.23","WELLPOINT [1015]","HB CH WELLPOINT","95.81","77.91","","63.92","25.16","245.73","18","54.66","122.97","percent of total billed charges",""
"GUIDEWIRE VASCULAR 145CM .035IN LUNDERQUIST-RING TORQUE EXTRA STIFF STRAIGHT TIP S/S TEFLON AMPLATZ","SUP-ITM-10011745","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","122.97","92.23","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","96.47","78.45","","97.25","24.56","207.80","18","61.49","96.47","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.00","27.00","AETNA [1001]","HB CH AETNA HMO / PPO","20.99","58.3","","161.55","62.25","161.55","1 through 10","16","36","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.00","27.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","19.08","53","","52.44","22.90","505.57","1 through 10","16","36","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.00","27.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","30.60","85","","68.52","68.52","68.52","1 through 10","16","36","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.00","27.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","36.00","100","","62.20","62.19","81.17","14","16","36","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.00","27.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","36.00","100","","43.22","31.95","953.91","1 through 10","16","36","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","both","","","36.00","27.00","WELLPOINT [1015]","HB CH WELLPOINT","28.05","77.91","","63.92","25.16","245.73","18","16","36","percent of total billed charges",""
"GUIDEWIRE WIRE .078X5.91 2MM 150 BONE KIRSCHNER SS THREADED TROCAR TIP BX/5EA","SUP-ITM-10154683","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","36.00","27.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.24","78.45","","97.25","24.56","207.80","18","18","28.24","percent of total billed charges",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","42251.41","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23329.29","","Standard inlier is a Case rate ($23,329.29). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,311.49) for the length of stay and the standard reimbursement.","22268.86","22268.86","22268.86","1 through 10","6347.17","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","42251.41","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6347.17","","Fee schedule rate ($6,347.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6347.17","6347.17","6347.17","1 through 10","6347.17","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MINOR","519","DRG","","","","","","","","inpatient","","","42251.41","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8003.42","","Case rate ($8,849.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,279.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8846.98","8846.98","8846.98","1 through 10","6347.17","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","62734.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27598.99","","Standard inlier is a Case rate ($27,598.99). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,928, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,917.78) for the length of stay and the standard reimbursement.","26344.84","26344.84","26344.84","1 through 10","6347.17","33582.13","case rate",""
"Gynecologic Procedures For Leiomyoma,MODERATE","519","DRG","","","","","","","","inpatient","","","62734.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10667.41","","Case rate ($11,794.66). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,224.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11791.76","11791.76","11791.76","1 through 10","6347.17","33582.13","case rate",""
"H Pylori Breath Test Analysis C-13","PX-30000488","CDM","83013","CPT","0301","RC","","","","both","","","553.00","414.75","AETNA [1001]","HB CH AETNA HMO / PPO","322.40","58.3","","305.05","305.05","305.05","1 through 10","66.01","403.69","percent of total billed charges",""
"H Pylori Breath Test Analysis C-13","PX-30000488","CDM","83013","CPT","0301","RC","","","","outpatient","","","553.00","414.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","327.93","59.3","","315.27","315.27","315.27","1 through 10","69.45","433.83","percent of total billed charges",""
"H Pylori Breath Test Analysis C-13","PX-30000488","CDM","83013","CPT","0301","RC","","","","outpatient","","","553.00","414.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","433.83","78.45","","413.62","240.98","413.62","1 through 10","69.45","433.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","AETNA [1001]","HB CH AETNA HMO / PPO","1004.99","58.3","","554.95","91.85","1421.75","94","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1258.40","73","","2490.03","2490.03","2490.03","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1004.99","58.3","","750.00","750.00","750.00","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","913.63","53","","1192.50","120.84","4149.90","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1465.26","85","","750.00","75.00","750.00","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1723.83","100","","657.00","121.50","1971.00","14","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1723.83","100","","75.00","75.00","75.00","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1723.83","100","","366.00","144.00","1971.00","45","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1258.40","73","","667.50","667.50","667.50","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","766.24","44.45","","123.77","123.77","123.77","1 through 10","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","both","","","1723.83","1292.87","WELLPOINT [1015]","HB CH WELLPOINT","1343.04","77.91","","483.51","229.32","1316.08","96","766.24","1723.83","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.83","1292.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","1022.23","59.3","","439.50","225.34","1872.27","197","861.92","1352.34","percent of total billed charges",""
"HAMMERLOCK2 15X5MM ANGLED","SUP-ITM-10211731","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1723.83","1292.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1352.34","78.45","","385.32","55.36","1815.62","58","861.92","1352.34","percent of total billed charges",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","29856.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20856.53","","Standard inlier is a Case rate ($20,856.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,567, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,960.50) for the length of stay and the standard reimbursement.","10920.70","10920.70","10920.70","1 through 10","8492.24","31132.75","case rate",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","29856.36","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8492.24","","Fee schedule rate ($8,492.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8492.24","8492.24","8492.24","1 through 10","8492.24","31132.75","case rate",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","29856.36","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9702.11","","Case rate ($10,727.36). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,157.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3494.11","3494.11","3494.11","1 through 10","8492.24","31132.75","case rate",""
"Hand And Wrist Procedures,MINOR","316","DRG","","","","","","","","inpatient","","","29856.36","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9702.11","","Case rate ($10,727.36). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,157.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10724.72","10724.72","10724.72","1 through 10","8492.24","31132.75","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","28780.51","","MASSHEALTH [3001]","HB BWF MEDICAID","12427.80","","Case rate ($13,741.07). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,171.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1809.67","1809.67","1809.67","1 through 10","8492.24","31132.75","case rate",""
"Hand And Wrist Procedures,MODERATE","316","DRG","","","","","","","","inpatient","","","28780.51","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12427.80","","Case rate ($13,741.07). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,171.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13737.70","13737.70","13737.70","1 through 10","8492.24","31132.75","case rate",""
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/McC","513","MS-DRG","","","","","","","","inpatient","","","36998.56","27748.92","MEDICARE [2001]","HB BWF MEDICARE","14834.56","","Case rate ($14,834.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,858.18, add-ons for qualifying new technology services are included. If operating cost exceeds $60,381.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,673.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,382.35 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,518.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,112.97. The transfer capital threshold is the transfer adjustment factor * $1,112.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15121.08","15121.08","15121.08","1 through 10","14537.87","15279.6","other","Inpatient Replacement Plans DRG"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/McC","513","MS-DRG","","","","","","","","inpatient","","","36998.56","27748.92","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14537.87","","Case rate ($14,834.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,858.18, add-ons for qualifying new technology services are included. If operating cost exceeds $60,381.91 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,673.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,382.35 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,518.94 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,112.97. The transfer capital threshold is the transfer adjustment factor * $1,112.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13673.75","13673.75","13673.75","1 through 10","14537.87","15279.6","other","Inpatient DRG"
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/McC","514","MS-DRG","","","","","","","","inpatient","","","29856.36","22392.27","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9557.00","","Case rate ($9,752.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,767.37, add-ons for qualifying new technology services are included. If operating cost exceeds $55,291.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,283.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,690.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,428.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $722.73. The transfer capital threshold is the transfer adjustment factor * $722.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10667.87","10667.87","10667.87","1 through 10","9557","10082.8244","other","Inpatient DRG"
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","AETNA [1001]","HB CH AETNA HMO / PPO","846.69","58.3","","554.95","91.85","1421.75","94","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1060.18","73","","2490.03","2490.03","2490.03","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","846.69","58.3","","750.00","750.00","750.00","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","769.72","53","","1192.50","120.84","4149.90","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1234.46","85","","750.00","75.00","750.00","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1452.30","100","","657.00","121.50","1971.00","14","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1452.30","100","","75.00","75.00","75.00","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1452.30","100","","366.00","144.00","1971.00","45","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1060.18","73","","667.50","667.50","667.50","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.55","44.45","","123.77","123.77","123.77","1 through 10","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","both","","","1452.30","1089.22","WELLPOINT [1015]","HB CH WELLPOINT","1131.49","77.91","","483.51","229.32","1316.08","96","645.55","1452.3","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.30","1089.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","861.21","59.3","","439.50","225.34","1872.27","197","726.15","1139.33","percent of total billed charges",""
"HAND PLATE 1.65X6.8 90.2MM 12 HOLE A.L.P.S. LOW PROFILE STRAIGHT","SUP-ITM-10056556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1452.30","1089.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1139.33","78.45","","385.32","55.36","1815.62","58","726.15","1139.33","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","AETNA [1001]","HB CH AETNA HMO / PPO","1529.82","58.3","","554.95","91.85","1421.75","94","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1915.55","73","","2490.03","2490.03","2490.03","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1529.82","58.3","","750.00","750.00","750.00","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1390.74","53","","1192.50","120.84","4149.90","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2230.43","85","","750.00","75.00","750.00","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2624.04","100","","657.00","121.50","1971.00","14","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2624.04","100","","75.00","75.00","75.00","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2624.04","100","","366.00","144.00","1971.00","45","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1915.55","73","","667.50","667.50","667.50","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.39","44.45","","123.77","123.77","123.77","1 through 10","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","both","","","2624.04","1968.03","WELLPOINT [1015]","HB CH WELLPOINT","2044.39","77.91","","483.51","229.32","1316.08","96","1166.39","2624.04","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2624.04","1968.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","1556.06","59.3","","439.50","225.34","1872.27","197","1312.02","2058.56","percent of total billed charges",""
"HAND PLATE 1.7MM 7 HOLE BONE PHALANGEAL VARIAX TITANIUM LOCKING T SHAPE","SUP-ITM-10143755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2624.04","1968.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2058.56","78.45","","385.32","55.36","1815.62","58","1312.02","2058.56","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","AETNA [1001]","HB CH AETNA HMO / PPO","943.97","58.3","","554.95","91.85","1421.75","94","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1181.99","73","","2490.03","2490.03","2490.03","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","943.97","58.3","","750.00","750.00","750.00","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","858.15","53","","1192.50","120.84","4149.90","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1376.29","85","","750.00","75.00","750.00","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1619.16","100","","657.00","121.50","1971.00","14","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1619.16","100","","75.00","75.00","75.00","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1619.16","100","","366.00","144.00","1971.00","45","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1181.99","73","","667.50","667.50","667.50","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","719.72","44.45","","123.77","123.77","123.77","1 through 10","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","both","","","1619.16","1214.37","WELLPOINT [1015]","HB CH WELLPOINT","1261.49","77.91","","483.51","229.32","1316.08","96","719.72","1619.16","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1619.16","1214.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","960.16","59.3","","439.50","225.34","1872.27","197","809.58","1270.23","percent of total billed charges",""
"HAND PLATE 2.5MM LOCKING WEB","SUP-ITM-10056560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1619.16","1214.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1270.23","78.45","","385.32","55.36","1815.62","58","809.58","1270.23","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","554.95","91.85","1421.75","94","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","2490.03","2490.03","2490.03","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","750.00","750.00","750.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","1192.50","120.84","4149.90","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3427.63","85","","750.00","75.00","750.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4032.50","100","","657.00","121.50","1971.00","14","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4032.50","100","","75.00","75.00","75.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4032.50","100","","366.00","144.00","1971.00","45","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","667.50","667.50","667.50","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1792.45","44.45","","123.77","123.77","123.77","1 through 10","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","483.51","229.32","1316.08","96","1792.45","4032.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","439.50","225.34","1872.27","197","2016.25","3163.5","percent of total billed charges",""
"HAND PLATE DORSAL SPANNING","SUP-ITM-10157822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","385.32","55.36","1815.62","58","2016.25","3163.5","percent of total billed charges",""
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","both","","","6900.00","5175.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6900.00","100","","3670.50","3670.50","6900.00","1 through 10","3657","6900","percent of total billed charges",""
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","both","","","6900.00","5175.00","WELLPOINT [1015]","HB CH WELLPOINT","5375.79","77.91","","3150.40","3150.40","3150.40","1 through 10","3657","6900","percent of total billed charges",""
"HANDPIECE RFA SONATA - ORDER IN MULTIPLES OF 5EA","SUP-ITM-10287871","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","6900.00","5175.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5413.05","78.45","","3075.20","1822.40","5304.72","1 through 10","3067.05","5413.05","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","62.94","62.94","62.94","1 through 10","12.33","83.22","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","65.05","65.05","111.00","1 through 10","12.97","89.43","percent of total billed charges",""
"Haptoglobin Qn","PX-30000486","CDM","83010","CPT","0301","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","50.57","49.45","85.34","1 through 10","12.97","89.43","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6232.00","4674.00","AETNA [1001]","HB CH AETNA HMO / PPO","3633.26","58.3","","66.84","33.42","66.84","3696","92.01","4855.35","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6232.00","4674.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3302.96","53","","16493.60","16493.60","16493.60","1 through 10","92.01","4855.35","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6232.00","4674.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4549.36","73","","10382.90","10382.90","10382.90","1 through 10","92.01","4855.35","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","both","","","6232.00","4674.00","WELLPOINT [1015]","HB CH WELLPOINT","4855.35","77.91","","31178.94","77.77","31197.77","2412","92.01","4855.35","percent of total billed charges",""
"HC Alloderm 108 Sq Cm T3","PX-27000988","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","6232.00","4674.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3253.10","52.2","","67.43","30.35","93.27","9212","3116","3253.1","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9262.00","6946.50","AETNA [1001]","HB CH AETNA HMO / PPO","5399.75","58.3","","66.84","33.42","66.84","3696","92.01","7216.02","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9262.00","6946.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4908.86","53","","16493.60","16493.60","16493.60","1 through 10","92.01","7216.02","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9262.00","6946.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6761.26","73","","10382.90","10382.90","10382.90","1 through 10","92.01","7216.02","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9262.00","6946.50","WELLPOINT [1015]","HB CH WELLPOINT","7216.02","77.91","","31178.94","77.77","31197.77","2412","92.01","7216.02","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000986","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9262.00","6946.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4834.76","52.2","","67.43","30.35","93.27","9212","4631","4834.76","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9260.00","6945.00","AETNA [1001]","HB CH AETNA HMO / PPO","5398.58","58.3","","66.84","33.42","66.84","3696","92.01","7214.47","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9260.00","6945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4907.80","53","","16493.60","16493.60","16493.60","1 through 10","92.01","7214.47","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9260.00","6945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6759.80","73","","10382.90","10382.90","10382.90","1 through 10","92.01","7214.47","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","both","","","9260.00","6945.00","WELLPOINT [1015]","HB CH WELLPOINT","7214.47","77.91","","31178.94","77.77","31197.77","2412","92.01","7214.47","percent of total billed charges",""
"HC Alloderm 160 Sq Cm T3","PX-27000991","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","9260.00","6945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4833.72","52.2","","67.43","30.35","93.27","9212","4630","4833.72","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11114.00","8335.50","AETNA [1001]","HB CH AETNA HMO / PPO","6479.46","58.3","","66.84","33.42","66.84","3696","92.01","8658.92","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11114.00","8335.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5890.42","53","","16493.60","16493.60","16493.60","1 through 10","92.01","8658.92","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11114.00","8335.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8113.22","73","","10382.90","10382.90","10382.90","1 through 10","92.01","8658.92","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11114.00","8335.50","WELLPOINT [1015]","HB CH WELLPOINT","8658.92","77.91","","31178.94","77.77","31197.77","2412","92.01","8658.92","percent of total billed charges",""
"HC Alloderm 192 Sq Cm T3","PX-27000989","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11114.00","8335.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5801.51","52.2","","67.43","30.35","93.27","9212","5557","5801.51","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11578.00","8683.50","AETNA [1001]","HB CH AETNA HMO / PPO","6749.97","58.3","","66.84","33.42","66.84","3696","92.01","9020.42","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11578.00","8683.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6136.34","53","","16493.60","16493.60","16493.60","1 through 10","92.01","9020.42","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11578.00","8683.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8451.94","73","","10382.90","10382.90","10382.90","1 through 10","92.01","9020.42","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","both","","","11578.00","8683.50","WELLPOINT [1015]","HB CH WELLPOINT","9020.42","77.91","","31178.94","77.77","31197.77","2412","92.01","9020.42","percent of total billed charges",""
"HC Alloderm 200 Sq Cm T3","PX-27000987","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","11578.00","8683.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","6043.72","52.2","","67.43","30.35","93.27","9212","5789","6043.72","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13894.00","10420.50","AETNA [1001]","HB CH AETNA HMO / PPO","8100.20","58.3","","66.84","33.42","66.84","3696","92.01","10824.82","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13894.00","10420.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7363.82","53","","16493.60","16493.60","16493.60","1 through 10","92.01","10824.82","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13894.00","10420.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10142.62","73","","10382.90","10382.90","10382.90","1 through 10","92.01","10824.82","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","both","","","13894.00","10420.50","WELLPOINT [1015]","HB CH WELLPOINT","10824.82","77.91","","31178.94","77.77","31197.77","2412","92.01","10824.82","percent of total billed charges",""
"HC Alloderm 240 Sq Cm T3","PX-27000990","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","13894.00","10420.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7252.67","52.2","","67.43","30.35","93.27","9212","6947","7252.67","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","44.23","79","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","46.61","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","156.00","156.00","156.00","1 through 10","11.83","170.56","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","58.40","73","","56.94","55.48","56.94","1 through 10","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.64","58.3","","44.23","44.23","78.00","1 through 10","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.40","53","","82.68","41.34","82.68","13","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","45.68","","APC Price ($46.61). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5.28","5.28","5.28","1 through 10","11.83","170.56","other","OPPS APC"
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","35.54","35.54","35.54","1 through 10","11.83","170.56","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","45.71","45.71","137.13","126","3.08","108.57","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","119.93","119.93","119.93","1 through 10","3.08","108.57","percent of total billed charges",""
"HC Blood Typing Serologic Rh (D)","PX-30000076","CDM","86901","CPT","0302","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","59.97","35.54","119.93","70","3.08","108.57","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier1","PX-27000174","CDM","C1886","HCPCS","0272","RC","","","","both","","","3498.00","2623.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3498.00","100","","3670.50","3670.50","6900.00","1 through 10","1853.94","3498","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier1","PX-27000174","CDM","C1886","HCPCS","0272","RC","","","","both","","","3498.00","2623.50","WELLPOINT [1015]","HB CH WELLPOINT","2725.29","77.91","","3150.40","3150.40","3150.40","1 through 10","1853.94","3498","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier1","PX-27000174","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","3498.00","2623.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2744.18","78.45","","3075.20","1822.40","5304.72","1 through 10","1554.86","2744.18","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier2","PX-27000175","CDM","C1886","HCPCS","0272","RC","","","","both","","","3296.14","2472.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3296.14","100","","3670.50","3670.50","6900.00","1 through 10","1746.95","3296.14","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier2","PX-27000175","CDM","C1886","HCPCS","0272","RC","","","","both","","","3296.14","2472.10","WELLPOINT [1015]","HB CH WELLPOINT","2568.02","77.91","","3150.40","3150.40","3150.40","1 through 10","1746.95","3296.14","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier2","PX-27000175","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","3296.14","2472.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2585.82","78.45","","3075.20","1822.40","5304.72","1 through 10","1465.13","2585.82","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier3","PX-27000176","CDM","C1886","HCPCS","0272","RC","","","","both","","","10112.96","7584.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10112.96","100","","3670.50","3670.50","6900.00","1 through 10","5359.87","10112.96","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier3","PX-27000176","CDM","C1886","HCPCS","0272","RC","","","","both","","","10112.96","7584.72","WELLPOINT [1015]","HB CH WELLPOINT","7879.01","77.91","","3150.40","3150.40","3150.40","1 through 10","5359.87","10112.96","percent of total billed charges",""
"HC Catheter Extravascular Tissue Ablation Tier3","PX-27000176","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","10112.96","7584.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7933.62","78.45","","3075.20","1822.40","5304.72","1 through 10","4495.21","7933.62","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","521.46","391.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.37","53","","262.35","194.30","262.35","1 through 10","231.79","521.46","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","both","","","521.46","391.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","521.46","100","","173.25","165.00","173.25","1 through 10","231.79","521.46","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier1","PX-27000177","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","521.46","391.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.09","78.45","","513.75","29.41","761.11","1 through 10","260.73","409.09","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1841.75","53","","262.35","194.30","262.35","1 through 10","1544.64","3475","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3475.00","100","","173.25","165.00","173.25","1 through 10","1544.64","3475","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier2","PX-27000178","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","3475.00","2606.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2726.14","78.45","","513.75","29.41","761.11","1 through 10","1737.5","2726.14","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","4523.33","3392.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2397.36","53","","262.35","194.30","262.35","1 through 10","2010.62","4523.33","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","both","","","4523.33","3392.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4523.33","100","","173.25","165.00","173.25","1 through 10","2010.62","4523.33","percent of total billed charges",""
"HC Catheter Guiding Infusion/Perfusion Cap Tier3","PX-27000179","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","4523.33","3392.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3548.55","78.45","","513.75","29.41","761.11","1 through 10","2261.67","3548.55","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","both","","","876.16","657.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","510.80","58.3","","686.91","686.91","686.91","1 through 10","389.45","876.16","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier1","PX-27000054","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","876.16","657.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","519.56","59.3","","709.93","709.93","709.93","1 through 10","438.08","687.35","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.59","58.3","","686.91","686.91","686.91","1 through 10","1625.2","3656.25","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier2","PX-27000055","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.16","59.3","","709.93","709.93","709.93","1 through 10","1828.13","2868.33","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","both","","","3807.60","2855.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2219.83","58.3","","686.91","686.91","686.91","1 through 10","1692.48","3807.6","percent of total billed charges",""
"HC Catheter Hemodialysis Peritoneal Longterm Tier3","PX-27000056","CDM","C1750","HCPCS","0278","RC","","","","outpatient","","","3807.60","2855.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2257.91","59.3","","709.93","709.93","709.93","1 through 10","1903.8","2987.06","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","548.04","411.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","290.46","53","","729.83","486.54","928.96","1 through 10","243.6","548.04","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","548.04","411.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","465.83","85","","459.00","459.00","459.00","1 through 10","243.6","548.04","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","548.04","411.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","548.04","100","","556.00","459.00","604.50","1 through 10","243.6","548.04","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","548.04","411.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","548.04","100","","459.00","459.00","459.00","1 through 10","243.6","548.04","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","both","","","548.04","411.03","WELLPOINT [1015]","HB CH WELLPOINT","426.98","77.91","","514.30","361.51","514.30","1 through 10","243.6","548.04","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier1","PX-27000036","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","548.04","411.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","429.94","78.45","","705.76","352.88","2982.17","1 through 10","274.02","429.94","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","729.83","486.54","928.96","1 through 10","1778","4000","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","459.00","459.00","459.00","1 through 10","1778","4000","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","556.00","459.00","604.50","1 through 10","1778","4000","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","459.00","459.00","459.00","1 through 10","1778","4000","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","514.30","361.51","514.30","1 through 10","1778","4000","percent of total billed charges",""
"HC Catheter Translumin Angioplasty Non-Laser Tier2","PX-27000037","CDM","C1725","HCPCS","0272","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","705.76","352.88","2982.17","1 through 10","2000","3138","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","688.91","688.91","688.91","1 through 10","774.32","1919.74","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","979.79","","Case rate ($979.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","914.55","914.55","914.55","1 through 10","774.32","1919.74","other","Multiple Surgery"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","MEDICARE [2001]","HB BWF MEDICARE","1400.23","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","700.11","700.11","1400.23","1 through 10","774.32","1919.74","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","774.32","1919.74","per diem",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","both","","","1742.00","1306.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1372.22","","APC Price ($1,400.23). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","686.12","686.12","1372.23","1 through 10","774.32","1919.74","other","OPPS APC"
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","1742.00","1306.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","808.97","792.16","808.97","1 through 10","871","1873.9","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","1742.00","1306.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","793.28","793.28","793.28","1 through 10","871","1873.9","other","ASC "
"HC Colsc Flx With Directed Submucosal Njx Any Sbst","PX-75000196","CDM","45381","CPT","0750","RC","","","","outpatient","","","1742.00","1306.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1033.01","59.3","","992.68","992.26","992.68","1 through 10","871","1873.9","percent of total billed charges",""
"HC Colsc Flx With Directed Submucosal Njx Any Sbst|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA","PX-75000196","CDM","45381","CPT","0750","RC","","","74","both","","","1742.00","1306.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1372.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","686.12","686.12","686.12","1 through 10","1372.09","2667.97","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","AETNA [1001]","HB CH AETNA HMO / PPO","2193.83","58.3","","2074.65","1812.13","2074.65","1 through 10","436","2931.75","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3094.03","3094.03","3094.03","1 through 10","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2231.46","59.3","","2144.17","2144.17","2144.17","1 through 10","436","2931.75","percent of total billed charges",""
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","ELDER SERVICES [1037]","HB BWF MEDICARE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1000.65","1000.65","1000.65","1 through 10","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","MEDICARE [2001]","HB BWF MEDICARE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3144.34","1000.65","3144.34","14","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3083.25","3083.25","3083.25","1 through 10","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","MOLINA [1014]","HB BWF MEDICARE","1000.55","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6227.99","6227.99","6227.99","1 through 10","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","980.54","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3094.03","3094.03","3094.03","1 through 10","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","980.54","","APC Price ($1,000.55). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3083.96","3081.45","3083.96","1 through 10","436","2931.75","other","OPPS APC"
"HC Critical Care; First 30-74 Minutes","PX-45000006","CDM","99291","CPT","0450","RC","","","","both","","","3763.00","2822.25","WELLPOINT [1015]","HB CH WELLPOINT","2931.75","77.91","","2881.83","2881.83","2881.83","1 through 10","436","2931.75","percent of total billed charges",""
"HC Ewo Rigit Without Joints Custom Tier1","PX-27000485","CDM","L3763","HCPCS","0274","RC","","","","outpatient","","","585.22","438.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","459.11","78.45","","449.92","449.92","449.92","1 through 10","260.13","1648.52","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","both","","","258.36","193.77","AETNA [1001]","HB CH AETNA HMO / PPO","150.62","58.3","","146.49","146.49","146.49","1 through 10","136.93","1036.27","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","both","","","258.36","193.77","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","163.80","63.4","","171.29","171.29","171.29","1 through 10","136.93","1036.27","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","both","","","258.36","193.77","WELLPOINT [1015]","HB CH WELLPOINT","201.29","77.91","","203.48","203.48","203.48","1 through 10","136.93","1036.27","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","outpatient","","","258.36","193.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","153.21","59.3","","151.40","151.40","151.40","1 through 10","114.84","727.76","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","outpatient","","","258.36","193.77","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","149.07","57.7","","155.79","155.79","155.79","1 through 10","114.84","727.76","percent of total billed charges",""
"HC Hfo With Nontorsion Joints Custom Tier1","PX-27000500","CDM","L3921","HCPCS","0274","RC","","","","outpatient","","","258.36","193.77","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","156.31","60.5","","163.54","163.54","163.54","1 through 10","114.84","727.76","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","310.00","232.50","AETNA [1001]","HB CH AETNA HMO / PPO","180.73","58.3","","147.99","147.99","147.99","1 through 10","34.39","241.52","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","both","","","310.00","232.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","226.30","73","","59.81","59.81","59.81","1 through 10","34.39","241.52","percent of total billed charges",""
"HC Iadna Mycoplasma Genitalium Amplified Probe Tech","PX-30003622","CDM","87563","CPT","0300","RC","","","","outpatient","","","310.00","232.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","183.83","59.3","","152.95","152.95","152.95","1 through 10","54.39","243.2","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.34","53","","91.69","91.69","91.69","1 through 10","14.69","129.94","percent of total billed charges",""
"HC Immunoassay Infectious Agent Antibody Quan","PX-30000827","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","15.46","139.64","percent of total billed charges",""
"HC Intro/Sheath Intrcard Ep Strble Non Peel Tier1","PX-27000081","CDM","C1766","HCPCS","0272","RC","","","","both","","","2716.78","2037.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2716.78","100","","1864.50","1864.50","1864.50","1 through 10","1165.5","2716.78","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.10","53","","69.13","15.86","85.00","1 through 10","82.27","185.09","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","157.33","85","","29.94","29.94","29.94","1 through 10","82.27","185.09","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","185.09","100","","60.23","29.94","60.23","12","82.27","185.09","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","185.09","100","","65.22","29.94","360.69","1 through 10","82.27","185.09","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","both","","","185.09","138.82","WELLPOINT [1015]","HB CH WELLPOINT","144.20","77.91","","51.37","51.37","284.08","1 through 10","82.27","185.09","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier1","PX-27000185","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","185.09","138.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.20","78.45","","123.30","23.02","333.57","1 through 10","92.55","145.2","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2027.58","53","","69.13","15.86","85.00","1 through 10","1700.49","3825.63","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3251.79","85","","29.94","29.94","29.94","1 through 10","1700.49","3825.63","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3825.63","100","","60.23","29.94","60.23","12","1700.49","3825.63","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3825.63","100","","65.22","29.94","360.69","1 through 10","1700.49","3825.63","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","both","","","3825.63","2869.22","WELLPOINT [1015]","HB CH WELLPOINT","2980.55","77.91","","51.37","51.37","284.08","1 through 10","1700.49","3825.63","percent of total billed charges",""
"HC Introducer/Sheath N/Guide N/Laser N/Ep Tier2","PX-27000186","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","3825.63","2869.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3001.21","78.45","","123.30","23.02","333.57","1 through 10","1912.82","3001.21","percent of total billed charges",""
"HC Ko Adj Knee Jnts Rigid Prefab Custom Fit Pt T1","PX-27000329","CDM","L1832","HCPCS","0274","RC","","","","outpatient","","","301.21","225.91","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.80","57.7","","188.64","188.64","375.40","1 through 10","150.61","1893.14","percent of total billed charges",""
"HC Ko Adj Knee Jnts Rigid Prefab Custom Fit Pt T1","PX-27000329","CDM","L1832","HCPCS","0274","RC","","","","outpatient","","","301.21","225.91","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.23","60.5","","594.09","198.03","594.09","1 through 10","150.61","1893.14","percent of total billed charges",""
"HC Ko Adj Knee Jnts Rigid Prefab Custom Fit Pt T1","PX-27000329","CDM","L1832","HCPCS","0274","RC","","","","outpatient","","","301.21","225.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.30","78.45","","240.51","240.51","240.51","1 through 10","150.61","1893.14","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000105","CDM","H0035","HCPCS","0912","RC","","","","both","","","1248.00","936.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","899.81","72.1","","1768.00","1768.00","1768.00","1 through 10","436.8","1248","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000105","CDM","H0035","HCPCS","0912","RC","","","","both","","","1248.00","936.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","791.23","63.4","","3465.00","665.00","4851.00","27","436.8","1248","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000105","CDM","H0035","HCPCS","0912","RC","","","","both","","","1248.00","936.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","436.80","35","","1280.35","476.03","1280.35","69","436.8","1248","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000105","CDM","H0035","HCPCS","0912","RC","","","","both","","","1248.00","936.00","WELLPOINT [1015]","HB CH WELLPOINT","972.32","77.91","","311.62","311.62","912.00","31","436.8","1248","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000106","CDM","H0035","HCPCS","0912","RC","","","","both","","","623.00","467.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","449.18","72.1","","1768.00","1768.00","1768.00","1 through 10","218.05","754","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000106","CDM","H0035","HCPCS","0912","RC","","","","both","","","623.00","467.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","394.98","63.4","","3465.00","665.00","4851.00","27","218.05","754","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000106","CDM","H0035","HCPCS","0912","RC","","","","both","","","623.00","467.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","218.05","35","","1280.35","476.03","1280.35","69","218.05","754","percent of total billed charges",""
"HC Mental Health Partial Hospitalization, Treatment Less Than 24 Hours","PX-90000106","CDM","H0035","HCPCS","0912","RC","","","","both","","","623.00","467.25","WELLPOINT [1015]","HB CH WELLPOINT","485.38","77.91","","311.62","311.62","912.00","31","218.05","754","percent of total billed charges",""
"HC Mml Flec Flecainide Serum","PX-3002350","CDM","80299","CPT","0300","RC","","","","both","","","165.00","123.75","AETNA [1001]","HB CH AETNA HMO / PPO","96.20","58.3","","121.91","121.91","121.91","1 through 10","18.27","120.45","percent of total billed charges",""
"HC Mml Flec Flecainide Serum","PX-3002350","CDM","80299","CPT","0300","RC","","","","outpatient","","","165.00","123.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","129.44","78.45","","165.29","165.29","165.29","1 through 10","14.12","129.44","percent of total billed charges",""
"HC Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level (Lt)","PX-76001531","CDM","64490","CPT","0761","RC","","","","both","","","2126.00","1594.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1036.13","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1043.63","981.92","1044.03","1 through 10","764.84","1627.62","other","OPPS APC"
"HC Open/Perq Placement Intravascular Stent Initial","PX-76001940","CDM","37236","CPT","0761","RC","","","","both","","","16762.00","12571.50","MEDICARE [2001]","HB BWF MEDICARE","13466.25","","APC Price ($13,466.25). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40402.83","40402.83","40402.83","1 through 10","7190.9","30885.95","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","202.00","151.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","475.48","291.68","476.26","21","107.06","222.51","other","OPPS APC"
"HC Psych W/Patient 30 Minutes","PX-90000050","CDM","90832","CPT","0914","RC","","","","both","","","202.00","151.50","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","1229.67","116","107.06","222.51","other","OPPS APC"
"HC Psych W/Patient 45 Minutes","PX-90000052","CDM","90834","CPT","0914","RC","","","","both","","","386.00","289.50","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","204.58","399.07","other","OPPS APC"
"HC Psych W/Patient 60 Minutes","PX-90000054","CDM","90837","CPT","0914","RC","","","","both","","","454.00","340.50","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","240.62","431.75","other","OPPS APC"
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","both","","","147.42","110.56","AETNA [1001]","HB CH AETNA HMO / PPO","85.95","58.3","","84.15","75.01","84.15","1 through 10","65.53","375.76","percent of total billed charges",""
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","both","","","147.42","110.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","78.13","53","","70.12","70.12","70.12","1 through 10","65.53","375.76","percent of total billed charges",""
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","147.42","110.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.42","59.3","","86.97","77.53","86.97","1 through 10","73.71","263.9","percent of total billed charges",""
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","147.42","110.56","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","85.06","57.7","","89.49","76.73","89.49","1 through 10","73.71","263.9","percent of total billed charges",""
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","147.42","110.56","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","89.19","60.5","","93.94","93.94","93.94","1 through 10","73.71","263.9","percent of total billed charges",""
"HC Shoulder Ortho Shoulder Brace Prefab Tier1","PX-27000474","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","147.42","110.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","115.65","78.45","","114.10","114.10","114.10","1 through 10","73.71","263.9","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","both","","","3932.19","2949.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3932.19","100","","6010.00","6010.00","6010.00","1 through 10","1747.86","3932.19","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier2","PX-27000151","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3932.19","2949.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3084.80","78.45","","5181.71","4620.49","5181.71","1 through 10","1966.1","3084.8","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","both","","","6215.94","4661.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6215.94","100","","6010.00","6010.00","6010.00","1 through 10","2762.99","6215.94","percent of total billed charges",""
"HC Stent Graft Endoprosthesis W/Delivery Sys Tier3","PX-27000152","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6215.94","4661.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.40","78.45","","5181.71","4620.49","5181.71","1 through 10","3107.97","4876.4","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","AETNA [1001]","HB CH AETNA HMO / PPO","167.34","58.3","","188.13","188.13","188.13","1 through 10","127.59","287.04","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","287.04","100","","331.80","331.80","331.80","1 through 10","127.59","287.04","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","both","","","287.04","215.28","WELLPOINT [1015]","HB CH WELLPOINT","223.63","77.91","","593.13","261.33","593.13","1 through 10","127.59","287.04","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","287.04","215.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.21","59.3","","194.44","194.43","583.31","13","143.52","225.18","percent of total billed charges",""
"HC Stent Non-Cor Temp W/O Delivery System Tier1","PX-27000200","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","287.04","215.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.18","78.45","","255.09","255.09","255.09","1 through 10","143.52","225.18","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier1","PX-27000156","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","1936.60","1452.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1519.26","78.45","","1574.12","1574.12","1574.12","1 through 10","968.3","1519.26","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier2","PX-27000157","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","3700.52","2775.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2903.06","78.45","","1574.12","1574.12","1574.12","1 through 10","1850.26","2903.06","percent of total billed charges",""
"HC Stent Noncoated/Noncovered Delivery Sys Tier3","PX-27000158","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4136.40","3102.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3245.01","78.45","","1574.12","1574.12","1574.12","1 through 10","2068.2","3245.01","percent of total billed charges",""
"HC Whfo With Nontorsion Joints Custome Tier1","PX-27000489","CDM","L3806","HCPCS","0274","RC","","","","both","","","365.35","274.01","WELLPOINT [1015]","HB CH WELLPOINT","284.64","77.91","","287.75","287.75","287.75","1 through 10","162.4","1465.53","percent of total billed charges",""
"HC Whfo With Nontorsion Joints Custome Tier1","PX-27000489","CDM","L3806","HCPCS","0274","RC","","","","outpatient","","","365.35","274.01","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","210.81","57.7","","220.31","220.31","220.31","1 through 10","182.68","1029.16","percent of total billed charges",""
"HC Who Cock-Up Control Extension Prefab Tier1","PX-27000496","CDM","L3908","HCPCS","0274","RC","","","","outpatient","","","14.94","11.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.86","59.3","","8.75","8.75","8.75","1 through 10","7.47","186.44","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","both","","","388.65","291.49","AETNA [1001]","HB CH AETNA HMO / PPO","226.58","58.3","","220.36","220.36","220.36","1 through 10","172.75","1558.92","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","388.65","291.49","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","224.25","57.7","","234.36","225.42","857.37","1 through 10","194.33","1094.8","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","388.65","291.49","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","235.13","60.5","","246.02","246.02","246.02","1 through 10","194.33","1094.8","percent of total billed charges",""
"HC Who Gauntlet Molded Custom Tier1","PX-27000495","CDM","L3906","HCPCS","0274","RC","","","","outpatient","","","388.65","291.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","304.90","78.45","","298.79","298.79","298.79","1 through 10","194.33","1094.8","percent of total billed charges",""
"HC Who With Nontorsion Joints Custom Tier1","PX-27000494","CDM","L3905","HCPCS","0274","RC","","","","both","","","797.64","598.23","AETNA [1001]","HB CH AETNA HMO / PPO","465.02","58.3","","452.26","452.26","452.26","1 through 10","422.75","3199.43","percent of total billed charges",""
"HC Who With Nontorsion Joints Custom Tier1","PX-27000494","CDM","L3905","HCPCS","0274","RC","","","","both","","","797.64","598.23","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","505.70","63.4","","528.84","528.84","528.84","1 through 10","422.75","3199.43","percent of total billed charges",""
"HC Who With Nontorsion Joints Custom Tier1","PX-27000494","CDM","L3905","HCPCS","0274","RC","","","","outpatient","","","797.64","598.23","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","625.75","78.45","","613.23","613.23","613.23","1 through 10","354.55","2246.82","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0300","RC","","","","inpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.44","56","","96.67","96.67","96.67","1 through 10","97.44","122.84","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0300","RC","","","","inpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.84","70.6","","129.93","129.93","129.93","1 through 10","97.44","122.84","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","AETNA [1001]","HB CH AETNA HMO / PPO","101.44","58.3","","95.82","95.82","95.83","12","14.75","127.02","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","both","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.34","44.45","","129.93","129.93","129.93","1 through 10","14.75","127.02","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.18","59.3","","99.03","99.03","99.03","13","15.53","136.5","percent of total billed charges",""
"Hcg Qn","PX-30000741","CDM","84702","CPT","0301","RC","","","","outpatient","","","174.00","130.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.50","78.45","","129.93","77.00","129.93","19","15.53","136.5","percent of total billed charges",""
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","475.48","291.68","476.26","21","161.12","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 30 Minutes","PX-96100030","CDM","90832","CPT","0961","RC","","","","both","","","304.00","228.00","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","1229.67","116","161.12","288.8","other","OPPS APC"
"Hcpr Psych W/Patient 45 Minutes","PX-96100032","CDM","90834","CPT","0961","RC","","","","both","","","401.00","300.75","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","212.53","399.07","other","OPPS APC"
"Hcpr Psych W/Patient 60 Minutes","PX-96100034","CDM","90837","CPT","0961","RC","","","","both","","","593.00","444.75","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","485.18","485.18","485.18","1 through 10","314.29","563.35","other","OPPS APC"
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","AETNA [1001]","HB CH AETNA HMO / PPO","526.45","58.3","","1634.24","1004.95","1718.99","42","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","659.19","73","","2123.89","1900.92","2123.89","1 through 10","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","526.45","58.3","","3729.00","1254.19","3729.00","1 through 10","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.59","53","","939.37","939.37","5593.65","1 through 10","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","767.55","85","","2323.25","1864.50","2882.25","16","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","903.00","100","","2909.44","1772.40","10952.08","45","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","903.00","100","","2323.25","2323.25","2323.25","1 through 10","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","903.00","100","","2882.25","1772.40","10169.17","187","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","659.19","73","","1659.41","1659.41","1659.41","1 through 10","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","WELLPOINT [1015]","HB CH WELLPOINT","703.53","77.91","","2050.91","1468.48","2902.83","52","401.38","903","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.48","59.3","","1548.60","1092.60","3613.79","82","451.5","708.4","percent of total billed charges",""
"HEAD FEMORAL 10 /12 TAPER 32MM PLUS 5MM SIGMA PFC COBALT CHROME","SUP-ITM-10002101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","708.40","78.45","","2085.51","998.68","6202.11","56","451.5","708.4","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HEAD FEMORAL 36MM 12/14 TAPERED PLUS 12MM ARTICULEZE BIOLOX DELTA","SUP-ITM-10114352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","AETNA [1001]","HB CH AETNA HMO / PPO","2740.10","58.3","","1634.24","1004.95","1718.99","42","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","2123.89","1900.92","2123.89","1 through 10","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2740.10","58.3","","3729.00","1254.19","3729.00","1 through 10","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2491.00","53","","939.37","939.37","5593.65","1 through 10","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3995.00","85","","2323.25","1864.50","2882.25","16","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4700.00","100","","2909.44","1772.40","10952.08","45","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4700.00","100","","2323.25","2323.25","2323.25","1 through 10","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4700.00","100","","2882.25","1772.40","10169.17","187","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","1659.41","1659.41","1659.41","1 through 10","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","WELLPOINT [1015]","HB CH WELLPOINT","3661.77","77.91","","2050.91","1468.48","2902.83","52","2089.15","4700","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2787.10","59.3","","1548.60","1092.60","3613.79","82","2350","3687.15","percent of total billed charges",""
"HEAD HUMERAL 50X19 CA REVERS UNIVERSAL","SUP-ITM-10240002","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3687.15","78.45","","2085.51","998.68","6202.11","56","2350","3687.15","percent of total billed charges",""
"Headaches With McC","102","MS-DRG","","","","","","","","inpatient","","","26994.25","20245.69","MEDICARE [2001]","HB BWF MEDICARE","11646.61","","Case rate ($11,646.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,676.70, add-ons for qualifying new technology services are included. If operating cost exceeds $56,200.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,353.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $10,514.96 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,337.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $792.43. The transfer capital threshold is the transfer adjustment factor * $792.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","10446.67","11646.61","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","31119.71","23339.78","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","8039.45","","Case rate ($8,039.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,052, add-ons for qualifying new technology services are included. If operating cost exceeds $53,575.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,152.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,108.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,712.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.23. The transfer capital threshold is the transfer adjustment factor * $591.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7849.92","7849.92","7849.92","1 through 10","7878.66","8584.62","other","Inpatient Replacement Plans DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","31119.71","23339.78","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7878.66","","Case rate ($8,039.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,052, add-ons for qualifying new technology services are included. If operating cost exceeds $53,575.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,152.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,108.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,712.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.23. The transfer capital threshold is the transfer adjustment factor * $591.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7839.61","7806.09","7879.45","1 through 10","7878.66","8584.62","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","31119.71","23339.78","MEDICARE [2001]","HB BWF MEDICARE","8039.45","","Case rate ($8,039.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,052, add-ons for qualifying new technology services are included. If operating cost exceeds $53,575.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,152.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,108.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,712.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.23. The transfer capital threshold is the transfer adjustment factor * $591.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8705.11","0.03","8705.11","1 through 10","7878.66","8584.62","other","Inpatient Replacement Plans DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","31119.71","23339.78","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7878.66","","Case rate ($8,039.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,052, add-ons for qualifying new technology services are included. If operating cost exceeds $53,575.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,152.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,108.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,712.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.23. The transfer capital threshold is the transfer adjustment factor * $591.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9684.90","9684.90","9684.90","1 through 10","7878.66","8584.62","other","Inpatient DRG"
"Headaches Without McC","103","MS-DRG","","","","","","","","inpatient","","","31119.71","23339.78","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7878.66","","Case rate ($8,039.45). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,052, add-ons for qualifying new technology services are included. If operating cost exceeds $53,575.73 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,152.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,108.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,712.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $591.23. The transfer capital threshold is the transfer adjustment factor * $591.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7857.48","7857.48","7857.48","1 through 10","7878.66","8584.62","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","36626.17","27469.63","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8401.07","","Case rate ($8,156.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,169.12, add-ons for qualifying new technology services are included. If operating cost exceeds $53,692.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,160.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,216.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,829.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $600.21. The transfer capital threshold is the transfer adjustment factor * $600.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","8323.85","8323.85","8323.85","1 through 10","7993.25","8903.77","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","36626.17","27469.63","MEDICARE [2001]","HB BWF MEDICARE","8903.77","","Case rate ($8,903.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,169.12, add-ons for qualifying new technology services are included. If operating cost exceeds $53,692.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,160.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,964.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,829.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $600.21. The transfer capital threshold is the transfer adjustment factor * $600.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8814.47","8814.47","8814.47","1 through 10","7993.25","8903.77","other","Inpatient DRG"
"Heart Failure And Shock With Cc","292","MS-DRG","","","","","","","","inpatient","","","36626.17","27469.63","WELLSENSE [1003]","HB BWF MEDICARE","8903.77","","Case rate ($8,903.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,169.12, add-ons for qualifying new technology services are included. If operating cost exceeds $53,692.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,160.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,964.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,829.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $600.21. The transfer capital threshold is the transfer adjustment factor * $600.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7937.42","7937.42","7937.42","1 through 10","7993.25","8903.77","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","12524.58","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","12475.25","12470.50","12475.81","1 through 10","11916.59","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11948.05","11948.05","11948.05","1 through 10","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11916.59","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11881.20","11848.38","18912.00","1 through 10","11916.59","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","FALLON HEALTH [1008]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12123.64","12123.64","12123.64","1 through 10","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11953.94","11953.94","11953.94","1 through 10","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","HUMANA [1012]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9234.53","9234.53","9234.53","1 through 10","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","MEDICARE [2001]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13137.90","0.03","13225.40","238","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11902.17","11902.17","11902.17","1 through 10","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","MOLINA [1014]","HB BWF MEDICARE","12159.79","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","24038.39","24004.87","42085.95","1 through 10","11916.59","13178.21","other","Inpatient Replacement Plans DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11916.59","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11875.88","11848.38","11947.35","16","11916.59","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11916.59","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13742.70","13742.70","13742.70","1 through 10","11916.59","13178.21","other","Inpatient DRG"
"Heart Failure And Shock With McC","291","MS-DRG","","","","","","","","inpatient","","","41691.13","31268.35","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11916.59","","Case rate ($12,159.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,179.05, add-ons for qualifying new technology services are included. If operating cost exceeds $57,702.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,468.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $10,912.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,839.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $907.60. The transfer capital threshold is the transfer adjustment factor * $907.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11881.20","11848.38","11920.70","40","11916.59","13178.21","other","Inpatient DRG"
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","60683.71","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15285.40","15285.40","15285.40","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,EXTREME","194","DRG","","","","","","","","inpatient","","","60683.71","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17089.09","17089.09","17089.09","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22502.32","","Standard inlier is a Case rate ($22,502.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,733, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,194.29) for the length of stay and the standard reimbursement.","21479.77","21479.77","21479.77","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24171.98","","Standard inlier is a Case rate ($24,171.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,733, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,431.11) for the length of stay and the standard reimbursement.","24171.97","24171.97","24171.97","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11561.0472","","Fee schedule rate ($61,795.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11561.0472","26913.24","26913.24","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12139.0404","","Fee schedule rate ($64,885.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12139.0404","27169.40","27169.40","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","MASSHEALTH [3001]","HB BWF MEDICAID","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10598.45","488.47","10598.45","12","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2781.16","2781.16","2781.16","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","20676.85","","Fee schedule rate ($20,676.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12402.91","12402.91","12402.91","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","44070.30","","Fee schedule rate ($44,070.30). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27228.78","27228.78","27228.78","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10598.45","847.95","10598.45","12","4775.09","101961.98","case rate",""
"Heart Failure,MAJOR","194","DRG","","","","","","","","inpatient","","","46496.61","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9587.88","","Case rate ($10,601.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,031.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10598.45","814.17","10598.45","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MINOR","194","DRG","","","","","","","","inpatient","","","19813.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12394.78","","Standard inlier is a Case rate ($12,394.78). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,364, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,759.49) for the length of stay and the standard reimbursement.","12394.78","12394.78","12394.78","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MINOR","194","DRG","","","","","","","","inpatient","","","19813.65","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4775.09","","Case rate ($5,279.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,709.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5278.39","5278.39","5278.39","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","37866.08","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11561.0472","","Fee schedule rate ($22,876.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11561.0472","15856.38","15856.38","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","37866.08","","MASSHEALTH [3001]","HB BWF MEDICAID","6856.48","","Case rate ($7,581.02). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,011.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7579.16","7579.16","10598.45","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","37866.08","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","18700.38","","Fee schedule rate ($18,700.38). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18971.57","18971.57","18971.57","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","37866.08","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6856.48","","Case rate ($7,581.02). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,011.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7579.16","7579.16","7891.76","1 through 10","4775.09","101961.98","case rate",""
"Heart Failure,MODERATE","194","DRG","","","","","","","","inpatient","","","37866.08","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6856.48","","Case rate ($7,581.02). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,011.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7579.16","7579.16","7579.16","1 through 10","4775.09","101961.98","case rate",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","207.04","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","103.13","103.13","103.13","1 through 10","34.39","207.04","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","131.85","13","26.86","181.22","percent of total billed charges",""
"Helicobacter Pylori With Clarithromycin","PX-30003739","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","24","26.86","181.22","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30000937","CDM","86682","CPT","0302","RC","","","","both","","","115.00","86.25","AETNA [1001]","HB CH AETNA HMO / PPO","67.05","58.3","","63.50","63.50","63.50","1 through 10","12.75","83.95","percent of total billed charges",""
"Helminth Not Specified Antibody","PX-30001442","CDM","86682","CPT","0302","RC","","","","both","","","115.00","86.25","AETNA [1001]","HB CH AETNA HMO / PPO","67.05","58.3","","63.50","63.50","63.50","1 through 10","12.75","83.95","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","58.40","58.40","1 through 10","12.61","77.38","percent of total billed charges",""
"Hemoglobin Electrophoresis","PX-30000492","CDM","83020","CPT","0301","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","60.36","60.36","1 through 10","13.27","83.16","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","1 through 10","17.7","110.96","percent of total billed charges",""
"Hemoglobin Fract Qn","PX-30000493","CDM","83021","CPT","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","1 through 10","18.62","119.24","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","61.80","217","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","81.76","73","","79.57","79.57","79.57","1 through 10","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","65.30","58.3","","61.80","61.80","61.80","1 through 10","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","59.36","53","","57.77","57.77","57.77","1 through 10","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","81.76","73","","79.57","62.35","79.57","1 through 10","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","49.66","48.94","83.80","1 through 10","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","both","","","112.00","84.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.78","44.45","","49.66","49.66","49.66","1 through 10","9.52","81.76","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","209","10.01","87.86","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","66.42","59.3","","63.87","63.87","63.87","1 through 10","10.01","87.86","percent of total billed charges",""
"Hemoglobin Glycosylated (A1c)","PX-30000497","CDM","83036","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","83.80","49.66","83.80","195","10.01","87.86","percent of total billed charges",""
"Hemorrhage Or Hematoma Due To Complication,MODERATE","810","DRG","","","","","","","","inpatient","","","8273.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15123.30","","Standard inlier is a Case rate ($15,123.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,767, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,146.81) for the length of stay and the standard reimbursement.","15123.30","15123.30","15123.30","1 through 10","5209.27","16245.44","case rate",""
"Hemorrhage Or Hematoma Due To Complication,MODERATE","810","DRG","","","","","","","","inpatient","","","8273.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16245.44","","Standard inlier is a Case rate ($16,245.44). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,162, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,305.97) for the length of stay and the standard reimbursement.","15507.01","15507.01","15507.01","1 through 10","5209.27","16245.44","case rate",""
"Hemorrhoidectomy External 2 or More","PX-75000217","CDM","46250","CPT","0750","RC","","","","outpatient","","","6767.00","5075.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3775.00","3775.00","3775.00","1 through 10","2101.12","7178","other","ASC "
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","MEDICARE [2001]","HB BWF MEDICARE","3256.42","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3256.75","3256.75","3256.75","1 through 10","2101.12","4842.11","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","2101.12","4842.11","per diem",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","3191.30","","APC Price ($3,256.42). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3203.37","3203.37","3203.37","1 through 10","2101.12","4842.11","other","OPPS APC"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","both","","","6215.00","4661.25","WELLPOINT [1015]","HB CH WELLPOINT","4842.11","77.91","","10131.69","8321.78","10131.69","1 through 10","2101.12","4842.11","percent of total billed charges",""
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3855.09","3855.09","3855.09","1 through 10","2101.12","7178","other","ASC "
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3860.43","3860.43","3860.43","1 through 10","2101.12","7178","other","ASC "
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","4937.63","4937.63","4937.63","1 through 10","2101.12","7178","other","Multiple Surgery"
"Hemorrhoidectomy Int & Xtrnl 2/> Column/Gro","PX-75000506","CDM","46260","CPT","0750","RC","","","","outpatient","","","6215.00","4661.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6177.29","6177.29","6177.29","1 through 10","2101.12","7178","other","Multiple Surgery"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1592.00","1194.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1065.39","1065.39","1065.39","1 through 10","744.89","2114.51","other","OPPS APC"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","both","","","1592.00","1194.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1060.95","","APC Price ($1,082.60). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1068.56","1068.56","1068.56","1 through 10","744.89","2114.51","other","OPPS APC"
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1592.00","1194.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","1231.73","1231.73","1 through 10","682.97","1873.9","other","ASC "
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1592.00","1194.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","944.06","59.3","","3498.42","3498.42","3498.42","1 through 10","682.97","1873.9","percent of total billed charges",""
"Hemorrhoidectomy Ligation","PX-75000215","CDM","46221","CPT","0761","RC","","","","outpatient","","","1592.00","1194.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1750.49","1750.49","1 through 10","682.97","1873.9","other","Multiple Surgery"
"Hemorrhoidectomy Singl Column/Group","PX-75000218","CDM","46255","CPT","0750","RC","","","","both","","","6419.00","4814.25","WELLPOINT [1015]","HB CH WELLPOINT","5001.04","77.91","","18887.78","18887.78","18887.78","1 through 10","2753.75","5001.04","percent of total billed charges",""
"Hemorrhoidectomy Singl Column/Group","PX-75000218","CDM","46255","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3149.80","49.07","","3855.09","3855.09","3855.09","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Hemorrhoidectomy Singl Column/Group","PX-75000218","CDM","46255","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3215.92","50.1","","3860.43","3780.34","3860.43","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","both","","","149.00","111.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","78.97","53","","76.85","76.85","76.85","1 through 10","12.83","108.77","percent of total billed charges",""
"Heparin Assay","PX-30001105","CDM","85520","CPT","0305","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.36","59.3","","84.97","84.97","259.60","1 through 10","13.5","116.89","percent of total billed charges",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","133840.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11064.6804","","Fee schedule rate ($75,316.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11064.6804","75316.82","75316.82","1 through 10","4649.43","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,EXTREME","279","DRG","","","","","","","","inpatient","","","133840.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23458.2168","","Fee schedule rate ($75,316.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23458.2168","75316.82","75316.82","1 through 10","4649.43","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","32637.20","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14659.97","","Standard inlier is a Case rate ($14,659.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,901, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,081.04) for the length of stay and the standard reimbursement.","22433.67","22433.67","22433.67","1 through 10","4649.43","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MAJOR","279","DRG","","","","","","","","inpatient","","","32637.20","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9448.72","","Fee schedule rate ($9,448.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9448.72","9448.72","9448.72","1 through 10","4649.43","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MINOR","279","DRG","","","","","","","","inpatient","","","11815.51","","MASSHEALTH [3001]","HB BWF MEDICAID","4649.43","","Case rate ($5,140.74). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,570.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5139.48","5139.48","5139.48","1 through 10","4649.43","124271.6","case rate",""
"Hepatic Coma And Other Major Acute Liver Disorders,MINOR","279","DRG","","","","","","","","inpatient","","","11815.51","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12932.16","","Fee schedule rate ($12,932.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12932.16","12932.16","12932.16","1 through 10","4649.43","124271.6","case rate",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0300","RC","","","","inpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.96","70.6","","94.56","94.56","94.56","1 through 10","70.56","88.96","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","69.74","69.74","69.74","117","8.01","91.98","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","89.79","89.79","89.79","1 through 10","8.01","91.98","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","89.79","69.74","89.79","1 through 10","8.01","91.98","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","both","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.01","44.45","","94.56","56.04","94.56","1 through 10","8.01","91.98","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","72.08","72.08","173.20","104","8.43","98.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","74.72","59.3","","72.08","72.07","72.08","1 through 10","8.43","98.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","94.56","94.56","94.56","1 through 10","8.43","98.85","percent of total billed charges",""
"Hepatic Function Panel","PX-30000010","CDM","80076","CPT","0301","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","94.56","56.04","94.56","109","8.43","98.85","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","both","","","132.00","99.00","AETNA [1001]","HB CH AETNA HMO / PPO","76.96","58.3","","72.58","72.58","72.58","1 through 10","11.03","96.36","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","132.00","99.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.28","59.3","","75.01","75.01","110.16","1 through 10","11.62","103.55","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) IGM","PX-30000960","CDM","86709","CPT","0302","RC","","","","outpatient","","","132.00","99.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","103.55","78.45","","98.41","98.41","98.41","1 through 10","11.62","103.55","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","73.14","1 through 10","12.14","97.09","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","133.00","99.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.87","59.3","","75.59","75.59","111.02","1 through 10","11.99","104.34","percent of total billed charges",""
"HEPATITIS A ANTIBODY (HAAb) TOTAL","PX-30000959","CDM","86708","CPT","0302","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","104.34","78.45","","99.18","58.77","99.18","1 through 10","11.99","104.34","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","55.57","1 through 10","11.53","73.73","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","57.43","1 through 10","12.15","79.23","percent of total billed charges",""
"Hepatitis B Core Antibody Igm","PX-30000956","CDM","86705","CPT","0302","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","75.34","42.12","75.34","1 through 10","12.15","79.23","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","AETNA [1001]","HB CH AETNA HMO / PPO","81.04","58.3","","76.55","76.55","76.55","40","11.81","101.47","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.79","44.45","","103.79","103.79","103.79","1 through 10","11.81","101.47","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","237.33","60","12.43","109.05","percent of total billed charges",""
"Hepatitis B Core Antibody Igm Igg","PX-30000955","CDM","86704","CPT","0302","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.05","78.45","","103.79","61.51","103.79","34","12.43","109.05","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","AETNA [1001]","HB CH AETNA HMO / PPO","71.13","58.3","","67.47","67.47","67.47","51","10.53","89.06","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","89.06","73","","89.75","89.75","89.75","1 through 10","10.53","89.06","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","both","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.23","44.45","","91.49","91.49","91.49","1 through 10","10.53","89.06","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","122.00","91.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.35","59.3","","69.73","69.73","209.19","64","10.79","95.71","percent of total billed charges",""
"Hepatitis B Surface Antibody","PX-30000957","CDM","86706","CPT","0302","RC","","","","outpatient","","","122.00","91.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.71","78.45","","91.49","54.22","91.49","37","10.79","95.71","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","57.27","49","13.98","93.51","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","75.92","73","","90.65","90.65","90.65","1 through 10","13.98","93.51","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","both","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.23","44.45","","77.65","46.02","77.65","1 through 10","13.98","93.51","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","104.00","78.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.67","59.3","","59.19","59.19","177.57","65","11.99","81.59","percent of total billed charges",""
"Hepatitis C Antibody","PX-30001014","CDM","86803","CPT","0302","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","46.02","77.65","49","11.99","81.59","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igg","PX-30003658","CDM","86790","CPT","0301","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","75.99","percent of total billed charges",""
"Hepatitis E Virus (Hev) Antibody, Igm","PX-30003657","CDM","86790","CPT","0301","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","75.99","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","207.04","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","103.13","103.13","103.13","1 through 10","34.39","207.04","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","131.85","13","26.86","181.22","percent of total billed charges",""
"Her Anaplasma Det Pcr","PX-30002297","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","24","26.86","181.22","percent of total billed charges",""
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","42589.33","31942.00","HUMANA [1012]","HB BWF MEDICARE","17310.94","","Case rate ($17,310.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,855.13, add-ons for qualifying new technology services are included. If operating cost exceeds $61,378.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,750.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $15,782.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,515.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.39. The transfer capital threshold is the transfer adjustment factor * $1,189.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14488.49","14488.49","14488.49","1 through 10","15513.3","17310.94","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","42589.33","31942.00","MEDICARE [2001]","HB BWF MEDICARE","17310.94","","Case rate ($17,310.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,855.13, add-ons for qualifying new technology services are included. If operating cost exceeds $61,378.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,750.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $15,782.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,515.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.39. The transfer capital threshold is the transfer adjustment factor * $1,189.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17166.00","17166.00","17166.00","1 through 10","15513.3","17310.94","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With Cc","354","MS-DRG","","","","","","","","inpatient","","","42589.33","31942.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15513.30","","Case rate ($15,829.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,855.13, add-ons for qualifying new technology services are included. If operating cost exceeds $61,378.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,750.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $14,301.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,515.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.39. The transfer capital threshold is the transfer adjustment factor * $1,189.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15454.56","15454.56","15454.56","1 through 10","15513.3","17310.94","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral With McC","353","MS-DRG","","","","","","","","inpatient","","","80597.42","60448.06","MEDICARE [2001]","HB BWF MEDICARE","27059.31","","Case rate ($27,059.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,102.86, add-ons for qualifying new technology services are included. If operating cost exceeds $72,626.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,612.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $24,668.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $26,763.62 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,051.60. The transfer capital threshold is the transfer adjustment factor * $2,051.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15334.88","15334.88","15334.88","1 through 10","26518.12","29004.437","other","Inpatient Replacement Plans DRG"
"Hernia Procedures Except Inguinal And Femoral With McC","353","MS-DRG","","","","","","","","inpatient","","","80597.42","60448.06","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","26518.12","","Case rate ($27,059.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,102.86, add-ons for qualifying new technology services are included. If operating cost exceeds $72,626.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,612.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $24,668.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $26,763.62 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,051.60. The transfer capital threshold is the transfer adjustment factor * $2,051.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","26400.05","26400.05","26400.05","1 through 10","26518.12","29004.437","other","Inpatient DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","39637.58","29728.18","MEDICARE [2001]","HB BWF MEDICARE","12723.28","","Case rate ($12,723.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,743.46, add-ons for qualifying new technology services are included. If operating cost exceeds $58,267.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,511.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,433.18 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,404.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.86. The transfer capital threshold is the transfer adjustment factor * $950.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13418.39","13418.39","13507.81","1 through 10","12468.81","13184.0148","other","Inpatient Replacement Plans DRG"
"Hernia Procedures Except Inguinal And Femoral Without Cc/McC","355","MS-DRG","","","","","","","","inpatient","","","39637.58","29728.18","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12468.81","","Case rate ($12,723.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,743.46, add-ons for qualifying new technology services are included. If operating cost exceeds $58,267.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,511.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $11,433.18 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,404.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.86. The transfer capital threshold is the transfer adjustment factor * $950.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13591.19","13591.19","13591.19","1 through 10","12468.81","13184.0148","other","Inpatient DRG"
"Hernia Procedures Except Inguinal, Femoral And Umbilical,MINOR","227","DRG","","","","","","","","inpatient","","","32510.73","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","34223.72","","Fee schedule rate ($34,223.72). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27816.55","27816.55","27816.55","1 through 10","9795.79","38063.16","case rate",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","both","","","169.00","126.75","AETNA [1001]","HB CH AETNA HMO / PPO","98.53","58.3","","92.99","92.99","92.99","1 through 10","14.1","123.37","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","169.00","126.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.22","59.3","","96.10","96.10","96.10","1 through 10","14.84","132.58","percent of total billed charges",""
"Herpes Simplex Antibody","PX-30000944","CDM","86694","CPT","0302","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","132.58","78.45","","126.08","126.08","126.08","1 through 10","14.84","132.58","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Herpesvirus7 Dna Quant Rlt Pcr","PX-30002299","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","1 through 10","5.08","33.93","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","26.37","1 through 10","5.34","36.09","percent of total billed charges",""
"Heterophile Antibody Screen","PX-30000822","CDM","86308","CPT","0302","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","20.50","20.50","20.50","1 through 10","5.34","36.09","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","217.84","163.38","AETNA [1001]","HB CH AETNA HMO / PPO","127.00","58.3","","123.52","123.52","123.52","1 through 10","115.46","873.78","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","217.84","163.38","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","138.11","63.4","","144.43","138.98","144.43","1 through 10","115.46","873.78","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","217.84","163.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","159.02","73","","159.02","159.02","159.02","1 through 10","115.46","873.78","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","217.84","163.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","115.46","53","","115.46","115.46","115.46","1 through 10","115.46","873.78","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","both","","","217.84","163.38","WELLPOINT [1015]","HB CH WELLPOINT","169.72","77.91","","171.57","171.57","171.57","1 through 10","115.46","873.78","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.18","59.3","","127.65","124.60","217.84","1 through 10","96.83","613.61","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","125.69","57.7","","131.36","131.36","131.36","15","96.83","613.61","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","131.79","60.5","","137.89","137.89","137.89","1 through 10","96.83","613.61","percent of total billed charges",""
"Hfo W/O Joints Cf","PX-27000498","CDM","L3913","HCPCS","0274","RC","","","","outpatient","","","217.84","163.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","170.90","78.45","","167.48","99.25","334.95","1 through 10","96.83","613.61","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","AETNA [1001]","HB CH AETNA HMO / PPO","2364.65","58.3","","554.95","91.85","1421.75","94","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2960.88","73","","2490.03","2490.03","2490.03","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2364.65","58.3","","750.00","750.00","750.00","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2149.68","53","","1192.50","120.84","4149.90","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3447.60","85","","750.00","75.00","750.00","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4056.00","100","","657.00","121.50","1971.00","14","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4056.00","100","","75.00","75.00","75.00","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4056.00","100","","366.00","144.00","1971.00","45","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2960.88","73","","667.50","667.50","667.50","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.89","44.45","","123.77","123.77","123.77","1 through 10","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","both","","","4056.00","3042.00","WELLPOINT [1015]","HB CH WELLPOINT","3160.03","77.91","","483.51","229.32","1316.08","96","1802.89","4056","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4056.00","3042.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2405.21","59.3","","439.50","225.34","1872.27","197","2028","3181.93","percent of total billed charges",""
"HINDFOOT PLATE 4.5MM 6 HOLE BONE RT TTC ADVANSYS","SUP-ITM-10091876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4056.00","3042.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3181.93","78.45","","385.32","55.36","1815.62","58","2028","3181.93","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1634.24","1004.95","1718.99","42","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","2123.89","1900.92","2123.89","1 through 10","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1089.63","58.3","","3729.00","1254.19","3729.00","1 through 10","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","939.37","939.37","5593.65","1 through 10","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1588.65","85","","2323.25","1864.50","2882.25","16","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1869.00","100","","2909.44","1772.40","10952.08","45","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1869.00","100","","2323.25","2323.25","2323.25","1 through 10","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1869.00","100","","2882.25","1772.40","10169.17","187","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","1659.41","1659.41","1659.41","1 through 10","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","2050.91","1468.48","2902.83","52","830.77","1869","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1548.60","1092.60","3613.79","82","934.5","1466.23","percent of total billed charges",""
"HINGE ROT 10MM MED IMPLANT KNEE DISTAL FEMORAL AUGMENT MOD ONC 09","SUP-ITM-10035440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","2085.51","998.68","6202.11","56","934.5","1466.23","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"HINGE ROTATING 3.0DEG INSERT TIBIAL KNEE TRIAL BUMPER MONOGRAM COBALT","SUP-ITM-10018021","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"HINGE ROTATING 3MM LG XL COMPONENT TIBIAL KNEE MODULAR POSTERIOR OFFSET","SUP-ITM-10035443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","AETNA [1001]","HB CH AETNA HMO / PPO","4984.65","58.3","","1634.24","1004.95","1718.99","42","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6241.50","73","","2123.89","1900.92","2123.89","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4984.65","58.3","","3729.00","1254.19","3729.00","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4531.50","53","","939.37","939.37","5593.65","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7267.50","85","","2323.25","1864.50","2882.25","16","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8550.00","100","","2909.44","1772.40","10952.08","45","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8550.00","100","","2323.25","2323.25","2323.25","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8550.00","100","","2882.25","1772.40","10169.17","187","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6241.50","73","","1659.41","1659.41","1659.41","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","WELLPOINT [1015]","HB CH WELLPOINT","6661.31","77.91","","2050.91","1468.48","2902.83","52","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5070.15","59.3","","1548.60","1092.60","3613.79","82","4275","6707.48","percent of total billed charges",""
"HINGE ROTATING 70X61MM MD IMPLANT KNEE FEMORAL MODULAR RT ONC 02","SUP-ITM-10016606","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6707.48","78.45","","2085.51","998.68","6202.11","56","4275","6707.48","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","AETNA [1001]","HB CH AETNA HMO / PPO","4984.65","58.3","","1634.24","1004.95","1718.99","42","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6241.50","73","","2123.89","1900.92","2123.89","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4984.65","58.3","","3729.00","1254.19","3729.00","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4531.50","53","","939.37","939.37","5593.65","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7267.50","85","","2323.25","1864.50","2882.25","16","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8550.00","100","","2909.44","1772.40","10952.08","45","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8550.00","100","","2323.25","2323.25","2323.25","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8550.00","100","","2882.25","1772.40","10169.17","187","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6241.50","73","","1659.41","1659.41","1659.41","1 through 10","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","both","","","8550.00","6412.50","WELLPOINT [1015]","HB CH WELLPOINT","6661.31","77.91","","2050.91","1468.48","2902.83","52","3800.48","8550","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5070.15","59.3","","1548.60","1092.60","3613.79","82","4275","6707.48","percent of total billed charges",""
"HINGE ROTATING 80X66MM XL COMPONENT FEMORAL KNEE MODULAR LEFT","SUP-ITM-10035437","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8550.00","6412.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6707.48","78.45","","2085.51","998.68","6202.11","56","4275","6707.48","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","AETNA [1001]","HB CH AETNA HMO / PPO","1603.83","58.3","","1634.24","1004.95","1718.99","42","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2008.23","73","","2123.89","1900.92","2123.89","1 through 10","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1603.83","58.3","","3729.00","1254.19","3729.00","1 through 10","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1458.03","53","","939.37","939.37","5593.65","1 through 10","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2338.35","85","","2323.25","1864.50","2882.25","16","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2751.00","100","","2909.44","1772.40","10952.08","45","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2751.00","100","","2323.25","2323.25","2323.25","1 through 10","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2751.00","100","","2882.25","1772.40","10169.17","187","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2008.23","73","","1659.41","1659.41","1659.41","1 through 10","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","both","","","2751.00","2063.25","WELLPOINT [1015]","HB CH WELLPOINT","2143.30","77.91","","2050.91","1468.48","2902.83","52","1222.82","2751","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1631.34","59.3","","1548.60","1092.60","3613.79","82","1375.5","2158.16","percent of total billed charges",""
"HINGE SWANSON SIZE 3 PROSTHESIS JOINT TOE FLEXIBLE GROMMET","SUP-ITM-10057351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2751.00","2063.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2158.16","78.45","","2085.51","998.68","6202.11","56","1375.5","2158.16","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1634.24","1004.95","1718.99","42","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","2123.89","1900.92","2123.89","1 through 10","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1944.89","58.3","","3729.00","1254.19","3729.00","1 through 10","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","939.37","939.37","5593.65","1 through 10","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2835.60","85","","2323.25","1864.50","2882.25","16","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3336.00","100","","2909.44","1772.40","10952.08","45","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3336.00","100","","2323.25","2323.25","2323.25","1 through 10","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3336.00","100","","2882.25","1772.40","10169.17","187","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","1659.41","1659.41","1659.41","1 through 10","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","2050.91","1468.48","2902.83","52","1482.85","3336","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1548.60","1092.60","3613.79","82","1668","2617.09","percent of total billed charges",""
"HINGE TIBIAL SIZE 3 BASEPLATE KNEE LEGION CEMENTED FEMALE TAPERED RIGHT","SUP-ITM-10100574","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","2085.51","998.68","6202.11","56","1668","2617.09","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","AETNA [1001]","HB CH AETNA HMO / PPO","526.45","58.3","","1634.24","1004.95","1718.99","42","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","659.19","73","","2123.89","1900.92","2123.89","1 through 10","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","526.45","58.3","","3729.00","1254.19","3729.00","1 through 10","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","478.59","53","","939.37","939.37","5593.65","1 through 10","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","767.55","85","","2323.25","1864.50","2882.25","16","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","903.00","100","","2909.44","1772.40","10952.08","45","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","903.00","100","","2323.25","2323.25","2323.25","1 through 10","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","903.00","100","","2882.25","1772.40","10169.17","187","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","659.19","73","","1659.41","1659.41","1659.41","1 through 10","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","both","","","903.00","677.25","WELLPOINT [1015]","HB CH WELLPOINT","703.53","77.91","","2050.91","1468.48","2902.83","52","401.38","903","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","535.48","59.3","","1548.60","1092.60","3613.79","82","451.5","708.4","percent of total billed charges",""
"HIP 22.2MM 2 2DEG PCA VITALLIUM COCR + 05","SUP-ITM-10017875","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","903.00","677.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","708.40","78.45","","2085.51","998.68","6202.11","56","451.5","708.4","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","AETNA [1001]","HB CH AETNA HMO / PPO","923.47","58.3","","1634.24","1004.95","1718.99","42","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1156.32","73","","2123.89","1900.92","2123.89","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","923.47","58.3","","3729.00","1254.19","3729.00","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","839.52","53","","939.37","939.37","5593.65","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1346.40","85","","2323.25","1864.50","2882.25","16","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1584.00","100","","2909.44","1772.40","10952.08","45","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1584.00","100","","2323.25","2323.25","2323.25","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1584.00","100","","2882.25","1772.40","10169.17","187","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1156.32","73","","1659.41","1659.41","1659.41","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","WELLPOINT [1015]","HB CH WELLPOINT","1234.09","77.91","","2050.91","1468.48","2902.83","52","704.09","1584","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","939.31","59.3","","1548.60","1092.60","3613.79","82","792","1242.65","percent of total billed charges",""
"HIP 26MM 5 LFIT COBALT CHROMIUM C TAPERED OFFSET","SUP-ITM-10002108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1242.65","78.45","","2085.51","998.68","6202.11","56","792","1242.65","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","AETNA [1001]","HB CH AETNA HMO / PPO","923.47","58.3","","1634.24","1004.95","1718.99","42","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1156.32","73","","2123.89","1900.92","2123.89","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","923.47","58.3","","3729.00","1254.19","3729.00","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","839.52","53","","939.37","939.37","5593.65","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1346.40","85","","2323.25","1864.50","2882.25","16","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1584.00","100","","2909.44","1772.40","10952.08","45","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1584.00","100","","2323.25","2323.25","2323.25","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1584.00","100","","2882.25","1772.40","10169.17","187","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1156.32","73","","1659.41","1659.41","1659.41","1 through 10","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","WELLPOINT [1015]","HB CH WELLPOINT","1234.09","77.91","","2050.91","1468.48","2902.83","52","704.09","1584","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","939.31","59.3","","1548.60","1092.60","3613.79","82","792","1242.65","percent of total billed charges",""
"HIP 28MM 10 C TAPER LFIT COBALT ION IMPLANTED TAPERED PLUS","SUP-ITM-10002442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1584.00","1188.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1242.65","78.45","","2085.51","998.68","6202.11","56","792","1242.65","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1634.24","1004.95","1718.99","42","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2123.89","1900.92","2123.89","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","3729.00","1254.19","3729.00","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","939.37","939.37","5593.65","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","2323.25","1864.50","2882.25","16","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","2909.44","1772.40","10952.08","45","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","2323.25","2323.25","2323.25","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","2882.25","1772.40","10169.17","187","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","1659.41","1659.41","1659.41","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","2050.91","1468.48","2902.83","52","533.4","1200","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1548.60","1092.60","3613.79","82","600","941.4","percent of total billed charges",""
"HIP 28X53MM UHR COBALT BIPOLAR UNIVERSAL","SUP-ITM-10036152","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","2085.51","998.68","6202.11","56","600","941.4","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1634.24","1004.95","1718.99","42","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2123.89","1900.92","2123.89","1 through 10","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","3729.00","1254.19","3729.00","1 through 10","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","939.37","939.37","5593.65","1 through 10","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","2323.25","1864.50","2882.25","16","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","2909.44","1772.40","10952.08","45","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","2323.25","2323.25","2323.25","1 through 10","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","2882.25","1772.40","10169.17","187","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","1659.41","1659.41","1659.41","1 through 10","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","2050.91","1468.48","2902.83","52","400.05","900","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1548.60","1092.60","3613.79","82","450","706.05","percent of total billed charges",""
"HIP 32MM 10 C TAPER COBALT PLUS","SUP-ITM-10034750","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","2085.51","998.68","6202.11","56","450","706.05","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1634.24","1004.95","1718.99","42","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","2123.89","1900.92","2123.89","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","734.58","58.3","","3729.00","1254.19","3729.00","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","939.37","939.37","5593.65","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1071.00","85","","2323.25","1864.50","2882.25","16","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1260.00","100","","2909.44","1772.40","10952.08","45","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1260.00","100","","2323.25","2323.25","2323.25","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1260.00","100","","2882.25","1772.40","10169.17","187","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","1659.41","1659.41","1659.41","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","2050.91","1468.48","2902.83","52","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1548.60","1092.60","3613.79","82","630","988.47","percent of total billed charges",""
"HIP 32MM 3.5 HD BIOLOX DELTA CERAMIC MINUS IMPLANT 04","SUP-ITM-10065824","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","2085.51","998.68","6202.11","56","630","988.47","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1634.24","1004.95","1718.99","42","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","2123.89","1900.92","2123.89","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","734.58","58.3","","3729.00","1254.19","3729.00","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","939.37","939.37","5593.65","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1071.00","85","","2323.25","1864.50","2882.25","16","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1260.00","100","","2909.44","1772.40","10952.08","45","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1260.00","100","","2323.25","2323.25","2323.25","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1260.00","100","","2882.25","1772.40","10169.17","187","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","1659.41","1659.41","1659.41","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","2050.91","1468.48","2902.83","52","560.07","1260","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1548.60","1092.60","3613.79","82","630","988.47","percent of total billed charges",""
"HIP 32MM 3.5 IMPLANT PLUS VERSYS 12TO14 COBALT 05 BX/1EA","SUP-ITM-10002382","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","2085.51","998.68","6202.11","56","630","988.47","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1634.24","1004.95","1718.99","42","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2123.89","1900.92","2123.89","1 through 10","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","3729.00","1254.19","3729.00","1 through 10","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","939.37","939.37","5593.65","1 through 10","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","2323.25","1864.50","2882.25","16","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","2909.44","1772.40","10952.08","45","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","2323.25","2323.25","2323.25","1 through 10","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","2882.25","1772.40","10169.17","187","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","1659.41","1659.41","1659.41","1 through 10","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","2050.91","1468.48","2902.83","52","400.05","900","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1548.60","1092.60","3613.79","82","450","706.05","percent of total billed charges",""
"HIP 36MM 0.0 C TAPER LFIT PLUS COBALT 05","SUP-ITM-10012314","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","2085.51","998.68","6202.11","56","450","706.05","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1634.24","1004.95","1718.99","42","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2123.89","1900.92","2123.89","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","3729.00","1254.19","3729.00","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","939.37","939.37","5593.65","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","2323.25","1864.50","2882.25","16","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","2909.44","1772.40","10952.08","45","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","2323.25","2323.25","2323.25","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","2882.25","1772.40","10169.17","187","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","1659.41","1659.41","1659.41","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","2050.91","1468.48","2902.83","52","533.4","1200","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1548.60","1092.60","3613.79","82","600","941.4","percent of total billed charges",""
"HIP 36MM 4 OXINIUM OXIDIZED ZIRCONIUM 14/16 TAPER PLUS","SUP-ITM-10026395","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","2085.51","998.68","6202.11","56","600","941.4","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","AETNA [1001]","HB CH AETNA HMO / PPO","734.58","58.3","","1634.24","1004.95","1718.99","42","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","2123.89","1900.92","2123.89","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","734.58","58.3","","3729.00","1254.19","3729.00","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","667.80","53","","939.37","939.37","5593.65","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1071.00","85","","2323.25","1864.50","2882.25","16","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1260.00","100","","2909.44","1772.40","10952.08","45","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1260.00","100","","2323.25","2323.25","2323.25","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1260.00","100","","2882.25","1772.40","10169.17","187","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","919.80","73","","1659.41","1659.41","1659.41","1 through 10","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","both","","","1260.00","945.00","WELLPOINT [1015]","HB CH WELLPOINT","981.67","77.91","","2050.91","1468.48","2902.83","52","560.07","1260","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","747.18","59.3","","1548.60","1092.60","3613.79","82","630","988.47","percent of total billed charges",""
"HIP 40MM 3.5 HD CERAMIC BIOLOX DELTA MINUS IMPLANT 04","SUP-ITM-10061788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1260.00","945.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","988.47","78.45","","2085.51","998.68","6202.11","56","630","988.47","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1634.24","1004.95","1718.99","42","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2123.89","1900.92","2123.89","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","3729.00","1254.19","3729.00","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","939.37","939.37","5593.65","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","2323.25","1864.50","2882.25","16","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","2909.44","1772.40","10952.08","45","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","2323.25","2323.25","2323.25","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","2882.25","1772.40","10169.17","187","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","1659.41","1659.41","1659.41","1 through 10","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","2050.91","1468.48","2902.83","52","533.4","1200","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1548.60","1092.60","3613.79","82","600","941.4","percent of total billed charges",""
"HIP 44X26MM UNIVERSAL UHR COBALT BIPOLAR","SUP-ITM-10015206","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","2085.51","998.68","6202.11","56","600","941.4","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","AETNA [1001]","HB CH AETNA HMO / PPO","2775.08","58.3","","1634.24","1004.95","1718.99","42","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3474.80","73","","2123.89","1900.92","2123.89","1 through 10","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2775.08","58.3","","3729.00","1254.19","3729.00","1 through 10","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2522.80","53","","939.37","939.37","5593.65","1 through 10","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4046.00","85","","2323.25","1864.50","2882.25","16","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4760.00","100","","2909.44","1772.40","10952.08","45","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4760.00","100","","2323.25","2323.25","2323.25","1 through 10","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4760.00","100","","2882.25","1772.40","10169.17","187","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3474.80","73","","1659.41","1659.41","1659.41","1 through 10","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4760.00","3570.00","WELLPOINT [1015]","HB CH WELLPOINT","3708.52","77.91","","2050.91","1468.48","2902.83","52","2115.82","4760","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4760.00","3570.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2822.68","59.3","","1548.60","1092.60","3613.79","82","2380","3734.22","percent of total billed charges",""
"HIP 50MM BIRMINGHAM RESURFACING COBALT HA COATED","SUP-ITM-10019001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4760.00","3570.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3734.22","78.45","","2085.51","998.68","6202.11","56","2380","3734.22","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 48D SHELL TRIDENT II TRITANIUM 3D SURFACE CLUSTERHOLE","SUP-ITM-10208615","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 50D SHELL TRIDENT I CLUSTERHOLE 3D SURFACE TRITANIUM","SUP-ITM-10208616","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","AETNA [1001]","HB CH AETNA HMO / PPO","2121.10","58.3","","1634.24","1004.95","1718.99","42","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2655.92","73","","2123.89","1900.92","2123.89","1 through 10","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2121.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1928.27","53","","939.37","939.37","5593.65","1 through 10","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3092.51","85","","2323.25","1864.50","2882.25","16","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3638.25","100","","2909.44","1772.40","10952.08","45","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3638.25","100","","2323.25","2323.25","2323.25","1 through 10","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3638.25","100","","2882.25","1772.40","10169.17","187","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2655.92","73","","1659.41","1659.41","1659.41","1 through 10","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","both","","","3638.25","2728.69","WELLPOINT [1015]","HB CH WELLPOINT","2834.56","77.91","","2050.91","1468.48","2902.83","52","1617.2","3638.25","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2157.48","59.3","","1548.60","1092.60","3613.79","82","1819.13","2854.21","percent of total billed charges",""
"HIP ACETABULAR 52MM SHELL E COBALT CHROME LIMITED OSSEOTI 3 HOLE","SUP-ITM-10208425","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3638.25","2728.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2854.21","78.45","","2085.51","998.68","6202.11","56","1819.13","2854.21","percent of total billed charges",""
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","45520.21","34140.16","ELDER SERVICES [1037]","HB BWF MEDICARE","19624.27","","Case rate ($19,624.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,655.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,179.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,041.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,804.31 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,316.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,480.73. The transfer capital threshold is the transfer adjustment factor * $1,480.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7204.67","7204.67","7204.67","1 through 10","19231.78","21500.04","other","Inpatient Replacement Plans DRG"
"Hip And Femur Procedures Except Major Joint With Cc","481","MS-DRG","","","","","","","","inpatient","","","45520.21","34140.16","MEDICARE [2001]","HB BWF MEDICARE","19624.27","","Case rate ($19,624.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,655.71, add-ons for qualifying new technology services are included. If operating cost exceeds $65,179.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,041.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,804.31 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,316.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,480.73. The transfer capital threshold is the transfer adjustment factor * $1,480.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","20743.74","20743.74","20743.74","1 through 10","19231.78","21500.04","other","Inpatient Replacement Plans DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","96591.24","72443.43","MEDICARE [2001]","HB BWF MEDICARE","29717.87","","Case rate ($29,717.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,197.85, add-ons for qualifying new technology services are included. If operating cost exceeds $72,721.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,619.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $27,319.76 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $26,858.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,058.88. The transfer capital threshold is the transfer adjustment factor * $2,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","29494.89","28798.89","29494.89","1 through 10","26611.05","29717.87","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint With McC","480","MS-DRG","","","","","","","","inpatient","","","96591.24","72443.43","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","26611.05","","Case rate ($27,154.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,197.85, add-ons for qualifying new technology services are included. If operating cost exceeds $72,721.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,619.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $24,756.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $26,858.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,058.88. The transfer capital threshold is the transfer adjustment factor * $2,058.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","26475.38","26475.38","26475.38","1 through 10","26611.05","29717.87","other","Inpatient DRG"
"Hip And Femur Procedures Except Major Joint Without Cc/McC","482","MS-DRG","","","","","","","","inpatient","","","53225.41","39919.06","MEDICARE [2001]","HB BWF MEDICARE","16792.40","","Case rate ($16,792.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,381.09, add-ons for qualifying new technology services are included. If operating cost exceeds $60,904.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,713.83, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.1)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,300.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,041.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,153.05. The transfer capital threshold is the transfer adjustment factor * $1,153.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","3962.37","3962.37","3962.37","1 through 10","15049.48","16792.4","other","Inpatient DRG"
"HIP CAGE 49MM IDX52MM OD ACETABULAR RT PROTRUSIO","SUP-ITM-10090248","CDM","C1889","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","AETNA [1001]","HB CH AETNA HMO / PPO","1254.03","58.3","","1830.28","315.58","1830.28","1 through 10","956.12","2151","percent of total billed charges",""
"HIP CAGE 49MM IDX52MM OD ACETABULAR RT PROTRUSIO","SUP-ITM-10090248","CDM","C1889","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1570.23","73","","4170.85","4170.85","4170.85","1 through 10","956.12","2151","percent of total billed charges",""
"HIP CAGE 49MM IDX52MM OD ACETABULAR RT PROTRUSIO","SUP-ITM-10090248","CDM","C1889","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","956.12","44.45","","649.55","649.55","649.55","1 through 10","956.12","2151","percent of total billed charges",""
"HIP CAGE 49MM IDX52MM OD ACETABULAR RT PROTRUSIO","SUP-ITM-10090248","CDM","C1889","HCPCS","0278","RC","","","","both","","","2151.00","1613.25","WELLPOINT [1015]","HB CH WELLPOINT","1675.84","77.91","","8998.38","2542.37","8998.38","20","956.12","2151","percent of total billed charges",""
"HIP CAGE 49MM IDX52MM OD ACETABULAR RT PROTRUSIO","SUP-ITM-10090248","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2151.00","1613.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1275.54","59.3","","1891.61","1609.14","3664.18","25","1075.5","1687.46","percent of total billed charges",""
"HIP CAGE 49MM IDX52MM OD ACETABULAR RT PROTRUSIO","SUP-ITM-10090248","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2151.00","1613.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1687.46","78.45","","1470.68","1310.06","2481.69","19","1075.5","1687.46","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","1634.24","1004.95","1718.99","42","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","2123.89","1900.92","2123.89","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","3729.00","1254.19","3729.00","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","939.37","939.37","5593.65","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.50","85","","2323.25","1864.50","2882.25","16","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.00","100","","2909.44","1772.40","10952.08","45","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.00","100","","2323.25","2323.25","2323.25","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","2882.25","1772.40","10169.17","187","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","1659.41","1659.41","1659.41","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","2050.91","1468.48","2902.83","52","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","1548.60","1092.60","3613.79","82","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 13MM IMPLANT STEM CEMENTRALIZER ALIGNMENT 16B","SUP-ITM-10011247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","2085.51","998.68","6202.11","56","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","554.95","91.85","1421.75","94","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","2490.03","2490.03","2490.03","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","750.00","750.00","750.00","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","1192.50","120.84","4149.90","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.50","85","","750.00","75.00","750.00","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.00","100","","657.00","121.50","1971.00","14","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.00","100","","75.00","75.00","75.00","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","366.00","144.00","1971.00","45","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","667.50","667.50","667.50","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","123.77","123.77","123.77","1 through 10","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","483.51","229.32","1316.08","96","66.68","150","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","439.50","225.34","1872.27","197","75","117.68","percent of total billed charges",""
"HIP CENTRALIZER 18MM CEMENTRALIZER PROSTALAC","SUP-ITM-10119288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","385.32","55.36","1815.62","58","75","117.68","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HIP COMPONENT 11/13 36MM PLUS 12 BIOLOX DELTA CERAMIC TAPERED","SUP-ITM-10114319","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HIP COMPONENT 36MM DEP1365 210 SROM CERAMIC FEM +0 11/13TAPER 04","SUP-ITM-10021385","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"HIP CUP 59MM ACETABULAR PLASMA SPRAY","SUP-ITM-10269564","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HIP CUP 60G ACETABULAR TRIDENT II TRITANIUM SOLIDBACK","SUP-ITM-10237557","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","AETNA [1001]","HB CH AETNA HMO / PPO","1780.48","58.3","","1634.24","1004.95","1718.99","42","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2229.42","73","","2123.89","1900.92","2123.89","1 through 10","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1780.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1618.62","53","","939.37","939.37","5593.65","1 through 10","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2595.90","85","","2323.25","1864.50","2882.25","16","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3054.00","100","","2909.44","1772.40","10952.08","45","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3054.00","100","","2323.25","2323.25","2323.25","1 through 10","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3054.00","100","","2882.25","1772.40","10169.17","187","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2229.42","73","","1659.41","1659.41","1659.41","1 through 10","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","both","","","3054.00","2290.50","WELLPOINT [1015]","HB CH WELLPOINT","2379.37","77.91","","2050.91","1468.48","2902.83","52","1357.5","3054","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1811.02","59.3","","1548.60","1092.60","3613.79","82","1527","2395.86","percent of total billed charges",""
"HIP IMPLANT 12/14 32MM 9.0MM PINNACLE BIOLOX DELTA CERAMIC TAPERED PLUS","SUP-ITM-10100919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3054.00","2290.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2395.86","78.45","","2085.51","998.68","6202.11","56","1527","2395.86","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","AETNA [1001]","HB CH AETNA HMO / PPO","2852.04","58.3","","1634.24","1004.95","1718.99","42","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3571.16","73","","2123.89","1900.92","2123.89","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2852.04","58.3","","3729.00","1254.19","3729.00","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2592.76","53","","939.37","939.37","5593.65","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4158.20","85","","2323.25","1864.50","2882.25","16","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4892.00","100","","2909.44","1772.40","10952.08","45","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4892.00","100","","2323.25","2323.25","2323.25","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4892.00","100","","2882.25","1772.40","10169.17","187","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3571.16","73","","1659.41","1659.41","1659.41","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","WELLPOINT [1015]","HB CH WELLPOINT","3811.36","77.91","","2050.91","1468.48","2902.83","52","2174.49","4892","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4892.00","3669.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2900.96","59.3","","1548.60","1092.60","3613.79","82","2446","3837.77","percent of total billed charges",""
"HIP IMPLANT 15DEG FEMORAL COMPONENT LPS PROXIMAL TROCHCHANTERIC BODY RT","SUP-ITM-10119727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4892.00","3669.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3837.77","78.45","","2085.51","998.68","6202.11","56","2446","3837.77","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","AETNA [1001]","HB CH AETNA HMO / PPO","4281.55","58.3","","1634.24","1004.95","1718.99","42","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","2123.89","1900.92","2123.89","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4281.55","58.3","","3729.00","1254.19","3729.00","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3892.32","53","","939.37","939.37","5593.65","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6242.40","85","","2323.25","1864.50","2882.25","16","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7344.00","100","","2909.44","1772.40","10952.08","45","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7344.00","100","","2323.25","2323.25","2323.25","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7344.00","100","","2882.25","1772.40","10169.17","187","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","1659.41","1659.41","1659.41","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","WELLPOINT [1015]","HB CH WELLPOINT","5721.71","77.91","","2050.91","1468.48","2902.83","52","3264.41","7344","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4354.99","59.3","","1548.60","1092.60","3613.79","82","3672","5761.37","percent of total billed charges",""
"HIP IMPLANT 18MM STEM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10024934","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5761.37","78.45","","2085.51","998.68","6202.11","56","3672","5761.37","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","AETNA [1001]","HB CH AETNA HMO / PPO","1311.75","58.3","","1634.24","1004.95","1718.99","42","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1642.50","73","","2123.89","1900.92","2123.89","1 through 10","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1311.75","58.3","","3729.00","1254.19","3729.00","1 through 10","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1192.50","53","","939.37","939.37","5593.65","1 through 10","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1912.50","85","","2323.25","1864.50","2882.25","16","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2250.00","100","","2909.44","1772.40","10952.08","45","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2250.00","100","","2323.25","2323.25","2323.25","1 through 10","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2250.00","100","","2882.25","1772.40","10169.17","187","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1642.50","73","","1659.41","1659.41","1659.41","1 through 10","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","WELLPOINT [1015]","HB CH WELLPOINT","1752.98","77.91","","2050.91","1468.48","2902.83","52","1000.13","2250","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","1548.60","1092.60","3613.79","82","1125","1765.13","percent of total billed charges",""
"HIP INSERT 22/36 OR3O DUAL MOBILITY XLPE","SUP-ITM-10280244","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.13","78.45","","2085.51","998.68","6202.11","56","1125","1765.13","percent of total billed charges",""
"Hip Joint Replacement,MINOR","301","DRG","","","","","","","","inpatient","","","41481.09","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","41100.7344","","Fee schedule rate ($41,100.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41100.7344","41100.74","41100.74","1 through 10","15606.47","89444.86","case rate",""
"Hip Joint Replacement,MINOR","301","DRG","","","","","","","","inpatient","","","41481.09","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","43155.5608","","Fee schedule rate ($43,155.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","43155.5608","43155.56","43155.56","1 through 10","15606.47","89444.86","case rate",""
"Hip Joint Replacement,MODERATE","301","DRG","","","","","","","","inpatient","","","52621.93","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","41100.7344","","Fee schedule rate ($42,810.66). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","41100.7344","42810.66","42810.66","1 through 10","15606.47","89444.86","case rate",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","1634.24","1004.95","1718.99","42","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","2123.89","1900.92","2123.89","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","3729.00","1254.19","3729.00","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","939.37","939.37","5593.65","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1861.50","85","","2323.25","1864.50","2882.25","16","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2190.00","100","","2909.44","1772.40","10952.08","45","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2190.00","100","","2323.25","2323.25","2323.25","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2190.00","100","","2882.25","1772.40","10169.17","187","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","1659.41","1659.41","1659.41","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","2050.91","1468.48","2902.83","52","973.46","2190","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1548.60","1092.60","3613.79","82","1095","1718.06","percent of total billed charges",""
"HIP LINER 28X60MM ACETABULAR NEUTRAL CERAMAX CERAMIC","SUP-ITM-10133978","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","2085.51","998.68","6202.11","56","1095","1718.06","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","AETNA [1001]","HB CH AETNA HMO / PPO","2444.32","58.3","","1634.24","1004.95","1718.99","42","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3060.64","73","","2123.89","1900.92","2123.89","1 through 10","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2444.32","58.3","","3729.00","1254.19","3729.00","1 through 10","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2222.11","53","","939.37","939.37","5593.65","1 through 10","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3563.76","85","","2323.25","1864.50","2882.25","16","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4192.66","100","","2909.44","1772.40","10952.08","45","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4192.66","100","","2323.25","2323.25","2323.25","1 through 10","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4192.66","100","","2882.25","1772.40","10169.17","187","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3060.64","73","","1659.41","1659.41","1659.41","1 through 10","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","both","","","4192.66","3144.49","WELLPOINT [1015]","HB CH WELLPOINT","3266.50","77.91","","2050.91","1468.48","2902.83","52","1863.64","4192.66","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4192.66","3144.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","2486.25","59.3","","1548.60","1092.60","3613.79","82","2096.33","3289.14","percent of total billed charges",""
"HIP LINER 36MM E ACETABULAR G7 VIT E +5MM","SUP-ITM-10268726","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4192.66","3144.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3289.14","78.45","","2085.51","998.68","6202.11","56","2096.33","3289.14","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","1634.24","1004.95","1718.99","42","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","2123.89","1900.92","2123.89","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","3729.00","1254.19","3729.00","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","939.37","939.37","5593.65","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1861.50","85","","2323.25","1864.50","2882.25","16","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2190.00","100","","2909.44","1772.40","10952.08","45","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2190.00","100","","2323.25","2323.25","2323.25","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2190.00","100","","2882.25","1772.40","10169.17","187","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","1659.41","1659.41","1659.41","1 through 10","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","2050.91","1468.48","2902.83","52","973.46","2190","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","1548.60","1092.60","3613.79","82","1095","1718.06","percent of total billed charges",""
"HIP LINER 36MM ECIMA TRINITY","SUP-ITM-10100165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","2085.51","998.68","6202.11","56","1095","1718.06","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","AETNA [1001]","HB CH AETNA HMO / PPO","2516.71","58.3","","1634.24","1004.95","1718.99","42","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3151.29","73","","2123.89","1900.92","2123.89","1 through 10","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2516.71","58.3","","3729.00","1254.19","3729.00","1 through 10","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2287.92","53","","939.37","939.37","5593.65","1 through 10","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3669.31","85","","2323.25","1864.50","2882.25","16","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4316.83","100","","2909.44","1772.40","10952.08","45","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4316.83","100","","2323.25","2323.25","2323.25","1 through 10","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4316.83","100","","2882.25","1772.40","10169.17","187","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3151.29","73","","1659.41","1659.41","1659.41","1 through 10","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4316.83","3237.62","WELLPOINT [1015]","HB CH WELLPOINT","3363.24","77.91","","2050.91","1468.48","2902.83","52","1918.83","4316.83","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4316.83","3237.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2559.88","59.3","","1548.60","1092.60","3613.79","82","2158.42","3386.55","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR G7 LONGEVITY +5MM","SUP-ITM-10268836","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4316.83","3237.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3386.55","78.45","","2085.51","998.68","6202.11","56","2158.42","3386.55","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","AETNA [1001]","HB CH AETNA HMO / PPO","640.92","58.3","","1634.24","1004.95","1718.99","42","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","802.53","73","","2123.89","1900.92","2123.89","1 through 10","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","640.92","58.3","","3729.00","1254.19","3729.00","1 through 10","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","582.66","53","","939.37","939.37","5593.65","1 through 10","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","934.45","85","","2323.25","1864.50","2882.25","16","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1099.35","100","","2909.44","1772.40","10952.08","45","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1099.35","100","","2323.25","2323.25","2323.25","1 through 10","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1099.35","100","","2882.25","1772.40","10169.17","187","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","802.53","73","","1659.41","1659.41","1659.41","1 through 10","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","both","","","1099.35","824.51","WELLPOINT [1015]","HB CH WELLPOINT","856.50","77.91","","2050.91","1468.48","2902.83","52","488.66","1099.35","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","651.91","59.3","","1548.60","1092.60","3613.79","82","549.68","862.44","percent of total billed charges",""
"HIP LINER 40MM F ACETABULAR NEUTRAL G7 LONGEVITY","SUP-ITM-10268923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1099.35","824.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","862.44","78.45","","2085.51","998.68","6202.11","56","549.68","862.44","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","AETNA [1001]","HB CH AETNA HMO / PPO","1662.76","58.3","","554.95","91.85","1421.75","94","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2082.01","73","","2490.03","2490.03","2490.03","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1662.76","58.3","","750.00","750.00","750.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1511.60","53","","1192.50","120.84","4149.90","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2424.26","85","","750.00","75.00","750.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2852.07","100","","657.00","121.50","1971.00","14","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2852.07","100","","75.00","75.00","75.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2852.07","100","","366.00","144.00","1971.00","45","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2082.01","73","","667.50","667.50","667.50","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1267.75","44.45","","123.77","123.77","123.77","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","WELLPOINT [1015]","HB CH WELLPOINT","2222.05","77.91","","483.51","229.32","1316.08","96","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1691.28","59.3","","439.50","225.34","1872.27","197","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034631","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2237.45","78.45","","385.32","55.36","1815.62","58","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","AETNA [1001]","HB CH AETNA HMO / PPO","1662.76","58.3","","554.95","91.85","1421.75","94","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2082.01","73","","2490.03","2490.03","2490.03","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1662.76","58.3","","750.00","750.00","750.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1511.60","53","","1192.50","120.84","4149.90","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2424.26","85","","750.00","75.00","750.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2852.07","100","","657.00","121.50","1971.00","14","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2852.07","100","","75.00","75.00","75.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2852.07","100","","366.00","144.00","1971.00","45","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2082.01","73","","667.50","667.50","667.50","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1267.75","44.45","","123.77","123.77","123.77","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","WELLPOINT [1015]","HB CH WELLPOINT","2222.05","77.91","","483.51","229.32","1316.08","96","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1691.28","59.3","","439.50","225.34","1872.27","197","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 130DEG STD BARREL OMEGA3 KEYLESS 130","SUP-ITM-10034671","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2237.45","78.45","","385.32","55.36","1815.62","58","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","AETNA [1001]","HB CH AETNA HMO / PPO","1662.76","58.3","","1634.24","1004.95","1718.99","42","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2082.01","73","","2123.89","1900.92","2123.89","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1662.76","58.3","","3729.00","1254.19","3729.00","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1511.60","53","","939.37","939.37","5593.65","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2424.26","85","","2323.25","1864.50","2882.25","16","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2852.07","100","","2909.44","1772.40","10952.08","45","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2852.07","100","","2323.25","2323.25","2323.25","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2852.07","100","","2882.25","1772.40","10169.17","187","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2082.01","73","","1659.41","1659.41","1659.41","1 through 10","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","both","","","2852.07","2139.05","WELLPOINT [1015]","HB CH WELLPOINT","2222.05","77.91","","2050.91","1468.48","2902.83","52","1267.75","2852.07","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1691.28","59.3","","1548.60","1092.60","3613.79","82","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE 79MM 4 HOLE 135DEG OMEGA3 KEYED SS STD BARREL","SUP-ITM-10034639","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2852.07","2139.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2237.45","78.45","","2085.51","998.68","6202.11","56","1426.04","2237.45","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","AETNA [1001]","HB CH AETNA HMO / PPO","1314.48","58.3","","1634.24","1004.95","1718.99","42","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1645.92","73","","2123.89","1900.92","2123.89","1 through 10","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1314.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1194.98","53","","939.37","939.37","5593.65","1 through 10","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1916.48","85","","2323.25","1864.50","2882.25","16","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2254.68","100","","2909.44","1772.40","10952.08","45","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2254.68","100","","2323.25","2323.25","2323.25","1 through 10","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2254.68","100","","2882.25","1772.40","10169.17","187","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1645.92","73","","1659.41","1659.41","1659.41","1 through 10","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","both","","","2254.68","1691.01","WELLPOINT [1015]","HB CH WELLPOINT","1756.62","77.91","","2050.91","1468.48","2902.83","52","1002.21","2254.68","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2254.68","1691.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","1337.03","59.3","","1548.60","1092.60","3613.79","82","1127.34","1768.8","percent of total billed charges",""
"HIP PLATE SHORT 4 HOLE 130DEG BARREL KEYED OMEGA3","SUP-ITM-10034711","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2254.68","1691.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1768.80","78.45","","2085.51","998.68","6202.11","56","1127.34","1768.8","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","AETNA [1001]","HB CH AETNA HMO / PPO","4562.56","58.3","","1634.24","1004.95","1718.99","42","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","2123.89","1900.92","2123.89","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4562.56","58.3","","3729.00","1254.19","3729.00","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4147.78","53","","939.37","939.37","5593.65","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6652.10","85","","2323.25","1864.50","2882.25","16","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7826.00","100","","2909.44","1772.40","10952.08","45","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7826.00","100","","2323.25","2323.25","2323.25","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7826.00","100","","2882.25","1772.40","10169.17","187","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","1659.41","1659.41","1659.41","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","WELLPOINT [1015]","HB CH WELLPOINT","6097.24","77.91","","2050.91","1468.48","2902.83","52","3478.66","7826","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1548.60","1092.60","3613.79","82","3913","6139.5","percent of total billed charges",""
"HIP POST 14DEG FEMORAL COMPONENT PROXIMALIMAL TROCHANTER ANTEVERTED RIGHT","SUP-ITM-10035511","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6139.50","78.45","","2085.51","998.68","6202.11","56","3913","6139.5","percent of total billed charges",""
"Hip Replacement With Principal Diagnosis Of Hip Fracture With McC","521","MS-DRG","","","","","","","","inpatient","","","110701.20","83025.90","MEDICARE [2001]","HB BWF MEDICARE","29293.19","","Case rate ($29,293.19). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $26,809.59, add-ons for qualifying new technology services are included. If operating cost exceeds $72,333.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,589.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,924.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $26,470.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,029.12. The transfer capital threshold is the transfer adjustment factor * $2,029.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","29233.39","29233.39","29233.39","1 through 10","26231.18","29293.19","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","69473.06","52104.79","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","20433.04","","Case rate ($19,837.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,869.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,393.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,057.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,001.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,530.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.13. The transfer capital threshold is the transfer adjustment factor * $1,497.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","20024.10","20024.10","20024.10","1 through 10","19441.14","21702.14","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","69473.06","52104.79","FALLON HEALTH [1008]","HB BWF MEDICARE","21702.14","","Case rate ($21,702.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,869.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,393.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,057.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,865.76 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,530.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.13. The transfer capital threshold is the transfer adjustment factor * $1,497.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","19432.94","19432.94","19432.94","1 through 10","19441.14","21702.14","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","69473.06","52104.79","MEDICARE [2001]","HB BWF MEDICARE","21702.14","","Case rate ($21,702.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,869.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,393.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,057.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $19,865.76 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,530.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.13. The transfer capital threshold is the transfer adjustment factor * $1,497.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","21212.99","21071.62","21212.99","1 through 10","19441.14","21702.14","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","69473.06","52104.79","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","19441.14","","Case rate ($19,837.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,869.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,393.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,057.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,001.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,530.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.13. The transfer capital threshold is the transfer adjustment factor * $1,497.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19048.31","19048.31","19048.31","1 through 10","19441.14","21702.14","other","Inpatient DRG"
"Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC","522","MS-DRG","","","","","","","","inpatient","","","69473.06","52104.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","19441.14","","Case rate ($19,837.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,869.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,393.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,057.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,001.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,530.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,497.13. The transfer capital threshold is the transfer adjustment factor * $1,497.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","19079.32","19079.32","19079.32","1 through 10","19441.14","21702.14","other","Inpatient DRG"
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"HIP STEM 10INX22.5MM 12/14 TAPER LG STATURE SOLUTION SYSTEM POROUS BOWED LT","SUP-ITM-10119469","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"HIP STEM 11MM DIAMETER SIZE 7 127DEG IMPLANT PRIMARY SECUR FIT PLUS MAX ANGLED 01","SUP-ITM-10016578","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1634.24","1004.95","1718.99","42","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","2123.89","1900.92","2123.89","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","939.37","939.37","5593.65","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3681.56","85","","2323.25","1864.50","2882.25","16","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4331.25","100","","2909.44","1772.40","10952.08","45","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4331.25","100","","2323.25","2323.25","2323.25","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4331.25","100","","2882.25","1772.40","10169.17","187","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","1659.41","1659.41","1659.41","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","2050.91","1468.48","2902.83","52","1925.24","4331.25","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1548.60","1092.60","3613.79","82","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 11X142MM TAPERLOC PPS COATED COMPLETE REDUCED STANDARD OFFSET","SUP-ITM-10115050","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","2085.51","998.68","6202.11","56","2165.63","3397.87","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1634.24","1004.95","1718.99","42","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2123.89","1900.92","2123.89","1 through 10","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","3729.00","1254.19","3729.00","1 through 10","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","939.37","939.37","5593.65","1 through 10","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","2323.25","1864.50","2882.25","16","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","2909.44","1772.40","10952.08","45","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","2323.25","2323.25","2323.25","1 through 10","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","2882.25","1772.40","10169.17","187","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","1659.41","1659.41","1659.41","1 through 10","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","2050.91","1468.48","2902.83","52","33.34","75","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1548.60","1092.60","3613.79","82","37.5","58.84","percent of total billed charges",""
"HIP STEM 12MM MD OMNIFIT ACCOLADE CENTRALIZER SPACER RING STYLE","SUP-ITM-10028278","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","2085.51","998.68","6202.11","56","37.5","58.84","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2915.00","58.3","","1634.24","1004.95","1718.99","42","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","2123.89","1900.92","2123.89","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2915.00","58.3","","3729.00","1254.19","3729.00","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.00","53","","939.37","939.37","5593.65","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4250.00","85","","2323.25","1864.50","2882.25","16","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5000.00","100","","2909.44","1772.40","10952.08","45","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5000.00","100","","2323.25","2323.25","2323.25","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5000.00","100","","2882.25","1772.40","10169.17","187","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","1659.41","1659.41","1659.41","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB CH WELLPOINT","3895.50","77.91","","2050.91","1468.48","2902.83","52","2222.5","5000","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.00","59.3","","1548.60","1092.60","3613.79","82","2500","3922.5","percent of total billed charges",""
"HIP STEM 12X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10015331","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3922.50","78.45","","2085.51","998.68","6202.11","56","2500","3922.5","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","AETNA [1001]","HB CH AETNA HMO / PPO","4281.55","58.3","","1634.24","1004.95","1718.99","42","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","2123.89","1900.92","2123.89","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4281.55","58.3","","3729.00","1254.19","3729.00","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3892.32","53","","939.37","939.37","5593.65","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6242.40","85","","2323.25","1864.50","2882.25","16","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7344.00","100","","2909.44","1772.40","10952.08","45","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7344.00","100","","2323.25","2323.25","2323.25","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7344.00","100","","2882.25","1772.40","10169.17","187","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","1659.41","1659.41","1659.41","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","WELLPOINT [1015]","HB CH WELLPOINT","5721.71","77.91","","2050.91","1468.48","2902.83","52","3264.41","7344","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4354.99","59.3","","1548.60","1092.60","3613.79","82","3672","5761.37","percent of total billed charges",""
"HIP STEM 12X150MM FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10035524","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5761.37","78.45","","2085.51","998.68","6202.11","56","3672","5761.37","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","AETNA [1001]","HB CH AETNA HMO / PPO","2203.74","58.3","","1634.24","1004.95","1718.99","42","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2759.40","73","","2123.89","1900.92","2123.89","1 through 10","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2203.74","58.3","","3729.00","1254.19","3729.00","1 through 10","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2003.40","53","","939.37","939.37","5593.65","1 through 10","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3213.00","85","","2323.25","1864.50","2882.25","16","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3780.00","100","","2909.44","1772.40","10952.08","45","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3780.00","100","","2323.25","2323.25","2323.25","1 through 10","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3780.00","100","","2882.25","1772.40","10169.17","187","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2759.40","73","","1659.41","1659.41","1659.41","1 through 10","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","both","","","3780.00","2835.00","WELLPOINT [1015]","HB CH WELLPOINT","2945.00","77.91","","2050.91","1468.48","2902.83","52","1680.21","3780","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2241.54","59.3","","1548.60","1092.60","3613.79","82","1890","2965.41","percent of total billed charges",""
"HIP STEM 130MM SZ 4 FEMORAL CPT PRIMARY COBALT ALLOY CEMENTED COLLARLESS EXTENDED 12 14 TAPER 02","SUP-ITM-10191803","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3780.00","2835.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2965.41","78.45","","2085.51","998.68","6202.11","56","1890","2965.41","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2915.00","58.3","","1634.24","1004.95","1718.99","42","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","2123.89","1900.92","2123.89","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2915.00","58.3","","3729.00","1254.19","3729.00","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.00","53","","939.37","939.37","5593.65","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4250.00","85","","2323.25","1864.50","2882.25","16","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5000.00","100","","2909.44","1772.40","10952.08","45","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5000.00","100","","2323.25","2323.25","2323.25","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5000.00","100","","2882.25","1772.40","10169.17","187","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","1659.41","1659.41","1659.41","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB CH WELLPOINT","3895.50","77.91","","2050.91","1468.48","2902.83","52","2222.5","5000","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.00","59.3","","1548.60","1092.60","3613.79","82","2500","3922.5","percent of total billed charges",""
"HIP STEM 13X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10022591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3922.50","78.45","","2085.51","998.68","6202.11","56","2500","3922.5","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"HIP STEM 148X34MM SZ 10 132DEG SECUR FIT ADVANCED 132 NECK ANGLE V40 01","SUP-ITM-10166386","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"HIP STEM 14MM X 115MM CONICAL DISTAL","SUP-ITM-10303394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"HIP STEM 14X150MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10016703","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","AETNA [1001]","HB CH AETNA HMO / PPO","2852.04","58.3","","1634.24","1004.95","1718.99","42","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3571.16","73","","2123.89","1900.92","2123.89","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2852.04","58.3","","3729.00","1254.19","3729.00","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2592.76","53","","939.37","939.37","5593.65","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4158.20","85","","2323.25","1864.50","2882.25","16","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4892.00","100","","2909.44","1772.40","10952.08","45","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4892.00","100","","2323.25","2323.25","2323.25","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4892.00","100","","2882.25","1772.40","10169.17","187","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3571.16","73","","1659.41","1659.41","1659.41","1 through 10","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","both","","","4892.00","3669.00","WELLPOINT [1015]","HB CH WELLPOINT","3811.36","77.91","","2050.91","1468.48","2902.83","52","2174.49","4892","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4892.00","3669.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2900.96","59.3","","1548.60","1092.60","3613.79","82","2446","3837.77","percent of total billed charges",""
"HIP STEM 15DEG FEMORAL LBS TITANIUM PROXIMAL STANDARD BODY RT","SUP-ITM-10018016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4892.00","3669.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3837.77","78.45","","2085.51","998.68","6202.11","56","2446","3837.77","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","AETNA [1001]","HB CH AETNA HMO / PPO","4281.55","58.3","","1634.24","1004.95","1718.99","42","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","2123.89","1900.92","2123.89","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4281.55","58.3","","3729.00","1254.19","3729.00","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3892.32","53","","939.37","939.37","5593.65","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6242.40","85","","2323.25","1864.50","2882.25","16","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7344.00","100","","2909.44","1772.40","10952.08","45","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7344.00","100","","2323.25","2323.25","2323.25","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7344.00","100","","2882.25","1772.40","10169.17","187","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","1659.41","1659.41","1659.41","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","WELLPOINT [1015]","HB CH WELLPOINT","5721.71","77.91","","2050.91","1468.48","2902.83","52","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4354.99","59.3","","1548.60","1092.60","3613.79","82","3672","5761.37","percent of total billed charges",""
"HIP STEM 15MM FEMORAL PRESS FIT INTRAMEDULLARY STRAIGHT FLUTED","SUP-ITM-10018094","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5761.37","78.45","","2085.51","998.68","6202.11","56","3672","5761.37","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","AETNA [1001]","HB CH AETNA HMO / PPO","4281.55","58.3","","1634.24","1004.95","1718.99","42","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","2123.89","1900.92","2123.89","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4281.55","58.3","","3729.00","1254.19","3729.00","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3892.32","53","","939.37","939.37","5593.65","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6242.40","85","","2323.25","1864.50","2882.25","16","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7344.00","100","","2909.44","1772.40","10952.08","45","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7344.00","100","","2323.25","2323.25","2323.25","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7344.00","100","","2882.25","1772.40","10169.17","187","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5361.12","73","","1659.41","1659.41","1659.41","1 through 10","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","both","","","7344.00","5508.00","WELLPOINT [1015]","HB CH WELLPOINT","5721.71","77.91","","2050.91","1468.48","2902.83","52","3264.41","7344","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4354.99","59.3","","1548.60","1092.60","3613.79","82","3672","5761.37","percent of total billed charges",""
"HIP STEM 15MMX200 LONG FEMORAL PRESS FIT INTRAMEDULLARY TOTAL BOWED","SUP-ITM-10029861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7344.00","5508.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5761.37","78.45","","2085.51","998.68","6202.11","56","3672","5761.37","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2915.00","58.3","","1634.24","1004.95","1718.99","42","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","2123.89","1900.92","2123.89","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2915.00","58.3","","3729.00","1254.19","3729.00","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.00","53","","939.37","939.37","5593.65","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4250.00","85","","2323.25","1864.50","2882.25","16","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5000.00","100","","2909.44","1772.40","10952.08","45","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5000.00","100","","2323.25","2323.25","2323.25","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5000.00","100","","2882.25","1772.40","10169.17","187","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","1659.41","1659.41","1659.41","1 through 10","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB CH WELLPOINT","3895.50","77.91","","2050.91","1468.48","2902.83","52","2222.5","5000","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.00","59.3","","1548.60","1092.60","3613.79","82","2500","3922.5","percent of total billed charges",""
"HIP STEM 15X125MM FEMORAL LPS COBALT CHROMIUM CEMENTED STRAIGHT","SUP-ITM-10016769","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3922.50","78.45","","2085.51","998.68","6202.11","56","2500","3922.5","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","AETNA [1001]","HB CH AETNA HMO / PPO","4757.28","58.3","","1634.24","1004.95","1718.99","42","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5956.80","73","","2123.89","1900.92","2123.89","1 through 10","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4757.28","58.3","","3729.00","1254.19","3729.00","1 through 10","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4324.80","53","","939.37","939.37","5593.65","1 through 10","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6936.00","85","","2323.25","1864.50","2882.25","16","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8160.00","100","","2909.44","1772.40","10952.08","45","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8160.00","100","","2323.25","2323.25","2323.25","1 through 10","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8160.00","100","","2882.25","1772.40","10169.17","187","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5956.80","73","","1659.41","1659.41","1659.41","1 through 10","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","both","","","8160.00","6120.00","WELLPOINT [1015]","HB CH WELLPOINT","6357.46","77.91","","2050.91","1468.48","2902.83","52","3627.12","8160","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8160.00","6120.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4838.88","59.3","","1548.60","1092.60","3613.79","82","4080","6401.52","percent of total billed charges",""
"HIP STEM 16.5X125MM FEMORAL LPS COBALT CHROMIUM POROUS STRAIGHT","SUP-ITM-10026985","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8160.00","6120.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6401.52","78.45","","2085.51","998.68","6202.11","56","4080","6401.52","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"HIP STEM 17.5X150MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10100980","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","AETNA [1001]","HB CH AETNA HMO / PPO","3688.82","58.3","","1634.24","1004.95","1718.99","42","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4618.93","73","","2123.89","1900.92","2123.89","1 through 10","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3688.82","58.3","","3729.00","1254.19","3729.00","1 through 10","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3353.47","53","","939.37","939.37","5593.65","1 through 10","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5378.21","85","","2323.25","1864.50","2882.25","16","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6327.30","100","","2909.44","1772.40","10952.08","45","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6327.30","100","","2323.25","2323.25","2323.25","1 through 10","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6327.30","100","","2882.25","1772.40","10169.17","187","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4618.93","73","","1659.41","1659.41","1659.41","1 through 10","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","both","","","6327.30","4745.47","WELLPOINT [1015]","HB CH WELLPOINT","4929.60","77.91","","2050.91","1468.48","2902.83","52","2812.48","6327.3","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","3752.09","59.3","","1548.60","1092.60","3613.79","82","3163.65","4963.77","percent of total billed charges",""
"HIP STEM 17X190MM 135DEG FEMORAL WAGNER SL REVISION PROTASUL 100 TITANIUM ALLOY GRIT BLASTED 12 14 TAPER","SUP-ITM-10115576","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6327.30","4745.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4963.77","78.45","","2085.51","998.68","6202.11","56","3163.65","4963.77","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"HIP STEM 17X200MM FEMORAL LPS COBALT CHROMIUM CEMENTED BOWED","SUP-ITM-10077607","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"HIP STEM 18.5X200MM FEMORAL LPS COBALT CHROMIUM POROUS BOWED","SUP-ITM-10046822","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"HIP STEM 27X93 28MM SIZE 0 132DEG FEMORAL ACCOLADE II 01","SUP-ITM-10100419","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"HIP STEM 30X130MM SIZE 7 127DEG PROSTHESIS SECUR FIT MAX PRIMARY ANGLED","SUP-ITM-10016785","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 OMNIFIT CEMENTED LEFT","SUP-ITM-10034827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"HIP STEM 30X200MM LONG SIZE 7 STR OMNIFIT CEMENTED 7 RT 03","SUP-ITM-10016599","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HIP STEM 30X36 140MM SIZE 8 132DEG STR OMNIFIT HFX 23A","SUP-ITM-10005201","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1634.24","1004.95","1718.99","42","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","2123.89","1900.92","2123.89","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2404.88","58.3","","3729.00","1254.19","3729.00","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","939.37","939.37","5593.65","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3506.25","85","","2323.25","1864.50","2882.25","16","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4125.00","100","","2909.44","1772.40","10952.08","45","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4125.00","100","","2323.25","2323.25","2323.25","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4125.00","100","","2882.25","1772.40","10169.17","187","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","1659.41","1659.41","1659.41","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","2050.91","1468.48","2902.83","52","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1548.60","1092.60","3613.79","82","2062.5","3236.06","percent of total billed charges",""
"HIP STEM 36.5MM SZ 11 127DEG COLLARED","SUP-ITM-10269535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","2085.51","998.68","6202.11","56","2062.5","3236.06","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1634.24","1004.95","1718.99","42","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","2123.89","1900.92","2123.89","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2404.88","58.3","","3729.00","1254.19","3729.00","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","939.37","939.37","5593.65","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3506.25","85","","2323.25","1864.50","2882.25","16","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4125.00","100","","2909.44","1772.40","10952.08","45","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4125.00","100","","2323.25","2323.25","2323.25","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4125.00","100","","2882.25","1772.40","10169.17","187","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","1659.41","1659.41","1659.41","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","2050.91","1468.48","2902.83","52","1833.56","4125","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1548.60","1092.60","3613.79","82","2062.5","3236.06","percent of total billed charges",""
"HIP STEM 36.5MM SZ 15 127DEG COLLARED","SUP-ITM-10269548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","2085.51","998.68","6202.11","56","2062.5","3236.06","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X140MM SIZE 8 127DEG FEMORAL SECUR FIT MAX HYDROXYAPATITE","SUP-ITM-10017579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"HIP STEM 40X47 170 13.5MM SIZE 11 132DEG STR SECUR FIT MAX NECK ANGLE 11 01","SUP-ITM-10016587","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HIP STEM 44MM 200 LONG SIZE 3 FEMORAL EXETER V40 OFFSET 0580-1-200","SUP-ITM-10034603","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","1634.24","1004.95","1718.99","42","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","2123.89","1900.92","2123.89","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2404.88","58.3","","3729.00","1254.19","3729.00","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","939.37","939.37","5593.65","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3506.25","85","","2323.25","1864.50","2882.25","16","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4125.00","100","","2909.44","1772.40","10952.08","45","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4125.00","100","","2323.25","2323.25","2323.25","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4125.00","100","","2882.25","1772.40","10169.17","187","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","1659.41","1659.41","1659.41","1 through 10","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","2050.91","1468.48","2902.83","52","1833.56","4125","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","1548.60","1092.60","3613.79","82","2062.5","3236.06","percent of total billed charges",""
"HIP STEM FEMORAL 36MM 15X20 165 PLUS 12 IMPLANT TAPER SROM STANDARD LATERAL NECK 03","SUP-ITM-10016595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","2085.51","998.68","6202.11","56","2062.5","3236.06","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","AETNA [1001]","HB CH AETNA HMO / PPO","4562.56","58.3","","1634.24","1004.95","1718.99","42","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","2123.89","1900.92","2123.89","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4562.56","58.3","","3729.00","1254.19","3729.00","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4147.78","53","","939.37","939.37","5593.65","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6652.10","85","","2323.25","1864.50","2882.25","16","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7826.00","100","","2909.44","1772.40","10952.08","45","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7826.00","100","","2323.25","2323.25","2323.25","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7826.00","100","","2882.25","1772.40","10169.17","187","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","1659.41","1659.41","1659.41","1 through 10","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","WELLPOINT [1015]","HB CH WELLPOINT","6097.24","77.91","","2050.91","1468.48","2902.83","52","3478.66","7826","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1548.60","1092.60","3613.79","82","3913","6139.5","percent of total billed charges",""
"HIP STEM FEMORAL KNEE COMPONENT PROXIMALIMAL TROCHANTERIC NEUTRAL","SUP-ITM-10018902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6139.50","78.45","","2085.51","998.68","6202.11","56","3913","6139.5","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","AETNA [1001]","HB CH AETNA HMO / PPO","2740.10","58.3","","1634.24","1004.95","1718.99","42","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","2123.89","1900.92","2123.89","1 through 10","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2740.10","58.3","","3729.00","1254.19","3729.00","1 through 10","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2491.00","53","","939.37","939.37","5593.65","1 through 10","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3995.00","85","","2323.25","1864.50","2882.25","16","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4700.00","100","","2909.44","1772.40","10952.08","45","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4700.00","100","","2323.25","2323.25","2323.25","1 through 10","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4700.00","100","","2882.25","1772.40","10169.17","187","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","1659.41","1659.41","1659.41","1 through 10","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","WELLPOINT [1015]","HB CH WELLPOINT","3661.77","77.91","","2050.91","1468.48","2902.83","52","2089.15","4700","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2787.10","59.3","","1548.60","1092.60","3613.79","82","2350","3687.15","percent of total billed charges",""
"HIP STEM L 40MM FEMORAL GMRS RECONSTRUCTION EXTENSION PC DISTAL","SUP-ITM-10017463","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3687.15","78.45","","2085.51","998.68","6202.11","56","2350","3687.15","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"HIP STEM SZ 1 125X35MM 130DEG FEMORAL SUMMIT POROCOAT TITANIUM HYDROXYAPATITE TAPERED HIGH OFFSET CEMENTLESS","SUP-ITM-10020393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 1 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"HIP STEM SZ 12 125DEG CORAIL AMT HA COATED STD COLLAR FEMORAL","SUP-ITM-10285159","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","AETNA [1001]","HB CH AETNA HMO / PPO","2727.27","58.3","","1634.24","1004.95","1718.99","42","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","2123.89","1900.92","2123.89","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2727.27","58.3","","3729.00","1254.19","3729.00","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2479.34","53","","939.37","939.37","5593.65","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3976.30","85","","2323.25","1864.50","2882.25","16","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4678.00","100","","2909.44","1772.40","10952.08","45","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4678.00","100","","2323.25","2323.25","2323.25","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4678.00","100","","2882.25","1772.40","10169.17","187","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3414.94","73","","1659.41","1659.41","1659.41","1 through 10","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4678.00","3508.50","WELLPOINT [1015]","HB CH WELLPOINT","3644.63","77.91","","2050.91","1468.48","2902.83","52","2079.37","4678","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2774.05","59.3","","1548.60","1092.60","3613.79","82","2339","3669.89","percent of total billed charges",""
"HIP STEM SZ 17 190MM REDAPT TITANIUM SLEEVELESS MONOLITHIC STANDARD OFFSET","SUP-ITM-10284731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4678.00","3508.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3669.89","78.45","","2085.51","998.68","6202.11","56","2339","3669.89","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"HIP STEM SZ 2 130X32MM 130DEG FEMORAL SUMMIT DUOFIX TITANIUM HYDROXYAPATITE TAPERED STANDARD OFFSET CEMENTLESS","SUP-ITM-10012987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","AETNA [1001]","HB CH AETNA HMO / PPO","1974.62","58.3","","1634.24","1004.95","1718.99","42","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2472.51","73","","2123.89","1900.92","2123.89","1 through 10","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1974.62","58.3","","3729.00","1254.19","3729.00","1 through 10","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1795.11","53","","939.37","939.37","5593.65","1 through 10","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2878.95","85","","2323.25","1864.50","2882.25","16","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3387.00","100","","2909.44","1772.40","10952.08","45","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3387.00","100","","2323.25","2323.25","2323.25","1 through 10","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3387.00","100","","2882.25","1772.40","10169.17","187","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2472.51","73","","1659.41","1659.41","1659.41","1 through 10","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","both","","","3387.00","2540.25","WELLPOINT [1015]","HB CH WELLPOINT","2638.81","77.91","","2050.91","1468.48","2902.83","52","1505.52","3387","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3387.00","2540.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2008.49","59.3","","1548.60","1092.60","3613.79","82","1693.5","2657.1","percent of total billed charges",""
"HIP STEM SZ 2 96X35MM FEMORAL SUMMIT BASIC COBALT ALLOY POROUS CEMENTED TAPERED","SUP-ITM-10013049","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3387.00","2540.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2657.10","78.45","","2085.51","998.68","6202.11","56","1693.5","2657.1","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1634.24","1004.95","1718.99","42","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","2123.89","1900.92","2123.89","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","939.37","939.37","5593.65","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3681.56","85","","2323.25","1864.50","2882.25","16","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4331.25","100","","2909.44","1772.40","10952.08","45","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4331.25","100","","2323.25","2323.25","2323.25","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4331.25","100","","2882.25","1772.40","10169.17","187","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","1659.41","1659.41","1659.41","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","2050.91","1468.48","2902.83","52","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1548.60","1092.60","3613.79","82","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 4 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238595","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","2085.51","998.68","6202.11","56","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 5 ACTIS COLLARLESS HIGH","SUP-ITM-10320000","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1634.24","1004.95","1718.99","42","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","2123.89","1900.92","2123.89","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","939.37","939.37","5593.65","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3681.56","85","","2323.25","1864.50","2882.25","16","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4331.25","100","","2909.44","1772.40","10952.08","45","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4331.25","100","","2323.25","2323.25","2323.25","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4331.25","100","","2882.25","1772.40","10169.17","187","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","1659.41","1659.41","1659.41","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","2050.91","1468.48","2902.83","52","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1548.60","1092.60","3613.79","82","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","2085.51","998.68","6202.11","56","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"HIP STEM SZ 5 HIGH OFFSET INSIGNIA COLLARED","SUP-ITM-10295247","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1634.24","1004.95","1718.99","42","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","2123.89","1900.92","2123.89","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","939.37","939.37","5593.65","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3681.56","85","","2323.25","1864.50","2882.25","16","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4331.25","100","","2909.44","1772.40","10952.08","45","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4331.25","100","","2323.25","2323.25","2323.25","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4331.25","100","","2882.25","1772.40","10169.17","187","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","1659.41","1659.41","1659.41","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","2050.91","1468.48","2902.83","52","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1548.60","1092.60","3613.79","82","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 6 AVENIR COMPLETE HA STD COLLAR","SUP-ITM-10238593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","2085.51","998.68","6202.11","56","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1634.24","1004.95","1718.99","42","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","2123.89","1900.92","2123.89","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","939.37","939.37","5593.65","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3681.56","85","","2323.25","1864.50","2882.25","16","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4331.25","100","","2909.44","1772.40","10952.08","45","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4331.25","100","","2323.25","2323.25","2323.25","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4331.25","100","","2882.25","1772.40","10169.17","187","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","1659.41","1659.41","1659.41","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","2050.91","1468.48","2902.83","52","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1548.60","1092.60","3613.79","82","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA HO COLLAR","SUP-ITM-10238579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","2085.51","998.68","6202.11","56","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","AETNA [1001]","HB CH AETNA HMO / PPO","2525.12","58.3","","1634.24","1004.95","1718.99","42","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","2123.89","1900.92","2123.89","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2525.12","58.3","","3729.00","1254.19","3729.00","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2295.56","53","","939.37","939.37","5593.65","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3681.56","85","","2323.25","1864.50","2882.25","16","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4331.25","100","","2909.44","1772.40","10952.08","45","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4331.25","100","","2323.25","2323.25","2323.25","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4331.25","100","","2882.25","1772.40","10169.17","187","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3161.81","73","","1659.41","1659.41","1659.41","1 through 10","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","both","","","4331.25","3248.44","WELLPOINT [1015]","HB CH WELLPOINT","3374.48","77.91","","2050.91","1468.48","2902.83","52","1925.24","4331.25","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2568.43","59.3","","1548.60","1092.60","3613.79","82","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 6.5 AVENIR COMPLETE HA VARIANCE COLLAR","SUP-ITM-10238567","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4331.25","3248.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3397.87","78.45","","2085.51","998.68","6202.11","56","2165.63","3397.87","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"HIP STEM SZ 9 ACTIS DUOFIX COLLARED CEMENTLESS HIGH OFFSET","SUP-ITM-10197794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"Histoplasma Antibody","PX-30000950","CDM","86698","CPT","0302","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","61.24","61.24","61.24","1 through 10","13.51","81.03","percent of total billed charges",""
"Hiv With Major Hiv Related Condition,MAJOR","892","DRG","","","","","","","","inpatient","","","25878.27","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11749.23","","Case rate ($12,990.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,420.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12987.61","12987.61","12987.61","1 through 10","8710.54","43735.76","case rate",""
"Hiv With Major Hiv Related Condition,MAJOR","892","DRG","","","","","","","","inpatient","","","25878.27","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11749.23","","Case rate ($12,990.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,420.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12987.61","12987.61","12987.61","1 through 10","8710.54","43735.76","case rate",""
"Hiv With Major Related Condition Without Cc/McC","976","MS-DRG","","","","","","","","inpatient","","","22519.25","16889.44","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8477.80","","Case rate ($8,650.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,664.37, add-ons for qualifying new technology services are included. If operating cost exceeds $54,188.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,198.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,673.41 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,325.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $638.17. The transfer capital threshold is the transfer adjustment factor * $638.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9222.64","9222.64","9222.64","1 through 10","8477.8","9266.22","other","Inpatient DRG"
"Hiv With Multiple Major Hiv Related Conditions,EXTREME","890","DRG","","","","","","","","inpatient","","","57345.21","","MASSHEALTH [3001]","HB BWF MEDICAID","29452.48","","Case rate ($32,564.78). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $74,994.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","24005.01","24005.01","24005.01","1 through 10","15413.94","137011.2","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,EXTREME","890","DRG","","","","","","","","inpatient","","","57345.21","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","29452.48","","Case rate ($32,564.78). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $74,994.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","32556.79","32556.79","32556.79","1 through 10","15413.94","137011.2","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,MAJOR","890","DRG","","","","","","","","inpatient","","","88817.26","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","15413.94","","Case rate ($17,042.77). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,472.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,570.76 and the sum of the standard inlier and any outlier amount.","17038.58","17038.58","17038.58","1 through 10","15413.94","137011.2","case rate",""
"Hiv With Multiple Major Hiv Related Conditions,MAJOR","890","DRG","","","","","","","","inpatient","","","88817.26","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","15413.94","","Case rate ($17,042.77). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,472.77, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,570.76 and the sum of the standard inlier and any outlier amount.","17038.58","17038.58","17038.58","1 through 10","15413.94","137011.2","case rate",""
"Hiv With One Significant Hiv Condition Or Without Significant Related Conditions,MAJOR","894","DRG","","","","","","","","inpatient","","","14085.99","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12351.26","","Case rate ($13,656.44). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,086.44, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13653.09","13653.09","13653.09","1 through 10","172.44","35116.94","case rate",""
"Hiv With One Significant Hiv Condition Or Without Significant Related Conditions,MODERATE","894","DRG","","","","","","","","inpatient","","","16027.54","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8114.23","","Case rate ($8,971.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,401.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8969.47","8969.47","8969.47","1 through 10","172.44","35116.94","case rate",""
"Hiv With Or Without Other Related Condition","977","MS-DRG","","","","","","","","inpatient","","","25592.23","19194.17","MEDICARE [2001]","HB BWF MEDICARE","13430.16","","Case rate ($13,430.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,307.24, add-ons for qualifying new technology services are included. If operating cost exceeds $57,830.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,478.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $12,173.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,968.00 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $917.42. The transfer capital threshold is the transfer adjustment factor * $917.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14491.97","14491.97","14491.97","1 through 10","12042.02","13430.16","other","Inpatient DRG"
"Hiv-1/Hiv-2 Antibody Single Result","PX-30000954","CDM","86703","CPT","0302","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","70.88","70.88","70.88","54","13.44","94.17","percent of total billed charges",""
"Hiv-1/Hiv-2 Antibody Single Result","PX-30000954","CDM","86703","CPT","0302","RC","","","","both","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.37","53","","66.25","66.25","66.25","1 through 10","13.44","94.17","percent of total billed charges",""
"Hiv-1/Hiv-2 Antibody Single Result","PX-30000954","CDM","86703","CPT","0302","RC","","","","both","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.34","44.45","","96.10","56.95","96.10","1 through 10","13.44","94.17","percent of total billed charges",""
"Hiv-1/Hiv-2 Antibody Single Result","PX-30000954","CDM","86703","CPT","0302","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","73.25","73.25","219.75","56","10.89","101.2","percent of total billed charges",""
"Hiv-1/Hiv-2 Antibody Single Result","PX-30000954","CDM","86703","CPT","0302","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","96.10","56.95","96.10","52","10.89","101.2","percent of total billed charges",""
"Hla Typing II Low Res 1 Locus Ea","PX-30000764","CDM","81376","CPT","0310","RC","","","","outpatient","","","985.00","738.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","772.73","78.45","","736.51","736.51","736.51","1 through 10","372.03","772.73","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","both","","","211.00","158.25","AETNA [1001]","HB CH AETNA HMO / PPO","123.01","58.3","","116.24","116.24","116.24","1 through 10","25.29","154.03","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","211.00","158.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.12","59.3","","120.13","120.13","120.13","1 through 10","26.61","165.53","percent of total billed charges",""
"Hla Typing Single Antigen a/B/C","PX-30001020","CDM","86812","CPT","0302","RC","","","","outpatient","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","165.53","78.45","","157.60","93.40","157.60","1 through 10","26.61","165.53","percent of total billed charges",""
"Ho W/O Joints Custom T1","PX-27000499","CDM","L3919","HCPCS","0274","RC","","","","both","","","217.84","163.38","AETNA [1001]","HB CH AETNA HMO / PPO","127.00","58.3","","123.52","123.52","123.52","1 through 10","115.46","873.78","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Home Hospital Observation per Hour","PX-76200013","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","196.00","147.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.23","59.3","","111.93","111.93","111.93","1 through 10","17.39","153.76","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","196.00","147.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","116.23","59.3","","111.93","111.93","111.93","1 through 10","17.39","153.76","percent of total billed charges",""
"Homocystine","PX-30000513","CDM","83090","CPT","0301","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","153.76","78.45","","146.84","146.84","146.84","1 through 10","17.39","153.76","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","AETNA [1001]","HB CH AETNA HMO / PPO","2208.28","58.3","","554.95","91.85","1421.75","94","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","2490.03","2490.03","2490.03","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2208.28","58.3","","750.00","750.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.52","53","","1192.50","120.84","4149.90","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.61","85","","750.00","75.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.78","100","","657.00","121.50","1971.00","14","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.78","100","","75.00","75.00","75.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.78","100","","366.00","144.00","1971.00","45","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","667.50","667.50","667.50","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.67","44.45","","123.77","123.77","123.77","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","WELLPOINT [1015]","HB CH WELLPOINT","2951.06","77.91","","483.51","229.32","1316.08","96","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2246.15","59.3","","439.50","225.34","1872.27","197","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 12MM 68 5 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10168304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.51","78.45","","385.32","55.36","1815.62","58","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","AETNA [1001]","HB CH AETNA HMO / PPO","2208.28","58.3","","554.95","91.85","1421.75","94","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","2490.03","2490.03","2490.03","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2208.28","58.3","","750.00","750.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.52","53","","1192.50","120.84","4149.90","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.61","85","","750.00","75.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.78","100","","657.00","121.50","1971.00","14","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.78","100","","75.00","75.00","75.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.78","100","","366.00","144.00","1971.00","45","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","667.50","667.50","667.50","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.67","44.45","","123.77","123.77","123.77","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","WELLPOINT [1015]","HB CH WELLPOINT","2951.06","77.91","","483.51","229.32","1316.08","96","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2246.15","59.3","","439.50","225.34","1872.27","197","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 12MM 90 7 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.51","78.45","","385.32","55.36","1815.62","58","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","AETNA [1001]","HB CH AETNA HMO / PPO","2208.28","58.3","","554.95","91.85","1421.75","94","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","2490.03","2490.03","2490.03","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2208.28","58.3","","750.00","750.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.52","53","","1192.50","120.84","4149.90","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.61","85","","750.00","75.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.78","100","","657.00","121.50","1971.00","14","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.78","100","","75.00","75.00","75.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.78","100","","366.00","144.00","1971.00","45","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","667.50","667.50","667.50","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.67","44.45","","123.77","123.77","123.77","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","WELLPOINT [1015]","HB CH WELLPOINT","2951.06","77.91","","483.51","229.32","1316.08","96","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2246.15","59.3","","439.50","225.34","1872.27","197","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL LEFT","SUP-ITM-10185928","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.51","78.45","","385.32","55.36","1815.62","58","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","AETNA [1001]","HB CH AETNA HMO / PPO","2208.28","58.3","","554.95","91.85","1421.75","94","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","2490.03","2490.03","2490.03","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2208.28","58.3","","750.00","750.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.52","53","","1192.50","120.84","4149.90","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.61","85","","750.00","75.00","750.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.78","100","","657.00","121.50","1971.00","14","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.78","100","","75.00","75.00","75.00","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.78","100","","366.00","144.00","1971.00","45","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2765.08","73","","667.50","667.50","667.50","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.67","44.45","","123.77","123.77","123.77","1 through 10","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.78","2840.83","WELLPOINT [1015]","HB CH WELLPOINT","2951.06","77.91","","483.51","229.32","1316.08","96","1683.67","3787.78","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2246.15","59.3","","439.50","225.34","1872.27","197","1893.89","2971.51","percent of total billed charges",""
"HOOK TITANIUM 16MM 111 9 HOLE PLATE BONE CLAVICLE DISTAL LATERAL RIGHT","SUP-ITM-10185925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.78","2840.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.51","78.45","","385.32","55.36","1815.62","58","1893.89","2971.51","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","AETNA [1001]","HB CH AETNA HMO / PPO","999.03","58.3","","1634.24","1004.95","1718.99","42","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1250.93","73","","2123.89","1900.92","2123.89","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","999.03","58.3","","3729.00","1254.19","3729.00","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","908.21","53","","939.37","939.37","5593.65","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1456.56","85","","2323.25","1864.50","2882.25","16","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1713.60","100","","2909.44","1772.40","10952.08","45","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1713.60","100","","2323.25","2323.25","2323.25","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1713.60","100","","2882.25","1772.40","10169.17","187","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1250.93","73","","1659.41","1659.41","1659.41","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","WELLPOINT [1015]","HB CH WELLPOINT","1335.07","77.91","","2050.91","1468.48","2902.83","52","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1548.60","1092.60","3613.79","82","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE COMPREHENSIVE STANDARD","SUP-ITM-10091554","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1344.32","78.45","","2085.51","998.68","6202.11","56","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","AETNA [1001]","HB CH AETNA HMO / PPO","999.03","58.3","","1634.24","1004.95","1718.99","42","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1250.93","73","","2123.89","1900.92","2123.89","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","999.03","58.3","","3729.00","1254.19","3729.00","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","908.21","53","","939.37","939.37","5593.65","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1456.56","85","","2323.25","1864.50","2882.25","16","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1713.60","100","","2909.44","1772.40","10952.08","45","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1713.60","100","","2323.25","2323.25","2323.25","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1713.60","100","","2882.25","1772.40","10169.17","187","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1250.93","73","","1659.41","1659.41","1659.41","1 through 10","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","both","","","1713.60","1285.20","WELLPOINT [1015]","HB CH WELLPOINT","1335.07","77.91","","2050.91","1468.48","2902.83","52","761.7","1713.6","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1016.16","59.3","","1548.60","1092.60","3613.79","82","856.8","1344.32","percent of total billed charges",""
"HUMERAL BEARING 44 36MM ARCOMXL POLYETHYLENE REVERSE RETENTIVE PLUS","SUP-ITM-10123216","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1713.60","1285.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1344.32","78.45","","2085.51","998.68","6202.11","56","856.8","1344.32","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1634.24","1004.95","1718.99","42","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","2123.89","1900.92","2123.89","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2984.96","58.3","","3729.00","1254.19","3729.00","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","939.37","939.37","5593.65","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4352.00","85","","2323.25","1864.50","2882.25","16","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5120.00","100","","2909.44","1772.40","10952.08","45","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5120.00","100","","2323.25","2323.25","2323.25","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5120.00","100","","2882.25","1772.40","10169.17","187","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","1659.41","1659.41","1659.41","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","2050.91","1468.48","2902.83","52","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1548.60","1092.60","3613.79","82","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 100X4MM DISCOVERY ELBOW RT FLANGE","SUP-ITM-10277347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","2085.51","998.68","6202.11","56","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1634.24","1004.95","1718.99","42","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","2123.89","1900.92","2123.89","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2984.96","58.3","","3729.00","1254.19","3729.00","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","939.37","939.37","5593.65","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4352.00","85","","2323.25","1864.50","2882.25","16","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5120.00","100","","2909.44","1772.40","10952.08","45","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5120.00","100","","2323.25","2323.25","2323.25","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5120.00","100","","2882.25","1772.40","10169.17","187","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","1659.41","1659.41","1659.41","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","2050.91","1468.48","2902.83","52","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1548.60","1092.60","3613.79","82","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 100X5MM DISCOVERY ELBOW LT FLANGE","SUP-ITM-10277355","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","2085.51","998.68","6202.11","56","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 4X100MM DISCOVERY LEFT FLANGED C","SUP-ITM-10275959","CDM","C1889","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1830.28","315.58","1830.28","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 4X100MM DISCOVERY LEFT FLANGED C","SUP-ITM-10275959","CDM","C1889","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","4170.85","4170.85","4170.85","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 4X100MM DISCOVERY LEFT FLANGED C","SUP-ITM-10275959","CDM","C1889","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2275.84","44.45","","649.55","649.55","649.55","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 4X100MM DISCOVERY LEFT FLANGED C","SUP-ITM-10275959","CDM","C1889","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","8998.38","2542.37","8998.38","20","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 4X100MM DISCOVERY LEFT FLANGED C","SUP-ITM-10275959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1891.61","1609.14","3664.18","25","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 4X100MM DISCOVERY LEFT FLANGED C","SUP-ITM-10275959","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","1470.68","1310.06","2481.69","19","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","AETNA [1001]","HB CH AETNA HMO / PPO","2984.96","58.3","","1634.24","1004.95","1718.99","42","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","2123.89","1900.92","2123.89","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2984.96","58.3","","3729.00","1254.19","3729.00","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2713.60","53","","939.37","939.37","5593.65","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4352.00","85","","2323.25","1864.50","2882.25","16","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5120.00","100","","2909.44","1772.40","10952.08","45","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5120.00","100","","2323.25","2323.25","2323.25","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5120.00","100","","2882.25","1772.40","10169.17","187","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3737.60","73","","1659.41","1659.41","1659.41","1 through 10","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","both","","","5120.00","3840.00","WELLPOINT [1015]","HB CH WELLPOINT","3988.99","77.91","","2050.91","1468.48","2902.83","52","2275.84","5120","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3036.16","59.3","","1548.60","1092.60","3613.79","82","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT 5X100MM DISCOVERY RIGHT FLANGED C","SUP-ITM-10276258","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5120.00","3840.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4016.64","78.45","","2085.51","998.68","6202.11","56","2560","4016.64","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","AETNA [1001]","HB CH AETNA HMO / PPO","2464.92","58.3","","1634.24","1004.95","1718.99","42","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3086.44","73","","2123.89","1900.92","2123.89","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2464.92","58.3","","3729.00","1254.19","3729.00","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2240.84","53","","939.37","939.37","5593.65","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3593.80","85","","2323.25","1864.50","2882.25","16","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4228.00","100","","2909.44","1772.40","10952.08","45","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4228.00","100","","2323.25","2323.25","2323.25","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4228.00","100","","2882.25","1772.40","10169.17","187","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3086.44","73","","1659.41","1659.41","1659.41","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB CH WELLPOINT","3294.03","77.91","","2050.91","1468.48","2902.83","52","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1548.60","1092.60","3613.79","82","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 1 HYDROXYAPATITE COATING DELTA MODULAR ECCENTRIC RT","SUP-ITM-10094101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3316.87","78.45","","2085.51","998.68","6202.11","56","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","AETNA [1001]","HB CH AETNA HMO / PPO","2464.92","58.3","","1634.24","1004.95","1718.99","42","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3086.44","73","","2123.89","1900.92","2123.89","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2464.92","58.3","","3729.00","1254.19","3729.00","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2240.84","53","","939.37","939.37","5593.65","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3593.80","85","","2323.25","1864.50","2882.25","16","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4228.00","100","","2909.44","1772.40","10952.08","45","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4228.00","100","","2323.25","2323.25","2323.25","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4228.00","100","","2882.25","1772.40","10169.17","187","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3086.44","73","","1659.41","1659.41","1659.41","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB CH WELLPOINT","3294.03","77.91","","2050.91","1468.48","2902.83","52","1879.35","4228","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1548.60","1092.60","3613.79","82","2114","3316.87","percent of total billed charges",""
"HUMERAL COMPONENT SZ 2 HYDROXYAPATITE COATED MODULAR ECCENTRIC EPIPHYSIS RT","SUP-ITM-10119279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3316.87","78.45","","2085.51","998.68","6202.11","56","2114","3316.87","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","AETNA [1001]","HB CH AETNA HMO / PPO","951.46","58.3","","1634.24","1004.95","1718.99","42","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1191.36","73","","2123.89","1900.92","2123.89","1 through 10","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","951.46","58.3","","3729.00","1254.19","3729.00","1 through 10","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.96","53","","939.37","939.37","5593.65","1 through 10","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1387.20","85","","2323.25","1864.50","2882.25","16","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1632.00","100","","2909.44","1772.40","10952.08","45","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1632.00","100","","2323.25","2323.25","2323.25","1 through 10","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1632.00","100","","2882.25","1772.40","10169.17","187","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1191.36","73","","1659.41","1659.41","1659.41","1 through 10","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","both","","","1632.00","1224.00","WELLPOINT [1015]","HB CH WELLPOINT","1271.49","77.91","","2050.91","1468.48","2902.83","52","725.42","1632","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.78","59.3","","1548.60","1092.60","3613.79","82","816","1280.3","percent of total billed charges",""
"HUMERAL CUP 30MM PLUS 9MM POLYETHYLENE DELTA EXTENDED REVERSE","SUP-ITM-10025727","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1632.00","1224.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.30","78.45","","2085.51","998.68","6202.11","56","816","1280.3","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","AETNA [1001]","HB CH AETNA HMO / PPO","1304.75","58.3","","1634.24","1004.95","1718.99","42","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1633.74","73","","2123.89","1900.92","2123.89","1 through 10","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1304.75","58.3","","3729.00","1254.19","3729.00","1 through 10","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1186.14","53","","939.37","939.37","5593.65","1 through 10","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1902.30","85","","2323.25","1864.50","2882.25","16","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2238.00","100","","2909.44","1772.40","10952.08","45","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2238.00","100","","2323.25","2323.25","2323.25","1 through 10","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2238.00","100","","2882.25","1772.40","10169.17","187","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1633.74","73","","1659.41","1659.41","1659.41","1 through 10","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","both","","","2238.00","1678.50","WELLPOINT [1015]","HB CH WELLPOINT","1743.63","77.91","","2050.91","1468.48","2902.83","52","994.79","2238","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2238.00","1678.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1327.13","59.3","","1548.60","1092.60","3613.79","82","1119","1755.71","percent of total billed charges",""
"HUMERAL CUP 38MM PLUS 3MM DELTA POLYETHYLENE STANDARD","SUP-ITM-10022559","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2238.00","1678.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1755.71","78.45","","2085.51","998.68","6202.11","56","1119","1755.71","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","AETNA [1001]","HB CH AETNA HMO / PPO","1979.69","58.3","","1634.24","1004.95","1718.99","42","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2478.86","73","","2123.89","1900.92","2123.89","1 through 10","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1979.69","58.3","","3729.00","1254.19","3729.00","1 through 10","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1799.72","53","","939.37","939.37","5593.65","1 through 10","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2886.35","85","","2323.25","1864.50","2882.25","16","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3395.70","100","","2909.44","1772.40","10952.08","45","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3395.70","100","","2323.25","2323.25","2323.25","1 through 10","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3395.70","100","","2882.25","1772.40","10169.17","187","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2478.86","73","","1659.41","1659.41","1659.41","1 through 10","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","both","","","3395.70","2546.77","WELLPOINT [1015]","HB CH WELLPOINT","2645.59","77.91","","2050.91","1468.48","2902.83","52","1509.39","3395.7","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2013.65","59.3","","1548.60","1092.60","3613.79","82","1697.85","2663.93","percent of total billed charges",""
"HUMERAL CUP 6MM 5 0DEG IMPLANT ANATOMICAL INVERSE REVERSE OFF CENTER RETRO 03 BX/1EA","SUP-ITM-10018285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3395.70","2546.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2663.93","78.45","","2085.51","998.68","6202.11","56","1697.85","2663.93","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","AETNA [1001]","HB CH AETNA HMO / PPO","172.14","58.3","","554.95","91.85","1421.75","94","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","215.54","73","","2490.03","2490.03","2490.03","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","172.14","58.3","","750.00","750.00","750.00","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","156.49","53","","1192.50","120.84","4149.90","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","250.97","85","","750.00","75.00","750.00","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","295.26","100","","657.00","121.50","1971.00","14","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","295.26","100","","75.00","75.00","75.00","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","295.26","100","","366.00","144.00","1971.00","45","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","215.54","73","","667.50","667.50","667.50","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","131.24","44.45","","123.77","123.77","123.77","1 through 10","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","both","","","295.26","221.44","WELLPOINT [1015]","HB CH WELLPOINT","230.04","77.91","","483.51","229.32","1316.08","96","131.24","295.26","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","175.09","59.3","","439.50","225.34","1872.27","197","147.63","231.63","percent of total billed charges",""
"HUMERAL ENDCAP 0MM NAIL EX TI EXTENSION T25 STARDRIVE RECESS","SUP-ITM-10039997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","295.26","221.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.63","78.45","","385.32","55.36","1815.62","58","147.63","231.63","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","AETNA [1001]","HB CH AETNA HMO / PPO","1647.56","58.3","","1634.24","1004.95","1718.99","42","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2062.98","73","","2123.89","1900.92","2123.89","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1647.56","58.3","","3729.00","1254.19","3729.00","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1497.78","53","","939.37","939.37","5593.65","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2402.10","85","","2323.25","1864.50","2882.25","16","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2826.00","100","","2909.44","1772.40","10952.08","45","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2826.00","100","","2323.25","2323.25","2323.25","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2826.00","100","","2882.25","1772.40","10169.17","187","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2062.98","73","","1659.41","1659.41","1659.41","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","WELLPOINT [1015]","HB CH WELLPOINT","2201.74","77.91","","2050.91","1468.48","2902.83","52","1256.16","2826","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1675.82","59.3","","1548.60","1092.60","3613.79","82","1413","2217","percent of total billed charges",""
"HUMERAL HEAD 135MM SZ 16 135DEG GLOBAL UNITE ANATOMICAL REVERSE","SUP-ITM-10136720","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2217.00","78.45","","2085.51","998.68","6202.11","56","1413","2217","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","AETNA [1001]","HB CH AETNA HMO / PPO","3142.37","58.3","","1634.24","1004.95","1718.99","42","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3934.70","73","","2123.89","1900.92","2123.89","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3142.37","58.3","","3729.00","1254.19","3729.00","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2856.70","53","","939.37","939.37","5593.65","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4581.50","85","","2323.25","1864.50","2882.25","16","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5390.00","100","","2909.44","1772.40","10952.08","45","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5390.00","100","","2323.25","2323.25","2323.25","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5390.00","100","","2882.25","1772.40","10169.17","187","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3934.70","73","","1659.41","1659.41","1659.41","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","WELLPOINT [1015]","HB CH WELLPOINT","4199.35","77.91","","2050.91","1468.48","2902.83","52","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5390.00","4042.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3196.27","59.3","","1548.60","1092.60","3613.79","82","2695","4228.46","percent of total billed charges",""
"HUMERAL HEAD 18X52MM DUOFIX POROCOAT GLOBAL CAP","SUP-ITM-10118764","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5390.00","4042.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4228.46","78.45","","2085.51","998.68","6202.11","56","2695","4228.46","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","AETNA [1001]","HB CH AETNA HMO / PPO","3138.29","58.3","","1634.24","1004.95","1718.99","42","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3929.59","73","","2123.89","1900.92","2123.89","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3138.29","58.3","","3729.00","1254.19","3729.00","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2852.99","53","","939.37","939.37","5593.65","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4575.55","85","","2323.25","1864.50","2882.25","16","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5383.00","100","","2909.44","1772.40","10952.08","45","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5383.00","100","","2323.25","2323.25","2323.25","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5383.00","100","","2882.25","1772.40","10169.17","187","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3929.59","73","","1659.41","1659.41","1659.41","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","WELLPOINT [1015]","HB CH WELLPOINT","4193.90","77.91","","2050.91","1468.48","2902.83","52","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3192.12","59.3","","1548.60","1092.60","3613.79","82","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 26X52MM DELTA XTEND CTA COBALT CHROMIUM ALLOY","SUP-ITM-10119287","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4222.96","78.45","","2085.51","998.68","6202.11","56","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","AETNA [1001]","HB CH AETNA HMO / PPO","2506.90","58.3","","1634.24","1004.95","1718.99","42","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3139.00","73","","2123.89","1900.92","2123.89","1 through 10","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2506.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2279.00","53","","939.37","939.37","5593.65","1 through 10","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3655.00","85","","2323.25","1864.50","2882.25","16","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4300.00","100","","2909.44","1772.40","10952.08","45","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4300.00","100","","2323.25","2323.25","2323.25","1 through 10","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4300.00","100","","2882.25","1772.40","10169.17","187","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3139.00","73","","1659.41","1659.41","1659.41","1 through 10","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","both","","","4300.00","3225.00","WELLPOINT [1015]","HB CH WELLPOINT","3350.13","77.91","","2050.91","1468.48","2902.83","52","1911.35","4300","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2549.90","59.3","","1548.60","1092.60","3613.79","82","2150","3373.35","percent of total billed charges",""
"HUMERAL HEAD 39MM ASSEMBLY ADAPTER CA REVERS UNIVERSAL","SUP-ITM-10277642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4300.00","3225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3373.35","78.45","","2085.51","998.68","6202.11","56","2150","3373.35","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","AETNA [1001]","HB CH AETNA HMO / PPO","3142.37","58.3","","1634.24","1004.95","1718.99","42","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3934.70","73","","2123.89","1900.92","2123.89","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3142.37","58.3","","3729.00","1254.19","3729.00","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2856.70","53","","939.37","939.37","5593.65","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4581.50","85","","2323.25","1864.50","2882.25","16","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5390.00","100","","2909.44","1772.40","10952.08","45","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5390.00","100","","2323.25","2323.25","2323.25","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5390.00","100","","2882.25","1772.40","10169.17","187","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3934.70","73","","1659.41","1659.41","1659.41","1 through 10","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","both","","","5390.00","4042.50","WELLPOINT [1015]","HB CH WELLPOINT","4199.35","77.91","","2050.91","1468.48","2902.83","52","2395.86","5390","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5390.00","4042.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3196.27","59.3","","1548.60","1092.60","3613.79","82","2695","4228.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM CTA GLOBAL CAP DUOFIX HYDROXYAPATITE COATING","SUP-ITM-10088677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5390.00","4042.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4228.46","78.45","","2085.51","998.68","6202.11","56","2695","4228.46","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 40X15MM GLOBAL UNITE ECC REVERSE 05","SUP-ITM-10118621","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HUMERAL HEAD 43/16 ECLIPSE","SUP-ITM-10274228","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1634.24","1004.95","1718.99","42","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","2123.89","1900.92","2123.89","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","909.48","58.3","","3729.00","1254.19","3729.00","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","939.37","939.37","5593.65","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1326.00","85","","2323.25","1864.50","2882.25","16","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1560.00","100","","2909.44","1772.40","10952.08","45","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1560.00","100","","2323.25","2323.25","2323.25","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1560.00","100","","2882.25","1772.40","10169.17","187","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","1659.41","1659.41","1659.41","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","2050.91","1468.48","2902.83","52","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1548.60","1092.60","3613.79","82","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD 44X18MM GLOBAL ADVANTAGE HUM CARBON COBALT CHROMIUM MOLYBDENUM ALLOY","SUP-ITM-10017432","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","2085.51","998.68","6202.11","56","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","AETNA [1001]","HB CH AETNA HMO / PPO","3138.29","58.3","","1634.24","1004.95","1718.99","42","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3929.59","73","","2123.89","1900.92","2123.89","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3138.29","58.3","","3729.00","1254.19","3729.00","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2852.99","53","","939.37","939.37","5593.65","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4575.55","85","","2323.25","1864.50","2882.25","16","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5383.00","100","","2909.44","1772.40","10952.08","45","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5383.00","100","","2323.25","2323.25","2323.25","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5383.00","100","","2882.25","1772.40","10169.17","187","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3929.59","73","","1659.41","1659.41","1659.41","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","WELLPOINT [1015]","HB CH WELLPOINT","4193.90","77.91","","2050.91","1468.48","2902.83","52","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3192.12","59.3","","1548.60","1092.60","3613.79","82","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 48X21MM CTA DELTA XTEND REVERSE","SUP-ITM-10026713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4222.96","78.45","","2085.51","998.68","6202.11","56","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","AETNA [1001]","HB CH AETNA HMO / PPO","3138.29","58.3","","1634.24","1004.95","1718.99","42","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3929.59","73","","2123.89","1900.92","2123.89","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3138.29","58.3","","3729.00","1254.19","3729.00","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2852.99","53","","939.37","939.37","5593.65","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4575.55","85","","2323.25","1864.50","2882.25","16","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5383.00","100","","2909.44","1772.40","10952.08","45","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5383.00","100","","2323.25","2323.25","2323.25","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5383.00","100","","2882.25","1772.40","10169.17","187","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3929.59","73","","1659.41","1659.41","1659.41","1 through 10","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","both","","","5383.00","4037.25","WELLPOINT [1015]","HB CH WELLPOINT","4193.90","77.91","","2050.91","1468.48","2902.83","52","2392.74","5383","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3192.12","59.3","","1548.60","1092.60","3613.79","82","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 52X21MM COBALT CHROMIUM ALLOY DELTA EXTEND","SUP-ITM-10118167","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5383.00","4037.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4222.96","78.45","","2085.51","998.68","6202.11","56","2691.5","4222.96","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1634.24","1004.95","1718.99","42","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","2123.89","1900.92","2123.89","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","909.48","58.3","","3729.00","1254.19","3729.00","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","939.37","939.37","5593.65","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1326.00","85","","2323.25","1864.50","2882.25","16","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1560.00","100","","2909.44","1772.40","10952.08","45","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1560.00","100","","2323.25","2323.25","2323.25","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1560.00","100","","2882.25","1772.40","10169.17","187","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","1659.41","1659.41","1659.41","1 through 10","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","2050.91","1468.48","2902.83","52","693.42","1560","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1548.60","1092.60","3613.79","82","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD 56X23MM GLOBAL AP CTA POROCOAT COATED","SUP-ITM-10118673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","2085.51","998.68","6202.11","56","780","1223.82","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","AETNA [1001]","HB CH AETNA HMO / PPO","781.24","58.3","","1634.24","1004.95","1718.99","42","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","978.22","73","","2123.89","1900.92","2123.89","1 through 10","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","781.24","58.3","","3729.00","1254.19","3729.00","1 through 10","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","710.22","53","","939.37","939.37","5593.65","1 through 10","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1139.03","85","","2323.25","1864.50","2882.25","16","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1340.03","100","","2909.44","1772.40","10952.08","45","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1340.03","100","","2323.25","2323.25","2323.25","1 through 10","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1340.03","100","","2882.25","1772.40","10169.17","187","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","978.22","73","","1659.41","1659.41","1659.41","1 through 10","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","both","","","1340.03","1005.02","WELLPOINT [1015]","HB CH WELLPOINT","1044.02","77.91","","2050.91","1468.48","2902.83","52","595.64","1340.03","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1340.03","1005.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","794.64","59.3","","1548.60","1092.60","3613.79","82","670.02","1051.25","percent of total billed charges",""
"HUMERAL HEAD LOW OFFSET MODULAR COUPLER TI PERFORM","SUP-ITM-10306271","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1340.03","1005.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1051.25","78.45","","2085.51","998.68","6202.11","56","670.02","1051.25","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","AETNA [1001]","HB CH AETNA HMO / PPO","2464.92","58.3","","1634.24","1004.95","1718.99","42","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3086.44","73","","2123.89","1900.92","2123.89","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2464.92","58.3","","3729.00","1254.19","3729.00","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2240.84","53","","939.37","939.37","5593.65","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3593.80","85","","2323.25","1864.50","2882.25","16","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4228.00","100","","2909.44","1772.40","10952.08","45","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4228.00","100","","2323.25","2323.25","2323.25","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4228.00","100","","2882.25","1772.40","10169.17","187","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3086.44","73","","1659.41","1659.41","1659.41","1 through 10","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","both","","","4228.00","3171.00","WELLPOINT [1015]","HB CH WELLPOINT","3294.03","77.91","","2050.91","1468.48","2902.83","52","1879.35","4228","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.20","59.3","","1548.60","1092.60","3613.79","82","2114","3316.87","percent of total billed charges",""
"HUMERAL HEAD SZ 1 DELTA XTEND EPIPHYSIS ECCENTRIC CEMENTLESS HA LT","SUP-ITM-10094364","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4228.00","3171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3316.87","78.45","","2085.51","998.68","6202.11","56","2114","3316.87","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","AETNA [1001]","HB CH AETNA HMO / PPO","4507.76","58.3","","1634.24","1004.95","1718.99","42","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5644.36","73","","2123.89","1900.92","2123.89","1 through 10","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4507.76","58.3","","3729.00","1254.19","3729.00","1 through 10","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4097.96","53","","939.37","939.37","5593.65","1 through 10","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6572.20","85","","2323.25","1864.50","2882.25","16","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7732.00","100","","2909.44","1772.40","10952.08","45","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7732.00","100","","2323.25","2323.25","2323.25","1 through 10","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7732.00","100","","2882.25","1772.40","10169.17","187","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5644.36","73","","1659.41","1659.41","1659.41","1 through 10","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","both","","","7732.00","5799.00","WELLPOINT [1015]","HB CH WELLPOINT","6024.00","77.91","","2050.91","1468.48","2902.83","52","3436.87","7732","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7732.00","5799.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4585.08","59.3","","1548.60","1092.60","3613.79","82","3866","6065.75","percent of total billed charges",""
"HUMERAL IMPLANT 11MM 132.5DEG STD PROXIMAL BODY PTC","SUP-ITM-10274374","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7732.00","5799.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6065.75","78.45","","2085.51","998.68","6202.11","56","3866","6065.75","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 6.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134592","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 12.5MM 36 PLUS 9.0 AEQUALIS ASCEND FLEXIBLE REVERSED ANGLE B","SUP-ITM-10134478","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","AETNA [1001]","HB CH AETNA HMO / PPO","1775.24","58.3","","1634.24","1004.95","1718.99","42","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2222.85","73","","2123.89","1900.92","2123.89","1 through 10","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1775.24","58.3","","3729.00","1254.19","3729.00","1 through 10","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1613.85","53","","939.37","939.37","5593.65","1 through 10","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2588.25","85","","2323.25","1864.50","2882.25","16","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3045.00","100","","2909.44","1772.40","10952.08","45","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3045.00","100","","2323.25","2323.25","2323.25","1 through 10","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3045.00","100","","2882.25","1772.40","10169.17","187","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2222.85","73","","1659.41","1659.41","1659.41","1 through 10","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","both","","","3045.00","2283.75","WELLPOINT [1015]","HB CH WELLPOINT","2372.36","77.91","","2050.91","1468.48","2902.83","52","1353.5","3045","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3045.00","2283.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1805.69","59.3","","1548.60","1092.60","3613.79","82","1522.5","2388.8","percent of total billed charges",""
"HUMERAL INSERT 36+3/39 COMBINATION","SUP-ITM-10285923","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3045.00","2283.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2388.80","78.45","","2085.51","998.68","6202.11","56","1522.5","2388.8","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","AETNA [1001]","HB CH AETNA HMO / PPO","1163.52","58.3","","1634.24","1004.95","1718.99","42","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1456.90","73","","2123.89","1900.92","2123.89","1 through 10","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1163.52","58.3","","3729.00","1254.19","3729.00","1 through 10","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1057.75","53","","939.37","939.37","5593.65","1 through 10","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1696.39","85","","2323.25","1864.50","2882.25","16","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1995.75","100","","2909.44","1772.40","10952.08","45","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1995.75","100","","2323.25","2323.25","2323.25","1 through 10","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1995.75","100","","2882.25","1772.40","10169.17","187","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1456.90","73","","1659.41","1659.41","1659.41","1 through 10","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","WELLPOINT [1015]","HB CH WELLPOINT","1554.89","77.91","","2050.91","1468.48","2902.83","52","887.11","1995.75","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1183.48","59.3","","1548.60","1092.60","3613.79","82","997.88","1565.67","percent of total billed charges",""
"HUMERAL INSERT 36MM 3 SM PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130302","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1565.67","78.45","","2085.51","998.68","6202.11","56","997.88","1565.67","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 36MM 9.0 12.5 AEQUALIS ASCEND FLEXIBLE RETENTIVE REVERSED PLUS","SUP-ITM-10136041","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","AETNA [1001]","HB CH AETNA HMO / PPO","1369.99","58.3","","1634.24","1004.95","1718.99","42","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1715.43","73","","2123.89","1900.92","2123.89","1 through 10","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1369.99","58.3","","3729.00","1254.19","3729.00","1 through 10","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1245.45","53","","939.37","939.37","5593.65","1 through 10","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1997.42","85","","2323.25","1864.50","2882.25","16","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2349.90","100","","2909.44","1772.40","10952.08","45","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2349.90","100","","2323.25","2323.25","2323.25","1 through 10","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2349.90","100","","2882.25","1772.40","10169.17","187","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1715.43","73","","1659.41","1659.41","1659.41","1 through 10","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","both","","","2349.90","1762.42","WELLPOINT [1015]","HB CH WELLPOINT","1830.81","77.91","","2050.91","1468.48","2902.83","52","1044.53","2349.9","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2349.90","1762.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","1393.49","59.3","","1548.60","1092.60","3613.79","82","1174.95","1843.5","percent of total billed charges",""
"HUMERAL INSERT 36X6MM IMPLANT ANATOMICAL INVERSE REVERSE PE 04 BX/1EA","SUP-ITM-10018526","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2349.90","1762.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1843.50","78.45","","2085.51","998.68","6202.11","56","1174.95","1843.5","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","AETNA [1001]","HB CH AETNA HMO / PPO","1932.65","58.3","","1634.24","1004.95","1718.99","42","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2419.95","73","","2123.89","1900.92","2123.89","1 through 10","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1932.65","58.3","","3729.00","1254.19","3729.00","1 through 10","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1756.95","53","","939.37","939.37","5593.65","1 through 10","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2817.75","85","","2323.25","1864.50","2882.25","16","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3315.00","100","","2909.44","1772.40","10952.08","45","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3315.00","100","","2323.25","2323.25","2323.25","1 through 10","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3315.00","100","","2882.25","1772.40","10169.17","187","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2419.95","73","","1659.41","1659.41","1659.41","1 through 10","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","WELLPOINT [1015]","HB CH WELLPOINT","2582.72","77.91","","2050.91","1468.48","2902.83","52","1473.52","3315","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1965.80","59.3","","1548.60","1092.60","3613.79","82","1657.5","2600.62","percent of total billed charges",""
"HUMERAL INSERT 36X9.0MM AEQUALIS REVERSED PRIMARY FRACTURE","SUP-ITM-10135939","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2600.62","78.45","","2085.51","998.68","6202.11","56","1657.5","2600.62","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT 42MM 6.0 12.5 AEQUALIS ASCEND FLEXIBLE REVISION REVERSED PLUS","SUP-ITM-10136038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"HUMERAL INSERT SZ 3/4 36 MM +0 PERFORM RETENTIVE REVERSED","SUP-ITM-10306351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","AETNA [1001]","HB CH AETNA HMO / PPO","2143.29","58.3","","554.95","91.85","1421.75","94","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2683.71","73","","2490.03","2490.03","2490.03","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2143.29","58.3","","750.00","750.00","750.00","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1948.45","53","","1192.50","120.84","4149.90","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3124.87","85","","750.00","75.00","750.00","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3676.32","100","","657.00","121.50","1971.00","14","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3676.32","100","","75.00","75.00","75.00","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3676.32","100","","366.00","144.00","1971.00","45","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2683.71","73","","667.50","667.50","667.50","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1634.12","44.45","","123.77","123.77","123.77","1 through 10","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","WELLPOINT [1015]","HB CH WELLPOINT","2864.22","77.91","","483.51","229.32","1316.08","96","1634.12","3676.32","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3676.32","2757.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","2180.06","59.3","","439.50","225.34","1872.27","197","1838.16","2884.07","percent of total billed charges",""
"HUMERAL NAIL 7MM/270 EX TI CANNULATED EX/270MM","SUP-ITM-10036449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3676.32","2757.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2884.07","78.45","","385.32","55.36","1815.62","58","1838.16","2884.07","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"HUMERAL SPACER 36MM AEQUALIS METAL REVERSED PLUS 9","SUP-ITM-10018227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","AETNA [1001]","HB CH AETNA HMO / PPO","1428.15","58.3","","1634.24","1004.95","1718.99","42","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1788.24","73","","2123.89","1900.92","2123.89","1 through 10","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1428.15","58.3","","3729.00","1254.19","3729.00","1 through 10","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1298.31","53","","939.37","939.37","5593.65","1 through 10","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2082.20","85","","2323.25","1864.50","2882.25","16","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2449.65","100","","2909.44","1772.40","10952.08","45","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2449.65","100","","2323.25","2323.25","2323.25","1 through 10","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2449.65","100","","2882.25","1772.40","10169.17","187","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1788.24","73","","1659.41","1659.41","1659.41","1 through 10","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2449.65","1837.24","WELLPOINT [1015]","HB CH WELLPOINT","1908.52","77.91","","2050.91","1468.48","2902.83","52","1088.87","2449.65","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2449.65","1837.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","1452.64","59.3","","1548.60","1092.60","3613.79","82","1224.83","1921.75","percent of total billed charges",""
"HUMERAL SPACER 42MM 9 ENER DELTA PLUS","SUP-ITM-10016676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2449.65","1837.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1921.75","78.45","","2085.51","998.68","6202.11","56","1224.83","1921.75","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","AETNA [1001]","HB CH AETNA HMO / PPO","1598.59","58.3","","1634.24","1004.95","1718.99","42","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","2123.89","1900.92","2123.89","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1598.59","58.3","","3729.00","1254.19","3729.00","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1453.26","53","","939.37","939.37","5593.65","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2330.70","85","","2323.25","1864.50","2882.25","16","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2742.00","100","","2909.44","1772.40","10952.08","45","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2742.00","100","","2323.25","2323.25","2323.25","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2742.00","100","","2882.25","1772.40","10169.17","187","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","1659.41","1659.41","1659.41","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","WELLPOINT [1015]","HB CH WELLPOINT","2136.29","77.91","","2050.91","1468.48","2902.83","52","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1626.01","59.3","","1548.60","1092.60","3613.79","82","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 10MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","2085.51","998.68","6202.11","56","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1634.24","1004.95","1718.99","42","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","2123.89","1900.92","2123.89","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2530.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","939.37","939.37","5593.65","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3689.00","85","","2323.25","1864.50","2882.25","16","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4340.00","100","","2909.44","1772.40","10952.08","45","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4340.00","100","","2323.25","2323.25","2323.25","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4340.00","100","","2882.25","1772.40","10169.17","187","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","1659.41","1659.41","1659.41","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","2050.91","1468.48","2902.83","52","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1548.60","1092.60","3613.79","82","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 10MM REUION TSA PRESS FIT 07B","SUP-ITM-10132454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","2085.51","998.68","6202.11","56","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","AETNA [1001]","HB CH AETNA HMO / PPO","2576.86","58.3","","1634.24","1004.95","1718.99","42","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3226.60","73","","2123.89","1900.92","2123.89","1 through 10","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2576.86","58.3","","3729.00","1254.19","3729.00","1 through 10","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2342.60","53","","939.37","939.37","5593.65","1 through 10","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3757.00","85","","2323.25","1864.50","2882.25","16","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4420.00","100","","2909.44","1772.40","10952.08","45","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4420.00","100","","2323.25","2323.25","2323.25","1 through 10","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4420.00","100","","2882.25","1772.40","10169.17","187","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3226.60","73","","1659.41","1659.41","1659.41","1 through 10","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","both","","","4420.00","3315.00","WELLPOINT [1015]","HB CH WELLPOINT","3443.62","77.91","","2050.91","1468.48","2902.83","52","1964.69","4420","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4420.00","3315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2621.06","59.3","","1548.60","1092.60","3613.79","82","2210","3467.49","percent of total billed charges",""
"HUMERAL STEM 10MM SZ 1 CEMENTED MONOBLOC EPIPHYSIS STANDARD REVERSE","SUP-ITM-10022560","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4420.00","3315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3467.49","78.45","","2085.51","998.68","6202.11","56","2210","3467.49","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1634.24","1004.95","1718.99","42","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","2123.89","1900.92","2123.89","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2530.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","939.37","939.37","5593.65","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3689.00","85","","2323.25","1864.50","2882.25","16","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4340.00","100","","2909.44","1772.40","10952.08","45","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4340.00","100","","2323.25","2323.25","2323.25","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4340.00","100","","2882.25","1772.40","10169.17","187","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","1659.41","1659.41","1659.41","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","2050.91","1468.48","2902.83","52","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1548.60","1092.60","3613.79","82","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 10X115MM TURON SY PRIMARY","SUP-ITM-10146943","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","2085.51","998.68","6202.11","56","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1634.24","1004.95","1718.99","42","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","2123.89","1900.92","2123.89","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2530.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","939.37","939.37","5593.65","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3689.00","85","","2323.25","1864.50","2882.25","16","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4340.00","100","","2909.44","1772.40","10952.08","45","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4340.00","100","","2323.25","2323.25","2323.25","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4340.00","100","","2882.25","1772.40","10169.17","187","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","1659.41","1659.41","1659.41","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","2050.91","1468.48","2902.83","52","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1548.60","1092.60","3613.79","82","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 10X135MM GLOBAL ADVANTAGE TITANIUM POROCOAT","SUP-ITM-10016926","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","2085.51","998.68","6202.11","56","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","AETNA [1001]","HB CH AETNA HMO / PPO","2060.91","58.3","","1634.24","1004.95","1718.99","42","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2580.55","73","","2123.89","1900.92","2123.89","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2060.91","58.3","","3729.00","1254.19","3729.00","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1873.55","53","","939.37","939.37","5593.65","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3004.75","85","","2323.25","1864.50","2882.25","16","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3535.00","100","","2909.44","1772.40","10952.08","45","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3535.00","100","","2323.25","2323.25","2323.25","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3535.00","100","","2882.25","1772.40","10169.17","187","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2580.55","73","","1659.41","1659.41","1659.41","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","WELLPOINT [1015]","HB CH WELLPOINT","2754.12","77.91","","2050.91","1468.48","2902.83","52","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2096.26","59.3","","1548.60","1092.60","3613.79","82","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 113MM SZ 10 POROCOAT GLOBAL UNITE REVERSE","SUP-ITM-10131898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2773.21","78.45","","2085.51","998.68","6202.11","56","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","AETNA [1001]","HB CH AETNA HMO / PPO","2453.26","58.3","","1634.24","1004.95","1718.99","42","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","2123.89","1900.92","2123.89","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2453.26","58.3","","3729.00","1254.19","3729.00","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2230.24","53","","939.37","939.37","5593.65","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3576.80","85","","2323.25","1864.50","2882.25","16","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4208.00","100","","2909.44","1772.40","10952.08","45","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4208.00","100","","2323.25","2323.25","2323.25","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4208.00","100","","2882.25","1772.40","10169.17","187","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","1659.41","1659.41","1659.41","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","WELLPOINT [1015]","HB CH WELLPOINT","3278.45","77.91","","2050.91","1468.48","2902.83","52","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2495.34","59.3","","1548.60","1092.60","3613.79","82","2104","3301.18","percent of total billed charges",""
"HUMERAL STEM 11X115MM WITHOUT BODY","SUP-ITM-10035505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3301.18","78.45","","2085.51","998.68","6202.11","56","2104","3301.18","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","AETNA [1001]","HB CH AETNA HMO / PPO","6092.52","58.3","","1634.24","1004.95","1718.99","42","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7628.72","73","","2123.89","1900.92","2123.89","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6092.52","58.3","","3729.00","1254.19","3729.00","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5538.66","53","","939.37","939.37","5593.65","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8882.76","85","","2323.25","1864.50","2882.25","16","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10450.30","100","","2909.44","1772.40","10952.08","45","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","10450.30","100","","2323.25","2323.25","2323.25","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10450.30","100","","2882.25","1772.40","10169.17","187","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7628.72","73","","1659.41","1659.41","1659.41","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","WELLPOINT [1015]","HB CH WELLPOINT","8141.83","77.91","","2050.91","1468.48","2902.83","52","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10450.30","7837.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","6197.03","59.3","","1548.60","1092.60","3613.79","82","5225.15","8198.26","percent of total billed charges",""
"HUMERAL STEM 12.0X220MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10072480","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10450.30","7837.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8198.26","78.45","","2085.51","998.68","6202.11","56","5225.15","8198.26","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","AETNA [1001]","HB CH AETNA HMO / PPO","2060.91","58.3","","1634.24","1004.95","1718.99","42","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2580.55","73","","2123.89","1900.92","2123.89","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2060.91","58.3","","3729.00","1254.19","3729.00","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1873.55","53","","939.37","939.37","5593.65","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3004.75","85","","2323.25","1864.50","2882.25","16","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3535.00","100","","2909.44","1772.40","10952.08","45","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3535.00","100","","2323.25","2323.25","2323.25","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3535.00","100","","2882.25","1772.40","10169.17","187","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2580.55","73","","1659.41","1659.41","1659.41","1 through 10","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","both","","","3535.00","2651.25","WELLPOINT [1015]","HB CH WELLPOINT","2754.12","77.91","","2050.91","1468.48","2902.83","52","1571.31","3535","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2096.26","59.3","","1548.60","1092.60","3613.79","82","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 120MM SZ 12 GLOBAL UNITE POROCOAT REVERSE","SUP-ITM-10124389","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3535.00","2651.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2773.21","78.45","","2085.51","998.68","6202.11","56","1767.5","2773.21","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","AETNA [1001]","HB CH AETNA HMO / PPO","1598.59","58.3","","1634.24","1004.95","1718.99","42","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","2123.89","1900.92","2123.89","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1598.59","58.3","","3729.00","1254.19","3729.00","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1453.26","53","","939.37","939.37","5593.65","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2330.70","85","","2323.25","1864.50","2882.25","16","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2742.00","100","","2909.44","1772.40","10952.08","45","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2742.00","100","","2323.25","2323.25","2323.25","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2742.00","100","","2882.25","1772.40","10169.17","187","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","1659.41","1659.41","1659.41","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","WELLPOINT [1015]","HB CH WELLPOINT","2136.29","77.91","","2050.91","1468.48","2902.83","52","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1626.01","59.3","","1548.60","1092.60","3613.79","82","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 12MM DELTA XTEND TITANIUM HYDROXYAPATITE COATING MODULAR","SUP-ITM-10094366","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","2085.51","998.68","6202.11","56","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","AETNA [1001]","HB CH AETNA HMO / PPO","5282.85","58.3","","554.95","91.85","1421.75","94","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6614.90","73","","2490.03","2490.03","2490.03","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5282.85","58.3","","750.00","750.00","750.00","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4802.60","53","","1192.50","120.84","4149.90","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7702.28","85","","750.00","75.00","750.00","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9061.50","100","","657.00","121.50","1971.00","14","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9061.50","100","","75.00","75.00","75.00","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9061.50","100","","366.00","144.00","1971.00","45","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6614.90","73","","667.50","667.50","667.50","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4027.84","44.45","","123.77","123.77","123.77","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","WELLPOINT [1015]","HB CH WELLPOINT","7059.81","77.91","","483.51","229.32","1316.08","96","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9061.50","6796.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","5373.47","59.3","","439.50","225.34","1872.27","197","4530.75","7108.75","percent of total billed charges",""
"HUMERAL STEM 12MM SZ 1 BLOCK DELTA COBALT CEMENTED MONO","SUP-ITM-10125970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9061.50","6796.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7108.75","78.45","","385.32","55.36","1815.62","58","4530.75","7108.75","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM 12X150MM GLOBAL FX POROCOAT","SUP-ITM-10029858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","AETNA [1001]","HB CH AETNA HMO / PPO","2365.52","58.3","","1634.24","1004.95","1718.99","42","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2961.98","73","","2123.89","1900.92","2123.89","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2365.52","58.3","","3729.00","1254.19","3729.00","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2150.48","53","","939.37","939.37","5593.65","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3448.88","85","","2323.25","1864.50","2882.25","16","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4057.50","100","","2909.44","1772.40","10952.08","45","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4057.50","100","","2323.25","2323.25","2323.25","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4057.50","100","","2882.25","1772.40","10169.17","187","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2961.98","73","","1659.41","1659.41","1659.41","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","WELLPOINT [1015]","HB CH WELLPOINT","3161.20","77.91","","2050.91","1468.48","2902.83","52","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2406.10","59.3","","1548.60","1092.60","3613.79","82","2028.75","3183.11","percent of total billed charges",""
"HUMERAL STEM 132MM SZ 10 GLOBAL PC AP","SUP-ITM-10041808","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3183.11","78.45","","2085.51","998.68","6202.11","56","2028.75","3183.11","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","AETNA [1001]","HB CH AETNA HMO / PPO","2365.52","58.3","","1634.24","1004.95","1718.99","42","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2961.98","73","","2123.89","1900.92","2123.89","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2365.52","58.3","","3729.00","1254.19","3729.00","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2150.48","53","","939.37","939.37","5593.65","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3448.88","85","","2323.25","1864.50","2882.25","16","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4057.50","100","","2909.44","1772.40","10952.08","45","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4057.50","100","","2323.25","2323.25","2323.25","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4057.50","100","","2882.25","1772.40","10169.17","187","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2961.98","73","","1659.41","1659.41","1659.41","1 through 10","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","WELLPOINT [1015]","HB CH WELLPOINT","3161.20","77.91","","2050.91","1468.48","2902.83","52","1803.56","4057.5","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2406.10","59.3","","1548.60","1092.60","3613.79","82","2028.75","3183.11","percent of total billed charges",""
"HUMERAL STEM 137MM SZ 8 GLOBAL PC AP","SUP-ITM-10048259","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3183.11","78.45","","2085.51","998.68","6202.11","56","2028.75","3183.11","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","AETNA [1001]","HB CH AETNA HMO / PPO","1598.59","58.3","","554.95","91.85","1421.75","94","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","2490.03","2490.03","2490.03","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1598.59","58.3","","750.00","750.00","750.00","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1453.26","53","","1192.50","120.84","4149.90","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2330.70","85","","750.00","75.00","750.00","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2742.00","100","","657.00","121.50","1971.00","14","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2742.00","100","","75.00","75.00","75.00","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2742.00","100","","366.00","144.00","1971.00","45","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2001.66","73","","667.50","667.50","667.50","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1218.82","44.45","","123.77","123.77","123.77","1 through 10","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","both","","","2742.00","2056.50","WELLPOINT [1015]","HB CH WELLPOINT","2136.29","77.91","","483.51","229.32","1316.08","96","1218.82","2742","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1626.01","59.3","","439.50","225.34","1872.27","197","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 16MM SIZE 1 IMPLANT CEMENTED DELTA REVERSE","SUP-ITM-10124344","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2742.00","2056.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2151.10","78.45","","385.32","55.36","1815.62","58","1371","2151.1","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","AETNA [1001]","HB CH AETNA HMO / PPO","2808.49","58.3","","1634.24","1004.95","1718.99","42","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3516.63","73","","2123.89","1900.92","2123.89","1 through 10","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2808.49","58.3","","3729.00","1254.19","3729.00","1 through 10","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2553.17","53","","939.37","939.37","5593.65","1 through 10","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4094.71","85","","2323.25","1864.50","2882.25","16","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4817.30","100","","2909.44","1772.40","10952.08","45","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4817.30","100","","2323.25","2323.25","2323.25","1 through 10","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4817.30","100","","2882.25","1772.40","10169.17","187","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3516.63","73","","1659.41","1659.41","1659.41","1 through 10","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","both","","","4817.30","3612.97","WELLPOINT [1015]","HB CH WELLPOINT","3753.16","77.91","","2050.91","1468.48","2902.83","52","2141.29","4817.3","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4817.30","3612.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","2856.66","59.3","","1548.60","1092.60","3613.79","82","2408.65","3779.17","percent of total billed charges",""
"HUMERAL STEM 5MM SIZE 135DEG REVERS MONOBLOCK COATED REVERSE 02","SUP-ITM-10135883","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4817.30","3612.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3779.17","78.45","","2085.51","998.68","6202.11","56","2408.65","3779.17","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","AETNA [1001]","HB CH AETNA HMO / PPO","1647.56","58.3","","1634.24","1004.95","1718.99","42","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2062.98","73","","2123.89","1900.92","2123.89","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1647.56","58.3","","3729.00","1254.19","3729.00","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1497.78","53","","939.37","939.37","5593.65","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2402.10","85","","2323.25","1864.50","2882.25","16","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2826.00","100","","2909.44","1772.40","10952.08","45","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2826.00","100","","2323.25","2323.25","2323.25","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2826.00","100","","2882.25","1772.40","10169.17","187","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2062.98","73","","1659.41","1659.41","1659.41","1 through 10","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","both","","","2826.00","2119.50","WELLPOINT [1015]","HB CH WELLPOINT","2201.74","77.91","","2050.91","1468.48","2902.83","52","1256.16","2826","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1675.82","59.3","","1548.60","1092.60","3613.79","82","1413","2217","percent of total billed charges",""
"HUMERAL STEM 5MM SZ 10 EPHIPHYSIS POROCOAT GLOBAL REVERSE","SUP-ITM-10118165","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2826.00","2119.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2217.00","78.45","","2085.51","998.68","6202.11","56","1413","2217","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","AETNA [1001]","HB CH AETNA HMO / PPO","6092.52","58.3","","1634.24","1004.95","1718.99","42","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7628.72","73","","2123.89","1900.92","2123.89","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6092.52","58.3","","3729.00","1254.19","3729.00","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5538.66","53","","939.37","939.37","5593.65","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8882.76","85","","2323.25","1864.50","2882.25","16","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10450.30","100","","2909.44","1772.40","10952.08","45","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","10450.30","100","","2323.25","2323.25","2323.25","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10450.30","100","","2882.25","1772.40","10169.17","187","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7628.72","73","","1659.41","1659.41","1659.41","1 through 10","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","both","","","10450.30","7837.72","WELLPOINT [1015]","HB CH WELLPOINT","8141.83","77.91","","2050.91","1468.48","2902.83","52","4645.16","10450.3","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10450.30","7837.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","6197.03","59.3","","1548.60","1092.60","3613.79","82","5225.15","8198.26","percent of total billed charges",""
"HUMERAL STEM 6X160MM GLOBAL FX POROCOAT FIXATOR POROUS COATED","SUP-ITM-10118651","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10450.30","7837.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8198.26","78.45","","2085.51","998.68","6202.11","56","5225.15","8198.26","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","AETNA [1001]","HB CH AETNA HMO / PPO","3148.20","58.3","","1634.24","1004.95","1718.99","42","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3942.00","73","","2123.89","1900.92","2123.89","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3148.20","58.3","","3729.00","1254.19","3729.00","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2862.00","53","","939.37","939.37","5593.65","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4590.00","85","","2323.25","1864.50","2882.25","16","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5400.00","100","","2909.44","1772.40","10952.08","45","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5400.00","100","","2323.25","2323.25","2323.25","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5400.00","100","","2882.25","1772.40","10169.17","187","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3942.00","73","","1659.41","1659.41","1659.41","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB CH WELLPOINT","4207.14","77.91","","2050.91","1468.48","2902.83","52","2400.3","5400","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1548.60","1092.60","3613.79","82","2700","4236.3","percent of total billed charges",""
"HUMERAL STEM 74MM SIZE 3 132.5DEG AEQUALIS ASCEND FLEX PURE TITANIUM COAT STANDARD B","SUP-ITM-10134593","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","2085.51","998.68","6202.11","56","2700","4236.3","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1634.24","1004.95","1718.99","42","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","2123.89","1900.92","2123.89","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2530.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","939.37","939.37","5593.65","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3689.00","85","","2323.25","1864.50","2882.25","16","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4340.00","100","","2909.44","1772.40","10952.08","45","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4340.00","100","","2323.25","2323.25","2323.25","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4340.00","100","","2882.25","1772.40","10169.17","187","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","1659.41","1659.41","1659.41","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","2050.91","1468.48","2902.83","52","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1548.60","1092.60","3613.79","82","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 8MM GLOBAL AP TITANIUM POROCOAT COATED COLLARLESS","SUP-ITM-10115708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","2085.51","998.68","6202.11","56","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","AETNA [1001]","HB CH AETNA HMO / PPO","6848.73","58.3","","1634.24","1004.95","1718.99","42","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8575.60","73","","2123.89","1900.92","2123.89","1 through 10","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6848.73","58.3","","3729.00","1254.19","3729.00","1 through 10","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6226.12","53","","939.37","939.37","5593.65","1 through 10","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9985.29","85","","2323.25","1864.50","2882.25","16","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11747.40","100","","2909.44","1772.40","10952.08","45","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11747.40","100","","2323.25","2323.25","2323.25","1 through 10","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11747.40","100","","2882.25","1772.40","10169.17","187","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8575.60","73","","1659.41","1659.41","1659.41","1 through 10","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","both","","","11747.40","8810.55","WELLPOINT [1015]","HB CH WELLPOINT","9152.40","77.91","","2050.91","1468.48","2902.83","52","5221.72","11747.4","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11747.40","8810.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","6966.21","59.3","","1548.60","1092.60","3613.79","82","5873.7","9215.84","percent of total billed charges",""
"HUMERAL STEM 8MM LONG LG GLOBAL AP REVISIONS TITANIUM ECCENTRIC","SUP-ITM-10118662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11747.40","8810.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9215.84","78.45","","2085.51","998.68","6202.11","56","5873.7","9215.84","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","AETNA [1001]","HB CH AETNA HMO / PPO","5282.85","58.3","","1634.24","1004.95","1718.99","42","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6614.90","73","","2123.89","1900.92","2123.89","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5282.85","58.3","","3729.00","1254.19","3729.00","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4802.60","53","","939.37","939.37","5593.65","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7702.28","85","","2323.25","1864.50","2882.25","16","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9061.50","100","","2909.44","1772.40","10952.08","45","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9061.50","100","","2323.25","2323.25","2323.25","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9061.50","100","","2882.25","1772.40","10169.17","187","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6614.90","73","","1659.41","1659.41","1659.41","1 through 10","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","both","","","9061.50","6796.12","WELLPOINT [1015]","HB CH WELLPOINT","7059.81","77.91","","2050.91","1468.48","2902.83","52","4027.84","9061.5","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9061.50","6796.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","5373.47","59.3","","1548.60","1092.60","3613.79","82","4530.75","7108.75","percent of total billed charges",""
"HUMERAL STEM 8MM SZ 1 LONG MONOBLOC CEMENTED","SUP-ITM-10042132","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9061.50","6796.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7108.75","78.45","","2085.51","998.68","6202.11","56","4530.75","7108.75","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","AETNA [1001]","HB CH AETNA HMO / PPO","3011.78","58.3","","1634.24","1004.95","1718.99","42","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3771.18","73","","2123.89","1900.92","2123.89","1 through 10","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3011.78","58.3","","3729.00","1254.19","3729.00","1 through 10","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2737.98","53","","939.37","939.37","5593.65","1 through 10","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4391.10","85","","2323.25","1864.50","2882.25","16","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5166.00","100","","2909.44","1772.40","10952.08","45","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5166.00","100","","2323.25","2323.25","2323.25","1 through 10","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5166.00","100","","2882.25","1772.40","10169.17","187","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3771.18","73","","1659.41","1659.41","1659.41","1 through 10","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","both","","","5166.00","3874.50","WELLPOINT [1015]","HB CH WELLPOINT","4024.83","77.91","","2050.91","1468.48","2902.83","52","2296.29","5166","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3063.44","59.3","","1548.60","1092.60","3613.79","82","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 8MMX194 PRIMARY REVISION REVERSE 01","SUP-ITM-10100472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5166.00","3874.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4052.73","78.45","","2085.51","998.68","6202.11","56","2583","4052.73","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","1634.24","1004.95","1718.99","42","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","2123.89","1900.92","2123.89","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2530.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","939.37","939.37","5593.65","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3689.00","85","","2323.25","1864.50","2882.25","16","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4340.00","100","","2909.44","1772.40","10952.08","45","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4340.00","100","","2323.25","2323.25","2323.25","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4340.00","100","","2882.25","1772.40","10169.17","187","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","1659.41","1659.41","1659.41","1 through 10","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","2050.91","1468.48","2902.83","52","1929.13","4340","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","1548.60","1092.60","3613.79","82","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 8X133MM GLOBAL W/POR REVERSE","SUP-ITM-10017433","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","2085.51","998.68","6202.11","56","2170","3404.73","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","AETNA [1001]","HB CH AETNA HMO / PPO","5339.58","58.3","","1634.24","1004.95","1718.99","42","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6685.92","73","","2123.89","1900.92","2123.89","1 through 10","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5339.58","58.3","","3729.00","1254.19","3729.00","1 through 10","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4854.16","53","","939.37","939.37","5593.65","1 through 10","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7784.98","85","","2323.25","1864.50","2882.25","16","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9158.80","100","","2909.44","1772.40","10952.08","45","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9158.80","100","","2323.25","2323.25","2323.25","1 through 10","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9158.80","100","","2882.25","1772.40","10169.17","187","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6685.92","73","","1659.41","1659.41","1659.41","1 through 10","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","both","","","9158.80","6869.10","WELLPOINT [1015]","HB CH WELLPOINT","7135.62","77.91","","2050.91","1468.48","2902.83","52","4071.09","9158.8","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9158.80","6869.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","5431.17","59.3","","1548.60","1092.60","3613.79","82","4579.4","7185.08","percent of total billed charges",""
"HUMERAL STEM 8X200MM GLOBAL ADVANTAGE HUM LNG","SUP-ITM-10019397","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9158.80","6869.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7185.08","78.45","","2085.51","998.68","6202.11","56","4579.4","7185.08","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","AETNA [1001]","HB CH AETNA HMO / PPO","2594.35","58.3","","1634.24","1004.95","1718.99","42","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3248.50","73","","2123.89","1900.92","2123.89","1 through 10","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2594.35","58.3","","3729.00","1254.19","3729.00","1 through 10","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2358.50","53","","939.37","939.37","5593.65","1 through 10","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3782.50","85","","2323.25","1864.50","2882.25","16","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4450.00","100","","2909.44","1772.40","10952.08","45","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4450.00","100","","2323.25","2323.25","2323.25","1 through 10","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4450.00","100","","2882.25","1772.40","10169.17","187","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3248.50","73","","1659.41","1659.41","1659.41","1 through 10","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","both","","","4450.00","3337.50","WELLPOINT [1015]","HB CH WELLPOINT","3467.00","77.91","","2050.91","1468.48","2902.83","52","1978.03","4450","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4450.00","3337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2638.85","59.3","","1548.60","1092.60","3613.79","82","2225","3491.03","percent of total billed charges",""
"HUMERAL STEM 8X95MM","SUP-ITM-10336722","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4450.00","3337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3491.03","78.45","","2085.51","998.68","6202.11","56","2225","3491.03","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","AETNA [1001]","HB CH AETNA HMO / PPO","2726.11","58.3","","1830.28","315.58","1830.28","1 through 10","2078.48","4676","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3413.48","73","","4170.85","4170.85","4170.85","1 through 10","2078.48","4676","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2078.48","44.45","","649.55","649.55","649.55","1 through 10","2078.48","4676","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","WELLPOINT [1015]","HB CH WELLPOINT","3643.07","77.91","","8998.38","2542.37","8998.38","20","2078.48","4676","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2772.87","59.3","","1891.61","1609.14","3664.18","25","2338","3668.32","percent of total billed charges",""
"HUMERAL STEM 9X75MM IMPLANT ELBOW MRS ONC 08","SUP-ITM-10011664","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3668.32","78.45","","1470.68","1310.06","2481.69","19","2338","3668.32","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","AETNA [1001]","HB CH AETNA HMO / PPO","2453.26","58.3","","1634.24","1004.95","1718.99","42","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","2123.89","1900.92","2123.89","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2453.26","58.3","","3729.00","1254.19","3729.00","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2230.24","53","","939.37","939.37","5593.65","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3576.80","85","","2323.25","1864.50","2882.25","16","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4208.00","100","","2909.44","1772.40","10952.08","45","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4208.00","100","","2323.25","2323.25","2323.25","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4208.00","100","","2882.25","1772.40","10169.17","187","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","1659.41","1659.41","1659.41","1 through 10","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","WELLPOINT [1015]","HB CH WELLPOINT","3278.45","77.91","","2050.91","1468.48","2902.83","52","1870.46","4208","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2495.34","59.3","","1548.60","1092.60","3613.79","82","2104","3301.18","percent of total billed charges",""
"HUMERAL STEM 9X75MM PROXIMALIMAL MODULE","SUP-ITM-10030827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3301.18","78.45","","2085.51","998.68","6202.11","56","2104","3301.18","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","AETNA [1001]","HB CH AETNA HMO / PPO","2373.85","58.3","","1634.24","1004.95","1718.99","42","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2972.40","73","","2123.89","1900.92","2123.89","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2373.85","58.3","","3729.00","1254.19","3729.00","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2158.04","53","","939.37","939.37","5593.65","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3461.01","85","","2323.25","1864.50","2882.25","16","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4071.78","100","","2909.44","1772.40","10952.08","45","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4071.78","100","","2323.25","2323.25","2323.25","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4071.78","100","","2882.25","1772.40","10169.17","187","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2972.40","73","","1659.41","1659.41","1659.41","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","WELLPOINT [1015]","HB CH WELLPOINT","3172.32","77.91","","2050.91","1468.48","2902.83","52","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1548.60","1092.60","3613.79","82","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 12 EM CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10132818","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3194.31","78.45","","2085.51","998.68","6202.11","56","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","AETNA [1001]","HB CH AETNA HMO / PPO","2897.51","58.3","","1634.24","1004.95","1718.99","42","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3628.10","73","","2123.89","1900.92","2123.89","1 through 10","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2897.51","58.3","","3729.00","1254.19","3729.00","1 through 10","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2634.10","53","","939.37","939.37","5593.65","1 through 10","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4224.50","85","","2323.25","1864.50","2882.25","16","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4970.00","100","","2909.44","1772.40","10952.08","45","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4970.00","100","","2323.25","2323.25","2323.25","1 through 10","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4970.00","100","","2882.25","1772.40","10169.17","187","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3628.10","73","","1659.41","1659.41","1659.41","1 through 10","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","both","","","4970.00","3727.50","WELLPOINT [1015]","HB CH WELLPOINT","3872.13","77.91","","2050.91","1468.48","2902.83","52","2209.17","4970","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2947.21","59.3","","1548.60","1092.60","3613.79","82","2485","3898.97","percent of total billed charges",""
"HUMERAL STEM SIZE 5 UNIVERS REVERS CAP COATED","SUP-ITM-10191774","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4970.00","3727.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3898.97","78.45","","2085.51","998.68","6202.11","56","2485","3898.97","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","AETNA [1001]","HB CH AETNA HMO / PPO","2373.85","58.3","","1634.24","1004.95","1718.99","42","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2972.40","73","","2123.89","1900.92","2123.89","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2373.85","58.3","","3729.00","1254.19","3729.00","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2158.04","53","","939.37","939.37","5593.65","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3461.01","85","","2323.25","1864.50","2882.25","16","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4071.78","100","","2909.44","1772.40","10952.08","45","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4071.78","100","","2323.25","2323.25","2323.25","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4071.78","100","","2882.25","1772.40","10169.17","187","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2972.40","73","","1659.41","1659.41","1659.41","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","WELLPOINT [1015]","HB CH WELLPOINT","3172.32","77.91","","2050.91","1468.48","2902.83","52","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1548.60","1092.60","3613.79","82","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 7 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3194.31","78.45","","2085.51","998.68","6202.11","56","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","AETNA [1001]","HB CH AETNA HMO / PPO","2373.85","58.3","","1634.24","1004.95","1718.99","42","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2972.40","73","","2123.89","1900.92","2123.89","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2373.85","58.3","","3729.00","1254.19","3729.00","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2158.04","53","","939.37","939.37","5593.65","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3461.01","85","","2323.25","1864.50","2882.25","16","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4071.78","100","","2909.44","1772.40","10952.08","45","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4071.78","100","","2323.25","2323.25","2323.25","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4071.78","100","","2882.25","1772.40","10169.17","187","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2972.40","73","","1659.41","1659.41","1659.41","1 through 10","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","both","","","4071.78","3053.83","WELLPOINT [1015]","HB CH WELLPOINT","3172.32","77.91","","2050.91","1468.48","2902.83","52","1809.91","4071.78","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","2414.57","59.3","","1548.60","1092.60","3613.79","82","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SIZE 8 CAP UNIVERS REVERS IMPLANTABLE","SUP-ITM-10130393","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4071.78","3053.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3194.31","78.45","","2085.51","998.68","6202.11","56","2035.89","3194.31","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","AETNA [1001]","HB CH AETNA HMO / PPO","4197.60","58.3","","1634.24","1004.95","1718.99","42","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5256.00","73","","2123.89","1900.92","2123.89","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4197.60","58.3","","3729.00","1254.19","3729.00","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3816.00","53","","939.37","939.37","5593.65","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6120.00","85","","2323.25","1864.50","2882.25","16","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7200.00","100","","2909.44","1772.40","10952.08","45","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7200.00","100","","2323.25","2323.25","2323.25","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7200.00","100","","2882.25","1772.40","10169.17","187","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5256.00","73","","1659.41","1659.41","1659.41","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","WELLPOINT [1015]","HB CH WELLPOINT","5609.52","77.91","","2050.91","1468.48","2902.83","52","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4269.60","59.3","","1548.60","1092.60","3613.79","82","3600","5648.4","percent of total billed charges",""
"HUMERAL STEM SZ 1 PERFORM SYSTEM","SUP-ITM-10281789","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5648.40","78.45","","2085.51","998.68","6202.11","56","3600","5648.4","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","AETNA [1001]","HB CH AETNA HMO / PPO","5830.00","58.3","","1634.24","1004.95","1718.99","42","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","2123.89","1900.92","2123.89","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5830.00","58.3","","3729.00","1254.19","3729.00","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5300.00","53","","939.37","939.37","5593.65","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8500.00","85","","2323.25","1864.50","2882.25","16","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10000.00","100","","2909.44","1772.40","10952.08","45","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","10000.00","100","","2323.25","2323.25","2323.25","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10000.00","100","","2882.25","1772.40","10169.17","187","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","1659.41","1659.41","1659.41","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB CH WELLPOINT","7791.00","77.91","","2050.91","1468.48","2902.83","52","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5930.00","59.3","","1548.60","1092.60","3613.79","82","5000","7845","percent of total billed charges",""
"HUMERAL STEM SZ 1 PLUS PERFORM LONG","SUP-ITM-10306222","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7845.00","78.45","","2085.51","998.68","6202.11","56","5000","7845","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM SZ 10 140MM STANDARD GLOBAL FX POROCOAT POROUS COATED","SUP-ITM-10042967","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","AETNA [1001]","HB CH AETNA HMO / PPO","4197.60","58.3","","1634.24","1004.95","1718.99","42","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5256.00","73","","2123.89","1900.92","2123.89","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4197.60","58.3","","3729.00","1254.19","3729.00","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3816.00","53","","939.37","939.37","5593.65","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6120.00","85","","2323.25","1864.50","2882.25","16","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7200.00","100","","2909.44","1772.40","10952.08","45","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7200.00","100","","2323.25","2323.25","2323.25","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7200.00","100","","2882.25","1772.40","10169.17","187","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5256.00","73","","1659.41","1659.41","1659.41","1 through 10","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","both","","","7200.00","5400.00","WELLPOINT [1015]","HB CH WELLPOINT","5609.52","77.91","","2050.91","1468.48","2902.83","52","3200.4","7200","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4269.60","59.3","","1548.60","1092.60","3613.79","82","3600","5648.4","percent of total billed charges",""
"HUMERAL STEM SZ 2 PERFORM SYSTEM","SUP-ITM-10281791","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7200.00","5400.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5648.40","78.45","","2085.51","998.68","6202.11","56","3600","5648.4","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","AETNA [1001]","HB CH AETNA HMO / PPO","5830.00","58.3","","1634.24","1004.95","1718.99","42","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","2123.89","1900.92","2123.89","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5830.00","58.3","","3729.00","1254.19","3729.00","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5300.00","53","","939.37","939.37","5593.65","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8500.00","85","","2323.25","1864.50","2882.25","16","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10000.00","100","","2909.44","1772.40","10952.08","45","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","10000.00","100","","2323.25","2323.25","2323.25","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10000.00","100","","2882.25","1772.40","10169.17","187","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7300.00","73","","1659.41","1659.41","1659.41","1 through 10","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","WELLPOINT [1015]","HB CH WELLPOINT","7791.00","77.91","","2050.91","1468.48","2902.83","52","4445","10000","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5930.00","59.3","","1548.60","1092.60","3613.79","82","5000","7845","percent of total billed charges",""
"HUMERAL STEM SZ 2 PLUS PERFORM LONG","SUP-ITM-10306221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7845.00","78.45","","2085.51","998.68","6202.11","56","5000","7845","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"HUMERUS HEAD 46X14MM PLATE BONE HUMERAL AEQUALIS TITANIUM LOW OFFSET","SUP-ITM-10135214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","AETNA [1001]","HB CH AETNA HMO / PPO","1873.53","58.3","","554.95","91.85","1421.75","94","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2345.93","73","","2490.03","2490.03","2490.03","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1873.53","58.3","","750.00","750.00","750.00","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1703.21","53","","1192.50","120.84","4149.90","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2731.56","85","","750.00","75.00","750.00","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3213.60","100","","657.00","121.50","1971.00","14","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3213.60","100","","75.00","75.00","75.00","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3213.60","100","","366.00","144.00","1971.00","45","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2345.93","73","","667.50","667.50","667.50","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1428.45","44.45","","123.77","123.77","123.77","1 through 10","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","both","","","3213.60","2410.20","WELLPOINT [1015]","HB CH WELLPOINT","2503.72","77.91","","483.51","229.32","1316.08","96","1428.45","3213.6","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.60","2410.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1905.66","59.3","","439.50","225.34","1872.27","197","1606.8","2521.07","percent of total billed charges",""
"HUMERUS PLATE 166MM 17 HOLE BONE ALPS ELBOW DISTAL HUMERAL MEDIAL RIGHT","SUP-ITM-10175705","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3213.60","2410.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2521.07","78.45","","385.32","55.36","1815.62","58","1606.8","2521.07","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","AETNA [1001]","HB CH AETNA HMO / PPO","1514.28","58.3","","554.95","91.85","1421.75","94","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","2490.03","2490.03","2490.03","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1514.28","58.3","","750.00","750.00","750.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1376.62","53","","1192.50","120.84","4149.90","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2207.79","85","","750.00","75.00","750.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2597.40","100","","657.00","121.50","1971.00","14","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2597.40","100","","75.00","75.00","75.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2597.40","100","","366.00","144.00","1971.00","45","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","667.50","667.50","667.50","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","123.77","123.77","123.77","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","WELLPOINT [1015]","HB CH WELLPOINT","2023.63","77.91","","483.51","229.32","1316.08","96","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1540.26","59.3","","439.50","225.34","1872.27","197","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7-3.5X108MM LONG 4 HOLE BONE VA LCP SS EXTENDED DISTAL MEDIAL LEFT","SUP-ITM-10114074","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","385.32","55.36","1815.62","58","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","AETNA [1001]","HB CH AETNA HMO / PPO","1666.36","58.3","","554.95","91.85","1421.75","94","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2086.52","73","","2490.03","2490.03","2490.03","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1666.36","58.3","","750.00","750.00","750.00","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1514.87","53","","1192.50","120.84","4149.90","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2429.51","85","","750.00","75.00","750.00","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2858.25","100","","657.00","121.50","1971.00","14","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2858.25","100","","75.00","75.00","75.00","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2858.25","100","","366.00","144.00","1971.00","45","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2086.52","73","","667.50","667.50","667.50","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1270.49","44.45","","123.77","123.77","123.77","1 through 10","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","WELLPOINT [1015]","HB CH WELLPOINT","2226.86","77.91","","483.51","229.32","1316.08","96","1270.49","2858.25","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","1694.94","59.3","","439.50","225.34","1872.27","197","1429.13","2242.3","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X153MM EXTRA LONG 9 HOLE VA LCP POSTEROLATERAL DISTAL TITANIUM RT","SUP-ITM-10125540","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2242.30","78.45","","385.32","55.36","1815.62","58","1429.13","2242.3","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","AETNA [1001]","HB CH AETNA HMO / PPO","1514.28","58.3","","554.95","91.85","1421.75","94","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","2490.03","2490.03","2490.03","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1514.28","58.3","","750.00","750.00","750.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1376.62","53","","1192.50","120.84","4149.90","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2207.79","85","","750.00","75.00","750.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2597.40","100","","657.00","121.50","1971.00","14","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2597.40","100","","75.00","75.00","75.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2597.40","100","","366.00","144.00","1971.00","45","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","667.50","667.50","667.50","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","123.77","123.77","123.77","1 through 10","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","WELLPOINT [1015]","HB CH WELLPOINT","2023.63","77.91","","483.51","229.32","1316.08","96","1154.54","2597.4","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1540.26","59.3","","439.50","225.34","1872.27","197","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 2.7/3.5X82MM MED 2 HOLE VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10114090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","385.32","55.36","1815.62","58","1298.7","2037.66","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","554.95","91.85","1421.75","94","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","2490.03","2490.03","2490.03","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2207.97","58.3","","750.00","750.00","750.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","1192.50","120.84","4149.90","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.16","85","","750.00","75.00","750.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.25","100","","657.00","121.50","1971.00","14","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.25","100","","75.00","75.00","75.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.25","100","","366.00","144.00","1971.00","45","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","667.50","667.50","667.50","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","123.77","123.77","123.77","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","483.51","229.32","1316.08","96","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","439.50","225.34","1872.27","197","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 3 HOLE DISTAL LATERAL RIGHT","SUP-ITM-10146195","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","385.32","55.36","1815.62","58","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","AETNA [1001]","HB CH AETNA HMO / PPO","1041.88","58.3","","554.95","91.85","1421.75","94","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1304.58","73","","2490.03","2490.03","2490.03","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1041.88","58.3","","750.00","750.00","750.00","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","947.16","53","","1192.50","120.84","4149.90","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1519.04","85","","750.00","75.00","750.00","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1787.10","100","","657.00","121.50","1971.00","14","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1787.10","100","","75.00","75.00","75.00","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1787.10","100","","366.00","144.00","1971.00","45","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1304.58","73","","667.50","667.50","667.50","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","794.37","44.45","","123.77","123.77","123.77","1 through 10","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","both","","","1787.10","1340.32","WELLPOINT [1015]","HB CH WELLPOINT","1392.33","77.91","","483.51","229.32","1316.08","96","794.37","1787.1","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","1059.75","59.3","","439.50","225.34","1872.27","197","893.55","1401.98","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 3 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10013763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1787.10","1340.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1401.98","78.45","","385.32","55.36","1815.62","58","893.55","1401.98","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","AETNA [1001]","HB CH AETNA HMO / PPO","1156.42","58.3","","554.95","91.85","1421.75","94","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1448.01","73","","2490.03","2490.03","2490.03","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.42","58.3","","750.00","750.00","750.00","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.29","53","","1192.50","120.84","4149.90","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1686.03","85","","750.00","75.00","750.00","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1983.57","100","","657.00","121.50","1971.00","14","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1983.57","100","","75.00","75.00","75.00","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1983.57","100","","366.00","144.00","1971.00","45","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.01","73","","667.50","667.50","667.50","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","881.70","44.45","","123.77","123.77","123.77","1 through 10","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","both","","","1983.57","1487.68","WELLPOINT [1015]","HB CH WELLPOINT","1545.40","77.91","","483.51","229.32","1316.08","96","881.7","1983.57","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1983.57","1487.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.26","59.3","","439.50","225.34","1872.27","197","991.79","1556.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 5 HOLE DISTAL MEDIAL LCP LOCKING SS LEFT","SUP-ITM-10014061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1983.57","1487.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.11","78.45","","385.32","55.36","1815.62","58","991.79","1556.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","AETNA [1001]","HB CH AETNA HMO / PPO","1271.61","58.3","","554.95","91.85","1421.75","94","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1592.24","73","","2490.03","2490.03","2490.03","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1271.61","58.3","","750.00","750.00","750.00","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1156.01","53","","1192.50","120.84","4149.90","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1853.98","85","","750.00","75.00","750.00","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2181.15","100","","657.00","121.50","1971.00","14","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2181.15","100","","75.00","75.00","75.00","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2181.15","100","","366.00","144.00","1971.00","45","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1592.24","73","","667.50","667.50","667.50","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","969.52","44.45","","123.77","123.77","123.77","1 through 10","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","both","","","2181.15","1635.86","WELLPOINT [1015]","HB CH WELLPOINT","1699.33","77.91","","483.51","229.32","1316.08","96","969.52","2181.15","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2181.15","1635.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","1293.42","59.3","","439.50","225.34","1872.27","197","1090.58","1711.11","percent of total billed charges",""
"HUMERUS PLATE 3.5MM 7 HOLE DISTAL MEDIAL LCP LOCKING SS RIGHT","SUP-ITM-10013256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2181.15","1635.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1711.11","78.45","","385.32","55.36","1815.62","58","1090.58","1711.11","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","AETNA [1001]","HB CH AETNA HMO / PPO","1772.63","58.3","","554.95","91.85","1421.75","94","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2219.59","73","","2490.03","2490.03","2490.03","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1772.63","58.3","","750.00","750.00","750.00","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1611.48","53","","1192.50","120.84","4149.90","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2584.45","85","","750.00","75.00","750.00","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3040.53","100","","657.00","121.50","1971.00","14","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3040.53","100","","75.00","75.00","75.00","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3040.53","100","","366.00","144.00","1971.00","45","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2219.59","73","","667.50","667.50","667.50","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1351.52","44.45","","123.77","123.77","123.77","1 through 10","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","both","","","3040.53","2280.40","WELLPOINT [1015]","HB CH WELLPOINT","2368.88","77.91","","483.51","229.32","1316.08","96","1351.52","3040.53","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.53","2280.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","1803.03","59.3","","439.50","225.34","1872.27","197","1520.27","2385.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X122MM 4 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10021235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3040.53","2280.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2385.30","78.45","","385.32","55.36","1815.62","58","1520.27","2385.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","AETNA [1001]","HB CH AETNA HMO / PPO","2203.22","58.3","","554.95","91.85","1421.75","94","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2758.74","73","","2490.03","2490.03","2490.03","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2203.22","58.3","","750.00","750.00","750.00","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2002.92","53","","1192.50","120.84","4149.90","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3212.24","85","","750.00","75.00","750.00","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3779.10","100","","657.00","121.50","1971.00","14","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3779.10","100","","75.00","75.00","75.00","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3779.10","100","","366.00","144.00","1971.00","45","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2758.74","73","","667.50","667.50","667.50","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1679.81","44.45","","123.77","123.77","123.77","1 through 10","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3779.10","2834.32","WELLPOINT [1015]","HB CH WELLPOINT","2944.30","77.91","","483.51","229.32","1316.08","96","1679.81","3779.1","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3779.10","2834.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","2241.01","59.3","","439.50","225.34","1872.27","197","1889.55","2964.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X127MM 4 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3779.10","2834.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2964.70","78.45","","385.32","55.36","1815.62","58","1889.55","2964.7","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","AETNA [1001]","HB CH AETNA HMO / PPO","2392.21","58.3","","554.95","91.85","1421.75","94","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2995.39","73","","2490.03","2490.03","2490.03","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2392.21","58.3","","750.00","750.00","750.00","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2174.74","53","","1192.50","120.84","4149.90","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3487.79","85","","750.00","75.00","750.00","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4103.28","100","","657.00","121.50","1971.00","14","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4103.28","100","","75.00","75.00","75.00","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4103.28","100","","366.00","144.00","1971.00","45","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2995.39","73","","667.50","667.50","667.50","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1823.91","44.45","","123.77","123.77","123.77","1 through 10","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","both","","","4103.28","3077.46","WELLPOINT [1015]","HB CH WELLPOINT","3196.87","77.91","","483.51","229.32","1316.08","96","1823.91","4103.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4103.28","3077.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","2433.25","59.3","","439.50","225.34","1872.27","197","2051.64","3219.02","percent of total billed charges",""
"HUMERUS PLATE 3.5X145MM 5 HOLE LCP SS PROXIMAL PERIARTICULAR LT","SUP-ITM-10090939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4103.28","3077.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3219.02","78.45","","385.32","55.36","1815.62","58","2051.64","3219.02","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","AETNA [1001]","HB CH AETNA HMO / PPO","2027.58","58.3","","554.95","91.85","1421.75","94","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2538.82","73","","2490.03","2490.03","2490.03","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2027.58","58.3","","750.00","750.00","750.00","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1843.26","53","","1192.50","120.84","4149.90","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2956.16","85","","750.00","75.00","750.00","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3477.84","100","","657.00","121.50","1971.00","14","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3477.84","100","","75.00","75.00","75.00","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3477.84","100","","366.00","144.00","1971.00","45","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2538.82","73","","667.50","667.50","667.50","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1545.90","44.45","","123.77","123.77","123.77","1 through 10","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3477.84","2608.38","WELLPOINT [1015]","HB CH WELLPOINT","2709.59","77.91","","483.51","229.32","1316.08","96","1545.9","3477.84","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3477.84","2608.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","2062.36","59.3","","439.50","225.34","1872.27","197","1738.92","2728.37","percent of total billed charges",""
"HUMERUS PLATE 3.5X158MM 6 HOLE DISTAL EXTRA ARTICULAR LCP LEFT","SUP-ITM-10022934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3477.84","2608.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2728.37","78.45","","385.32","55.36","1815.62","58","1738.92","2728.37","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","AETNA [1001]","HB CH AETNA HMO / PPO","2451.12","58.3","","554.95","91.85","1421.75","94","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3069.16","73","","2490.03","2490.03","2490.03","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2451.12","58.3","","750.00","750.00","750.00","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2228.29","53","","1192.50","120.84","4149.90","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3573.68","85","","750.00","75.00","750.00","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4204.33","100","","657.00","121.50","1971.00","14","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4204.33","100","","75.00","75.00","75.00","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4204.33","100","","366.00","144.00","1971.00","45","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3069.16","73","","667.50","667.50","667.50","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1868.82","44.45","","123.77","123.77","123.77","1 through 10","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","both","","","4204.33","3153.25","WELLPOINT [1015]","HB CH WELLPOINT","3275.59","77.91","","483.51","229.32","1316.08","96","1868.82","4204.33","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4204.33","3153.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2493.17","59.3","","439.50","225.34","1872.27","197","2102.17","3298.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X163MM 6 HOLE LCP SS PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10079599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4204.33","3153.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3298.30","78.45","","385.32","55.36","1815.62","58","2102.17","3298.3","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","AETNA [1001]","HB CH AETNA HMO / PPO","2152.42","58.3","","554.95","91.85","1421.75","94","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2695.15","73","","2490.03","2490.03","2490.03","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2152.42","58.3","","750.00","750.00","750.00","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1956.75","53","","1192.50","120.84","4149.90","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3138.18","85","","750.00","75.00","750.00","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3691.98","100","","657.00","121.50","1971.00","14","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3691.98","100","","75.00","75.00","75.00","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3691.98","100","","366.00","144.00","1971.00","45","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2695.15","73","","667.50","667.50","667.50","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1641.09","44.45","","123.77","123.77","123.77","1 through 10","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3691.98","2768.98","WELLPOINT [1015]","HB CH WELLPOINT","2876.42","77.91","","483.51","229.32","1316.08","96","1641.09","3691.98","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3691.98","2768.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","2189.34","59.3","","439.50","225.34","1872.27","197","1845.99","2896.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE DISTAL EXTRA ARTICULAR LCP RIGHT","SUP-ITM-10022937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3691.98","2768.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2896.36","78.45","","385.32","55.36","1815.62","58","1845.99","2896.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","AETNA [1001]","HB CH AETNA HMO / PPO","1972.31","58.3","","554.95","91.85","1421.75","94","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2469.61","73","","2490.03","2490.03","2490.03","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1972.31","58.3","","750.00","750.00","750.00","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1793.01","53","","1192.50","120.84","4149.90","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2875.58","85","","750.00","75.00","750.00","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3383.03","100","","657.00","121.50","1971.00","14","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3383.03","100","","75.00","75.00","75.00","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3383.03","100","","366.00","144.00","1971.00","45","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2469.61","73","","667.50","667.50","667.50","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1503.76","44.45","","123.77","123.77","123.77","1 through 10","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","both","","","3383.03","2537.27","WELLPOINT [1015]","HB CH WELLPOINT","2635.72","77.91","","483.51","229.32","1316.08","96","1503.76","3383.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3383.03","2537.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","2006.14","59.3","","439.50","225.34","1872.27","197","1691.52","2653.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X194MM 8 HOLE LCP STEEL EXTRA ARTICULAR DISTAL LT STERILE","SUP-ITM-10036533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3383.03","2537.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2653.99","78.45","","385.32","55.36","1815.62","58","1691.52","2653.99","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","AETNA [1001]","HB CH AETNA HMO / PPO","2004.75","58.3","","554.95","91.85","1421.75","94","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2510.24","73","","2490.03","2490.03","2490.03","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2004.75","58.3","","750.00","750.00","750.00","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1822.50","53","","1192.50","120.84","4149.90","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2922.88","85","","750.00","75.00","750.00","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3438.68","100","","657.00","121.50","1971.00","14","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3438.68","100","","75.00","75.00","75.00","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3438.68","100","","366.00","144.00","1971.00","45","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2510.24","73","","667.50","667.50","667.50","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1528.49","44.45","","123.77","123.77","123.77","1 through 10","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","both","","","3438.68","2579.01","WELLPOINT [1015]","HB CH WELLPOINT","2679.08","77.91","","483.51","229.32","1316.08","96","1528.49","3438.68","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3438.68","2579.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","2039.14","59.3","","439.50","225.34","1872.27","197","1719.34","2697.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X196MM LONG 8 HOLE SHAFT PROXIMAL LCP","SUP-ITM-10017461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3438.68","2579.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2697.64","78.45","","385.32","55.36","1815.62","58","1719.34","2697.64","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","AETNA [1001]","HB CH AETNA HMO / PPO","2523.82","58.3","","554.95","91.85","1421.75","94","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3160.19","73","","2490.03","2490.03","2490.03","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2523.82","58.3","","750.00","750.00","750.00","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2294.39","53","","1192.50","120.84","4149.90","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3679.68","85","","750.00","75.00","750.00","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4329.03","100","","657.00","121.50","1971.00","14","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4329.03","100","","75.00","75.00","75.00","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4329.03","100","","366.00","144.00","1971.00","45","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3160.19","73","","667.50","667.50","667.50","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1924.25","44.45","","123.77","123.77","123.77","1 through 10","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","both","","","4329.03","3246.77","WELLPOINT [1015]","HB CH WELLPOINT","3372.75","77.91","","483.51","229.32","1316.08","96","1924.25","4329.03","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4329.03","3246.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2567.11","59.3","","439.50","225.34","1872.27","197","2164.52","3396.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X199MM 8 HOLE LCP SS PROXIMAL PERIARTICULAR LEFT","SUP-ITM-10090941","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4329.03","3246.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3396.12","78.45","","385.32","55.36","1815.62","58","2164.52","3396.12","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","AETNA [1001]","HB CH AETNA HMO / PPO","1898.35","58.3","","554.95","91.85","1421.75","94","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2377.01","73","","2490.03","2490.03","2490.03","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1898.35","58.3","","750.00","750.00","750.00","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1725.78","53","","1192.50","120.84","4149.90","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2767.75","85","","750.00","75.00","750.00","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3256.18","100","","657.00","121.50","1971.00","14","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3256.18","100","","75.00","75.00","75.00","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3256.18","100","","366.00","144.00","1971.00","45","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2377.01","73","","667.50","667.50","667.50","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1447.37","44.45","","123.77","123.77","123.77","1 through 10","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","both","","","3256.18","2442.13","WELLPOINT [1015]","HB CH WELLPOINT","2536.89","77.91","","483.51","229.32","1316.08","96","1447.37","3256.18","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.18","2442.13","CIGNA [1006]","HB CH CIGNA HMO / PPO","1930.91","59.3","","439.50","225.34","1872.27","197","1628.09","2554.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X230MM 10 HOLE LCP SS EXTRA ARTICULAR DISTAL LEFT","SUP-ITM-10022935","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3256.18","2442.13","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2554.47","78.45","","385.32","55.36","1815.62","58","1628.09","2554.47","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","AETNA [1001]","HB CH AETNA HMO / PPO","2196.55","58.3","","554.95","91.85","1421.75","94","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2750.39","73","","2490.03","2490.03","2490.03","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2196.55","58.3","","750.00","750.00","750.00","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1996.86","53","","1192.50","120.84","4149.90","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3202.51","85","","750.00","75.00","750.00","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3767.66","100","","657.00","121.50","1971.00","14","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3767.66","100","","75.00","75.00","75.00","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3767.66","100","","366.00","144.00","1971.00","45","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2750.39","73","","667.50","667.50","667.50","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1674.72","44.45","","123.77","123.77","123.77","1 through 10","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","both","","","3767.66","2825.74","WELLPOINT [1015]","HB CH WELLPOINT","2935.38","77.91","","483.51","229.32","1316.08","96","1674.72","3767.66","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3767.66","2825.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","2234.22","59.3","","439.50","225.34","1872.27","197","1883.83","2955.73","percent of total billed charges",""
"HUMERUS PLATE 3.5X271MM 12 HOLE LCP SS RIGHT PROXIMAL PERIARTICULAR","SUP-ITM-10090943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3767.66","2825.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2955.73","78.45","","385.32","55.36","1815.62","58","1883.83","2955.73","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","AETNA [1001]","HB CH AETNA HMO / PPO","1195.25","58.3","","554.95","91.85","1421.75","94","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1496.62","73","","2490.03","2490.03","2490.03","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1195.25","58.3","","750.00","750.00","750.00","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1086.59","53","","1192.50","120.84","4149.90","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1742.64","85","","750.00","75.00","750.00","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2050.17","100","","657.00","121.50","1971.00","14","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2050.17","100","","75.00","75.00","75.00","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2050.17","100","","366.00","144.00","1971.00","45","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1496.62","73","","667.50","667.50","667.50","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","911.30","44.45","","123.77","123.77","123.77","1 through 10","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","both","","","2050.17","1537.63","WELLPOINT [1015]","HB CH WELLPOINT","1597.29","77.91","","483.51","229.32","1316.08","96","911.3","2050.17","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2050.17","1537.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","1215.75","59.3","","439.50","225.34","1872.27","197","1025.09","1608.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X65MM 3 HOLE LCP SS LEFT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014441","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2050.17","1537.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1608.36","78.45","","385.32","55.36","1815.62","58","1025.09","1608.36","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","AETNA [1001]","HB CH AETNA HMO / PPO","2138.99","58.3","","554.95","91.85","1421.75","94","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2678.33","73","","2490.03","2490.03","2490.03","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2138.99","58.3","","750.00","750.00","750.00","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1944.54","53","","1192.50","120.84","4149.90","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3118.60","85","","750.00","75.00","750.00","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3668.94","100","","657.00","121.50","1971.00","14","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3668.94","100","","75.00","75.00","75.00","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3668.94","100","","366.00","144.00","1971.00","45","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2678.33","73","","667.50","667.50","667.50","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1630.84","44.45","","123.77","123.77","123.77","1 through 10","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","both","","","3668.94","2751.70","WELLPOINT [1015]","HB CH WELLPOINT","2858.47","77.91","","483.51","229.32","1316.08","96","1630.84","3668.94","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3668.94","2751.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2175.68","59.3","","439.50","225.34","1872.27","197","1834.47","2878.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X90MM 6 HOLE HD 3 SHAFT PROXIMAL LCP STANDARD","SUP-ITM-10010226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3668.94","2751.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2878.28","78.45","","385.32","55.36","1815.62","58","1834.47","2878.28","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","AETNA [1001]","HB CH AETNA HMO / PPO","1303.32","58.3","","554.95","91.85","1421.75","94","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1631.94","73","","2490.03","2490.03","2490.03","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1303.32","58.3","","750.00","750.00","750.00","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1184.84","53","","1192.50","120.84","4149.90","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1900.21","85","","750.00","75.00","750.00","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2235.54","100","","657.00","121.50","1971.00","14","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2235.54","100","","75.00","75.00","75.00","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2235.54","100","","366.00","144.00","1971.00","45","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1631.94","73","","667.50","667.50","667.50","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.70","44.45","","123.77","123.77","123.77","1 through 10","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","both","","","2235.54","1676.65","WELLPOINT [1015]","HB CH WELLPOINT","1741.71","77.91","","483.51","229.32","1316.08","96","993.7","2235.54","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2235.54","1676.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","1325.68","59.3","","439.50","225.34","1872.27","197","1117.77","1753.78","percent of total billed charges",""
"HUMERUS PLATE 3.5X91MM 5 HOLE HUMERAL LCP SS RT LATERAL SUPPORT DORSOLATERAL DISTAL","SUP-ITM-10014442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2235.54","1676.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1753.78","78.45","","385.32","55.36","1815.62","58","1117.77","1753.78","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","AETNA [1001]","HB CH AETNA HMO / PPO","1681.49","58.3","","554.95","91.85","1421.75","94","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2105.47","73","","2490.03","2490.03","2490.03","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1681.49","58.3","","750.00","750.00","750.00","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1528.63","53","","1192.50","120.84","4149.90","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2451.57","85","","750.00","75.00","750.00","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2884.20","100","","657.00","121.50","1971.00","14","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2884.20","100","","75.00","75.00","75.00","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2884.20","100","","366.00","144.00","1971.00","45","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2105.47","73","","667.50","667.50","667.50","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1282.03","44.45","","123.77","123.77","123.77","1 through 10","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","WELLPOINT [1015]","HB CH WELLPOINT","2247.08","77.91","","483.51","229.32","1316.08","96","1282.03","2884.2","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2884.20","2163.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","1710.33","59.3","","439.50","225.34","1872.27","197","1442.1","2262.65","percent of total billed charges",""
"HUMERUS PLATE 7 HOLE BONE ELBOW LATERAL HUMERAL RIGHT","SUP-ITM-10071489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2884.20","2163.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2262.65","78.45","","385.32","55.36","1815.62","58","1442.1","2262.65","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","554.95","91.85","1421.75","94","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","2490.03","2490.03","2490.03","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2207.97","58.3","","750.00","750.00","750.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","1192.50","120.84","4149.90","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.16","85","","750.00","75.00","750.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.25","100","","657.00","121.50","1971.00","14","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.25","100","","75.00","75.00","75.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.25","100","","366.00","144.00","1971.00","45","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","667.50","667.50","667.50","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","123.77","123.77","123.77","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","483.51","229.32","1316.08","96","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","439.50","225.34","1872.27","197","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 72MM 3 HOLE DISTAL MEDIAL LT / RIGHT","SUP-ITM-10165190","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","385.32","55.36","1815.62","58","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","AETNA [1001]","HB CH AETNA HMO / PPO","2311.89","58.3","","554.95","91.85","1421.75","94","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2894.82","73","","2490.03","2490.03","2490.03","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2311.89","58.3","","750.00","750.00","750.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2101.72","53","","1192.50","120.84","4149.90","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3370.68","85","","750.00","75.00","750.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3965.50","100","","657.00","121.50","1971.00","14","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3965.50","100","","75.00","75.00","75.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3965.50","100","","366.00","144.00","1971.00","45","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2894.82","73","","667.50","667.50","667.50","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.66","44.45","","123.77","123.77","123.77","1 through 10","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","WELLPOINT [1015]","HB CH WELLPOINT","3089.52","77.91","","483.51","229.32","1316.08","96","1762.66","3965.5","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3965.50","2974.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2351.54","59.3","","439.50","225.34","1872.27","197","1982.75","3110.93","percent of total billed charges",""
"HUMERUS PLATE 73MM PROXIMALIMAL A.L.P.S. LOW 3 HOLE LEFT","SUP-ITM-10175477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3965.50","2974.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3110.93","78.45","","385.32","55.36","1815.62","58","1982.75","3110.93","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","AETNA [1001]","HB CH AETNA HMO / PPO","2416.97","58.3","","554.95","91.85","1421.75","94","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3026.40","73","","2490.03","2490.03","2490.03","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2416.97","58.3","","750.00","750.00","750.00","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2197.25","53","","1192.50","120.84","4149.90","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3523.89","85","","750.00","75.00","750.00","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4145.75","100","","657.00","121.50","1971.00","14","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4145.75","100","","75.00","75.00","75.00","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4145.75","100","","366.00","144.00","1971.00","45","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3026.40","73","","667.50","667.50","667.50","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1842.79","44.45","","123.77","123.77","123.77","1 through 10","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","both","","","4145.75","3109.31","WELLPOINT [1015]","HB CH WELLPOINT","3229.95","77.91","","483.51","229.32","1316.08","96","1842.79","4145.75","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4145.75","3109.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","2458.43","59.3","","439.50","225.34","1872.27","197","2072.88","3252.34","percent of total billed charges",""
"HUMERUS PLATE 90MM PROXIMALIMAL A.L.P.S. HIGH 4 HOLE LEFT","SUP-ITM-10175172","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4145.75","3109.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3252.34","78.45","","385.32","55.36","1815.62","58","2072.88","3252.34","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","554.95","91.85","1421.75","94","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","2490.03","2490.03","2490.03","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2207.97","58.3","","750.00","750.00","750.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","1192.50","120.84","4149.90","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.16","85","","750.00","75.00","750.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.25","100","","657.00","121.50","1971.00","14","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.25","100","","75.00","75.00","75.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.25","100","","366.00","144.00","1971.00","45","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","667.50","667.50","667.50","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1683.43","44.45","","123.77","123.77","123.77","1 through 10","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","483.51","229.32","1316.08","96","1683.43","3787.25","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","439.50","225.34","1872.27","197","1893.63","2971.1","percent of total billed charges",""
"HUMERUS PLATE L 84MM 3 HOLE DISTAL LATERAL FOR LT / 629203","SUP-ITM-10138628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","385.32","55.36","1815.62","58","1893.63","2971.1","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","AETNA [1001]","HB CH AETNA HMO / PPO","2573.36","58.3","","1634.24","1004.95","1718.99","42","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","2123.89","1900.92","2123.89","1 through 10","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2573.36","58.3","","3729.00","1254.19","3729.00","1 through 10","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2339.42","53","","939.37","939.37","5593.65","1 through 10","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3751.90","85","","2323.25","1864.50","2882.25","16","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4414.00","100","","2909.44","1772.40","10952.08","45","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4414.00","100","","2323.25","2323.25","2323.25","1 through 10","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4414.00","100","","2882.25","1772.40","10169.17","187","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","1659.41","1659.41","1659.41","1 through 10","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","WELLPOINT [1015]","HB CH WELLPOINT","3438.95","77.91","","2050.91","1468.48","2902.83","52","1962.02","4414","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2617.50","59.3","","1548.60","1092.60","3613.79","82","2207","3462.78","percent of total billed charges",""
"HUMERUS STEM 25MMX75 HUMERAL PROXIMALIMAL MODULAR COBALT","SUP-ITM-10035497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3462.78","78.45","","2085.51","998.68","6202.11","56","2207","3462.78","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","AETNA [1001]","HB CH AETNA HMO / PPO","2726.11","58.3","","1830.28","315.58","1830.28","1 through 10","2078.48","4676","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3413.48","73","","4170.85","4170.85","4170.85","1 through 10","2078.48","4676","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2078.48","44.45","","649.55","649.55","649.55","1 through 10","2078.48","4676","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","WELLPOINT [1015]","HB CH WELLPOINT","3643.07","77.91","","8998.38","2542.37","8998.38","20","2078.48","4676","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2772.87","59.3","","1891.61","1609.14","3664.18","25","2338","3668.32","percent of total billed charges",""
"HUMERUS STEM 7X115MM IMPLANT ELBOW HUMERAL MRS ONC 08","SUP-ITM-10010874","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3668.32","78.45","","1470.68","1310.06","2481.69","19","2338","3668.32","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","AETNA [1001]","HB CH AETNA HMO / PPO","3148.20","58.3","","1634.24","1004.95","1718.99","42","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3942.00","73","","2123.89","1900.92","2123.89","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3148.20","58.3","","3729.00","1254.19","3729.00","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2862.00","53","","939.37","939.37","5593.65","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4590.00","85","","2323.25","1864.50","2882.25","16","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5400.00","100","","2909.44","1772.40","10952.08","45","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5400.00","100","","2323.25","2323.25","2323.25","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5400.00","100","","2882.25","1772.40","10169.17","187","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3942.00","73","","1659.41","1659.41","1659.41","1 through 10","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB CH WELLPOINT","4207.14","77.91","","2050.91","1468.48","2902.83","52","2400.3","5400","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1548.60","1092.60","3613.79","82","2700","4236.3","percent of total billed charges",""
"HUMERUS STEM SIZE 4 SHOULDER HUMERAL AEQUALIS PURE TITANIUM COAT ASCEND FLEXIABLE STANDARD ANATOMIC C","SUP-ITM-10135225","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","2085.51","998.68","6202.11","56","2700","4236.3","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","both","","","224.00","168.00","AETNA [1001]","HB CH AETNA HMO / PPO","130.59","58.3","","123.61","123.61","123.61","1 through 10","26.63","163.52","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","224.00","168.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.83","59.3","","127.75","127.75","127.75","1 through 10","28.01","175.73","percent of total billed charges",""
"Hydroxyprogesterone 17-D","PX-30000517","CDM","83498","CPT","0301","RC","","","","outpatient","","","224.00","168.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","175.73","78.45","","167.60","99.32","167.60","1 through 10","28.01","175.73","percent of total billed charges",""
"Hymenectomy Part or Revision","PX-76001337","CDM","56700","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2269.49","49.07","","3818.15","3818.15","3818.15","1 through 10","1850","3628.31","percent of total billed charges",""
"Hymenectomy Part or Revision","PX-76001337","CDM","56700","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2317.13","50.1","","3904.56","3823.55","3904.56","1 through 10","1850","3628.31","percent of total billed charges",""
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","36455.83","27341.87","MEDICARE [2001]","HB BWF MEDICARE","11296.13","","Case rate ($11,296.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,313.98, add-ons for qualifying new technology services are included. If operating cost exceeds $56,837.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,402.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,115.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,974.74 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.28. The transfer capital threshold is the transfer adjustment factor * $841.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11853.98","11853.98","11853.98","1 through 10","11070.21","11635.01","other","Inpatient Replacement Plans DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","36455.83","27341.87","MOLINA [1014]","HB BWF MEDICARE","11296.13","","Case rate ($11,296.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,313.98, add-ons for qualifying new technology services are included. If operating cost exceeds $56,837.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,402.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,115.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,974.74 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.28. The transfer capital threshold is the transfer adjustment factor * $841.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21636.59","21636.59","21636.59","1 through 10","11070.21","11635.01","other","Inpatient Replacement Plans DRG"
"Hypertension With McC","304","MS-DRG","","","","","","","","inpatient","","","36455.83","27341.87","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11070.21","","Case rate ($11,296.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,313.98, add-ons for qualifying new technology services are included. If operating cost exceeds $56,837.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,402.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $10,115.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,974.74 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $841.28. The transfer capital threshold is the transfer adjustment factor * $841.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12211.10","12211.10","12211.10","1 through 10","11070.21","11635.01","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","25978.59","19483.94","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7145.97","","Case rate ($7,291.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,303.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,826.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,418.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,963.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.83. The transfer capital threshold is the transfer adjustment factor * $533.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6954.86","6954.86","6954.86","1 through 10","7145.97","7956.54","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","25978.59","19483.94","HUMANA [1012]","HB BWF MEDICARE","7956.54","","Case rate ($7,956.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,303.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,826.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,083.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,963.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.83. The transfer capital threshold is the transfer adjustment factor * $533.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","3014.65","3014.65","3014.65","1 through 10","7145.97","7956.54","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","25978.59","19483.94","MEDICARE [2001]","HB BWF MEDICARE","7956.54","","Case rate ($7,956.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,303.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,826.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,083.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,963.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.83. The transfer capital threshold is the transfer adjustment factor * $533.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7665.39","534.73","7715.72","15","7145.97","7956.54","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","25978.59","19483.94","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7145.97","","Case rate ($7,291.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,303.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,826.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,418.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,963.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.83. The transfer capital threshold is the transfer adjustment factor * $533.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6945.34","6945.34","6945.34","1 through 10","7145.97","7956.54","other","Inpatient DRG"
"Hypertension Without McC","305","MS-DRG","","","","","","","","inpatient","","","25978.59","19483.94","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7145.97","","Case rate ($7,291.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,303.14, add-ons for qualifying new technology services are included. If operating cost exceeds $52,826.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,418.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,963.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.83. The transfer capital threshold is the transfer adjustment factor * $533.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6936.34","6936.34","6936.34","1 through 10","7145.97","7956.54","other","Inpatient DRG"
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","52024.54","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7505.08","","Fee schedule rate ($7,505.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7505.08","7505.08","7505.08","1 through 10","3740.11","29925.66","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","52030.67","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21786.12","","Standard inlier is a Case rate ($21,786.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,453, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,092.45) for the length of stay and the standard reimbursement.","20795.84","20795.84","21786.11","1 through 10","3740.11","29925.66","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","52030.67","","MASSHEALTH [3001]","HB BWF MEDICAID","9446.22","","Case rate ($10,444.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,874.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10441.86","10441.86","10441.86","1 through 10","3740.11","29925.66","case rate",""
"Hypertension,MAJOR","199","DRG","","","","","","","","inpatient","","","52030.67","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9446.22","","Case rate ($10,444.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,874.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10441.86","10441.86","10441.86","1 through 10","3740.11","29925.66","case rate",""
"Hypertension,MINOR","199","DRG","","","","","","","","inpatient","","","11046.04","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12943.16","","Standard inlier is a Case rate ($12,943.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,008, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,837.23) for the length of stay and the standard reimbursement.","12943.16","12943.16","12943.16","1 through 10","3740.11","29925.66","case rate",""
"Hypertension,MODERATE","199","DRG","","","","","","","","inpatient","","","20559.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14723.71","","Standard inlier is a Case rate ($14,723.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,008, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,090.09) for the length of stay and the standard reimbursement.","14723.70","14723.70","14723.70","1 through 10","3740.11","29925.66","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","25151.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12890.49","","Standard inlier is a Case rate ($12,890.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,959, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,829.75) for the length of stay and the standard reimbursement.","1723.29","1723.29","1723.29","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","25151.97","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4641.43","","Case rate ($5,131.90). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,561.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8778.79","8778.79","8778.79","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MAJOR","422","DRG","","","","","","","","inpatient","","","25151.97","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4641.43","","Case rate ($5,131.90). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,561.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8778.79","8778.79","8778.79","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","18230.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12000.09","","Standard inlier is a Case rate ($12,000.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $19,919, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,703.46) for the length of stay and the standard reimbursement.","11454.78","11454.78","11454.78","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","18230.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12890.49","","Standard inlier is a Case rate ($12,890.49). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,959, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,829.75) for the length of stay and the standard reimbursement.","12890.49","12890.49","12890.49","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","18230.54","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","6925.6848","","Fee schedule rate ($10,349.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6925.6848","19952.38","19952.38","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","18230.54","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4641.43","","Case rate ($5,131.90). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,561.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5130.64","5130.64","5130.64","1 through 10","4641.43","31950.58","case rate",""
"Hypovolemia And Related Electrolyte Disorders,MODERATE","422","DRG","","","","","","","","inpatient","","","18230.54","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4641.43","","Case rate ($5,131.90). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,561.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5130.64","5130.64","5130.64","1 through 10","4641.43","31950.58","case rate",""
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","6812.97","6812.97","6812.97","1 through 10","3713.25","7939.38","other","ASC "
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","41959.75","41959.75","41959.75","1 through 10","3713.25","7939.38","other","Multiple Surgery"
"Hysteroscopy Ablat Endometrial","PX-76001397","CDM","58563","CPT","0761","RC","","","","outpatient","","","9474.00","7105.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","27515.19","27515.19","27515.19","1 through 10","3713.25","7939.38","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","3888.77","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3892.38","3885.38","3892.38","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","AETNA [1001]","HB CH AETNA HMO / PPO","3457.19","58.3","","4687.96","3384.99","9375.92","13","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3715.47","3715.47","3715.47","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","6247.91","6247.91","6247.91","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","11008.22","5291.60","11008.22","12","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3457.19","58.3","","5990.90","1492.50","5990.90","1 through 10","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3142.90","53","","11822.98","3164.10","11822.98","1 through 10","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MEDICARE [2001]","HB BWF MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3775.88","3775.88","3775.88","36","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","3775.50","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3702.86","3702.86","3702.86","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","13","2125.14","4626.56","per diem",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","11124.48","11124.48","11124.48","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2543.97","42.9","","6356.43","6356.43","6356.43","1 through 10","2125.14","4626.56","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","both","","","5930.00","4447.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","3699.99","","APC Price ($3,775.50). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3708.27","3708.27","3708.27","1 through 10","2125.14","4626.56","other","OPPS APC"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","41","2125.14","4652.09","other","ASC "
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","66","2125.14","4652.09","other","ASC "
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3516.49","59.3","","7197.25","3496.66","27598.26","25","2125.14","4652.09","percent of total billed charges",""
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","14982.24","4994.08","24970.40","49","2125.14","4652.09","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","6247.91","5249.10","15747.30","16","2125.14","4652.09","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2624.55","2624.55","2624.55","1 through 10","2125.14","4652.09","other","Multiple Surgery"
"Hysteroscopy Biopsy Endometrium","PX-76001392","CDM","58558","CPT","0761","RC","","","","outpatient","","","5930.00","4447.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4652.09","78.45","","6356.44","3885.52","6356.44","12","2125.14","4652.09","percent of total billed charges",""
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","1 through 10","1873.9","3257.24","other","ASC "
"Hysteroscopy Diagnostic","PX-76001391","CDM","58555","CPT","0761","RC","","","","outpatient","","","4152.00","3114.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3904.56","3904.56","1 through 10","1873.9","3257.24","other","ASC "
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","outpatient","","","6632.00","4974.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3254.32","49.07","","3335.71","3335.71","3335.71","1 through 10","2652.8","5202.8","percent of total billed charges",""
"Hysteroscopy Div/Rescj Intrauterine Septum","PX-76001394","CDM","58560","CPT","0761","RC","","","","outpatient","","","6632.00","4974.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3322.63","50.1","","6680.86","3340.43","6822.40","1 through 10","2652.8","5202.8","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","AETNA [1001]","HB CH AETNA HMO / PPO","4660.50","58.3","","3646.94","3384.99","5990.92","1 through 10","3713.25","8083.96","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","9617.32","9617.32","9617.32","1 through 10","3713.25","8083.96","other","Multiple Surgery"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4660.50","58.3","","3384.98","3384.98","3384.98","1 through 10","3713.25","8083.96","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4236.82","53","","9498.66","9498.66","9498.66","1 through 10","3713.25","8083.96","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MEDICARE [2001]","HB BWF MEDICARE","5861.74","","APC Price ($5,861.74). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","5862.33","5462.20","5862.33","1 through 10","3713.25","8083.96","other","OPPS APC"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","3713.25","8083.96","per diem",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","both","","","7994.00","5995.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","3713.25","8083.96","per diem",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","6812.97","6671.42","6812.97","1 through 10","3553.33","7939.38","other","ASC "
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6822.40","6680.86","6822.40","14","3553.33","7939.38","other","ASC "
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4740.44","59.3","","6392.09","1793.45","12948.79","1 through 10","3553.33","7939.38","percent of total billed charges",""
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","26178.42","17452.28","26178.42","1 through 10","3553.33","7939.38","other","Multiple Surgery"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","3713.25","","Case rate ($3,713.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","26512.62","9171.73","27515.19","1 through 10","3553.33","7939.38","other","Multiple Surgery"
"Hysteroscopy Leiomyomata","PX-76001395","CDM","58561","CPT","0761","RC","","","","outpatient","","","7994.00","5995.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6271.29","78.45","","3453.90","3453.90","3453.90","1 through 10","3553.33","7939.38","percent of total billed charges",""
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4718.12","","Case rate ($4,718.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6822.40","6680.86","6822.40","1 through 10","2300.73","4718.12","other","ASC "
"Hysteroscopy Lysis Adhesions","PX-76001393","CDM","58559","CPT","0761","RC","","","","outpatient","","","5176.00","3882.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3069.37","59.3","","3769.15","3769.15","3769.15","1 through 10","2300.73","4718.12","percent of total billed charges",""
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","both","","","4336.00","3252.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5504.11","2752.06","5504.11","1 through 10","2125.14","4626.56","other","Multiple Surgery"
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","1 through 10","1927.35","7178","other","ASC "
"Hysteroscopy Rem FB Impacted","PX-76001396","CDM","58562","CPT","0761","RC","","","","outpatient","","","4336.00","3252.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","14982.24","4994.08","14982.24","1 through 10","1927.35","7178","other","Multiple Surgery"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","both","","","559.00","419.25","MEDICARE [2001]","HB BWF MEDICARE","474.42","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","948.94","948.94","948.94","1 through 10","296.27","926.73","other","OPPS APC"
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","outpatient","","","559.00","419.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","253.94","253.94","253.94","1 through 10","248.48","567.68","other","ASC "
"I&D Abscess Cplx","PX-76000005","CDM","10061","CPT","0761","RC","","","","outpatient","","","559.00","419.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","519.36","519.36","519.36","1 through 10","248.48","567.68","other","ASC "
"I&D Abscess Ischiorectal/Perirectal","PX-75000211","CDM","46040","CPT","0750","RC","","","","outpatient","","","3390.00","2542.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1698.39","50.1","","1620.17","1586.56","1620.17","1 through 10","1356","2659.46","percent of total billed charges",""
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","both","","","5409.00","4056.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","365.67","4214.15","per diem",""
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","outpatient","","","5409.00","4056.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1963.63","1922.84","1963.63","1 through 10","2140.46","4472.66","other","ASC "
"I&D Abscess Neck/Thorax","PX-76000340","CDM","21501","CPT","0761","RC","","","","outpatient","","","5409.00","4056.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","1925.56","3851.11","1 through 10","2140.46","4472.66","other","ASC "
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","853.00","853.00","853.00","1 through 10","206.14","1873.9","other","ASC "
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","235.73","","Case rate ($235.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","333.79","333.79","333.79","1 through 10","206.14","1873.9","other","ASC "
"I&D Abscess Peritonsillar","PX-75000061","CDM","42700","CPT","0761","RC","","","","outpatient","","","877.00","657.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","206.14","","Case rate ($206.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","356.50","356.50","356.50","1 through 10","206.14","1873.9","other","Multiple Surgery"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","449.00","336.75","AETNA [1001]","HB CH AETNA HMO / PPO","261.77","58.3","","5471.55","5471.55","5471.55","1 through 10","176.45","484.93","percent of total billed charges",""
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","449.00","336.75","ELDER SERVICES [1037]","HB BWF MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","316.45","316.45","316.45","1 through 10","176.45","484.93","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","449.00","336.75","HUMANA [1012]","HB BWF MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","231.25","231.25","231.25","1 through 10","176.45","484.93","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","both","","","449.00","336.75","MEDICARE [2001]","HB BWF MEDICARE","235.94","","APC Price ($235.94). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","235.97","235.97","235.97","1 through 10","176.45","484.93","other","OPPS APC"
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","285.32","285.32","285.32","1 through 10","176.45","567.68","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","449.00","336.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","291.77","285.72","291.77","1 through 10","176.45","567.68","other","ASC "
"I&D Abscess Smp","PX-76000004","CDM","10060","CPT","0761","RC","","","","outpatient","","","449.00","336.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","352.24","78.45","","228.51","228.51","228.51","1 through 10","176.45","567.68","percent of total billed charges",""
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2840.00","2130.00","AETNA [1001]","HB CH AETNA HMO / PPO","1655.72","58.3","","4168.58","4168.58","4168.58","1 through 10","1237.95","3916.38","percent of total billed charges",""
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2840.00","2130.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3206.29","3206.29","3206.29","1 through 10","1237.95","3916.38","other","Multiple Surgery"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","both","","","2840.00","2130.00","MEDICARE [2001]","HB BWF MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3916.38","other","OPPS APC"
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2274.50","2271.35","2274.50","1 through 10","1237.95","2227.98","other","ASC "
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1572.96","","Case rate ($1,572.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2274.50","1137.25","2274.50","1 through 10","1237.95","2227.98","other","ASC "
"I&D Hematoma/Seroma/Fluid","PX-76000010","CDM","10140","CPT","0761","RC","","","","outpatient","","","2840.00","2130.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1237.95","","Case rate ($1,237.95). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1528.87","1528.87","1528.87","1 through 10","1237.95","2227.98","other","Multiple Surgery"
"I&D Ischiorct/Intramural Absc W/WO Seton","PX-75000213","CDM","46060","CPT","0750","RC","","","","both","","","4775.00","3581.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","6453.00","6453.00","6453.00","1 through 10","2048.48","3720.2","per diem",""
"I&D Ischiorct/Intramural Absc W/WO Seton","PX-75000213","CDM","46060","CPT","0750","RC","","","","outpatient","","","4775.00","3581.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2343.09","49.07","","3780.34","3780.34","3780.34","1 through 10","1910","3745.99","percent of total billed charges",""
"I&D Wound Post OP Complex","PX-76000012","CDM","10180","CPT","0761","RC","","","","both","","","5277.00","3957.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3344.48","3344.48","3344.48","1 through 10","2140.46","4111.31","other","OPPS APC"
"I&D Wound Post OP Complex","PX-76000012","CDM","10180","CPT","0761","RC","","","","outpatient","","","5277.00","3957.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4139.81","78.45","","4061.57","4061.57","4061.57","1 through 10","2140.46","4472.66","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","301.00","225.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","190.83","63.4","","134.49","134.49","134.49","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB CH WELLPOINT","234.51","77.91","","230.77","230.77","230.77","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.68","57.7","","176.68","176.68","176.68","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","185.47","178.44","194.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Anaplasma Phagocytophilum Amplifed Prb Tq","PX-30003805","CDM","87468","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","301.00","225.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","190.83","63.4","","134.49","134.49","134.49","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB CH WELLPOINT","234.51","77.91","","230.77","230.77","230.77","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.68","57.7","","176.68","176.68","176.68","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","178.44","178.44","178.44","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Babesia Microti Amplified Probe Technique","PX-30003806","CDM","87469","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Borrelia Miyamotoi Amplified Prb Technique","PX-30003807","CDM","87478","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","178.44","178.44","178.44","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","301.00","225.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","190.83","63.4","","134.49","134.49","134.49","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","both","","","301.00","225.75","WELLPOINT [1015]","HB CH WELLPOINT","234.51","77.91","","230.77","230.77","230.77","1 through 10","34.39","286.25","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","173.68","57.7","","176.68","176.68","176.68","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","182.11","60.5","","185.47","178.44","194.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Ehrlichia Chaffeensis Amplified Probe Tq","PX-30003808","CDM","87484","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","1 through 10","87.89","236.13","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","619.00","464.25","AETNA [1001]","HB CH AETNA HMO / PPO","360.88","58.3","","341.33","341.33","341.33","1 through 10","68.8","588.67","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","619.00","464.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED A","588.67","95.1","","598.99","598.99","598.99","1 through 10","68.8","588.67","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","619.00","464.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","446.30","72.1","","453.91","453.91","598.99","1 through 10","68.8","588.67","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","619.00","464.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","392.45","63.4","","399.13","397.32","399.13","1 through 10","68.8","588.67","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","619.00","464.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","360.88","58.3","","341.33","341.33","341.33","1 through 10","68.8","588.67","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","both","","","619.00","464.25","WELLPOINT [1015]","HB CH WELLPOINT","482.26","77.91","","1076.14","474.14","1076.14","32","68.8","588.67","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","619.00","464.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","367.07","59.3","","352.77","352.77","352.77","37","175.58","485.61","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","619.00","464.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","374.50","60.5","","453.91","381.07","453.91","1 through 10","175.58","485.61","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","619.00","464.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","374.50","60.5","","381.07","381.07","381.07","1 through 10","175.58","485.61","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","619.00","464.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","275.15","44.45","","462.82","462.82","462.82","1 through 10","175.58","485.61","percent of total billed charges",""
"Iadna Hpv Sep Rprt Hi-Rsk Typ&Hi-Rsk Poold Rslts","PX-30003844","CDM","87626","CPT","0306","RC","","","","outpatient","","","619.00","464.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","485.61","78.45","","462.82","274.27","462.82","39","175.58","485.61","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","both","","","303.00","227.25","AETNA [1001]","HB CH AETNA HMO / PPO","176.65","58.3","","167.27","167.27","167.27","1 through 10","34.39","221.19","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","179.68","59.3","","172.87","133.95","174.51","1 through 10","106.55","237.7","percent of total billed charges",""
"Iadna Human Papillomavirus High-Risk Types","PX-30002925","CDM","87624","CPT","0306","RC","","","","outpatient","","","303.00","227.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","237.70","78.45","","226.80","132.57","226.80","1 through 10","106.55","237.7","percent of total billed charges",""
"Iadna Respiratry Probe & Rev Trnscr 3-5 Targets","PX-30001402","CDM","87631","CPT","0306","RC","","","","outpatient","","","800.00","600.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","474.40","59.3","","455.91","455.91","455.91","1 through 10","78.13","627.6","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","42.81","0.57","85.05","1 through 10","50.28","272.51","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","449.00","87.90","449.00","1 through 10","54.9","173.46","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq","PX-30003640","CDM","87635","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","68.34","68.34","115.32","1 through 10","54.9","173.46","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","150.02","150.02","150.02","1 through 10","64.35","150","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech","PX-30003645","CDM","U0003","HCPCS","0300","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","145.96","145.96","145.96","1 through 10","54.9","117.68","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","both","","","25.00","18.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","25.00","100","","50.00","50.00","50.00","1 through 10","10.73","25","percent of total billed charges",""
"Iadna Sars-Cov-2 Covid-19 Amplified Probe Tq High Throughput Tech; Rsltd","PX-30003731","CDM","U0005","HCPCS","0300","RC","","","","outpatient","","","25.00","18.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","14.83","59.3","","24.32","24.32","24.32","1 through 10","9.15","25.01","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","AETNA [1001]","HB CH AETNA HMO / PPO","130.01","58.3","","123.04","123.04","123.04","24","34.39","207.04","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.12","44.45","","98.87","98.87","98.87","1 through 10","34.39","207.04","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","both","","","223.00","167.25","WELLPOINT [1015]","HB CH WELLPOINT","173.74","77.91","","289.00","170.91","604.91","28","34.39","207.04","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","223.00","167.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","665.22","42","26.86","174.94","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","223.00","167.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","132.24","59.3","","124.12","124.12","124.12","1 through 10","26.86","174.94","percent of total billed charges",""
"Iadna Trichomonas Vaginalis Amplified Probe Tech","PX-30001852","CDM","87661","CPT","0306","RC","","","","outpatient","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.94","78.45","","166.83","98.87","166.83","22","26.86","174.94","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Igats (Igg Asialo Gm1 Titer)","PX-30003556","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Igdts (Igg Disialo Gd1b Titer)","PX-30003554","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Igmts (Igg Monos Gm1 Titer)","PX-30003551","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Iiv Vaccine Preserv Free Increased Ag Content Im","PX-63601114","CDM","90662","CPT","0636","RC","","","","both","","","128.17","96.13","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","44.86","35","","95.70","31.90","95.70","1 through 10","44.86","264.41","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","30.28","22.71","AETNA [1001]","HB CH AETNA HMO / PPO","17.65","58.3","","21.63","21.63","21.63","1 through 10","10.6","70.78","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","both","","","30.28","22.71","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10.60","35","","9.60","9.60","9.60","1 through 10","10.6","70.78","percent of total billed charges",""
"Iiv3 Vacc Preservative Free 0.5 Ml Dosage Im Use","PX-63601002","CDM","90656","CPT","0636","RC","","","","outpatient","","","30.28","22.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","15.81","52.2","","87.28","43.64","87.28","1 through 10","15.14","45.09","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Il-6 Quant by Ia","PX-30002795","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Iliac Bone Augmentation","PX-76002510","CDM","27299","CPT","0761","RC","","","","both","","","1966.00","1474.50","MEDICARE [2001]","HB BWF MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","257.38","257.38","257.38","1 through 10","270.63","1869.67","other","OPPS APC"
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","3858.00","2893.50","AETNA [1001]","HB CH AETNA HMO / PPO","2249.21","58.3","","2126.82","2126.82","2126.82","1 through 10","1237.95","3005.77","percent of total billed charges",""
"Image Cath Fluid Peri/Retro","PX-76001947","CDM","49406","CPT","0761","RC","","","","both","","","3858.00","2893.50","MEDICARE [2001]","HB BWF MEDICARE","1923.94","","APC Price ($1,923.94). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1924.13","1924.13","1924.13","1 through 10","1237.95","3005.77","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","both","","","3408.00","2556.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1113.30","","APC Price ($1,113.30). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1095.60","1095.60","1095.60","1 through 10","761.55","2655.17","other","OPPS APC"
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","outpatient","","","3408.00","2556.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2020.94","59.3","","4666.70","4666.70","4666.70","1 through 10","761.55","3159.22","percent of total billed charges",""
"Image GI Tract Esoph Ileum W/Rep","PX-75000320","CDM","91110","CPT","0750","RC","","","","outpatient","","","3408.00","2556.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","761.55","","Case rate ($761.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","894.82","894.82","894.82","1 through 10","761.55","3159.22","other","Multiple Surgery"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","782.00","586.50","MEDICARE [2001]","HB BWF MEDICARE","835.47","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","335.48","860.54","other","OPPS APC"
"Image-Guided Catheter Fluid Collection Drainage","PX-76001973","CDM","10030","CPT","0761","RC","","","","both","","","782.00","586.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","818.76","","APC Price ($835.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","824.25","824.25","824.25","1 through 10","335.48","860.54","other","OPPS APC"
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Imats (Igm Asialo Gm1 Titer)","PX-30003555","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Imdts (Igm Disialo Gd1b Titer)","PX-30003553","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","AETNA [1001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","108.86","1 through 10","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","143.81","73","","181.77","181.77","181.77","1 through 10","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","124.50","1 through 10","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","167.45","85","","187.51","187.51","187.51","1 through 10","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","197.00","100","","192.00","192.00","192.00","1 through 10","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","197.00","100","","192.00","192.00","192.00","14","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","87.48","87.48","87.48","1 through 10","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","both","","","197.00","147.75","WELLPOINT [1015]","HB CH WELLPOINT","153.48","77.91","","2839.22","151.22","4759.22","104","87.57","197","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","197.00","147.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.82","59.3","","112.51","112.43","125.55","94","98.5","154.55","percent of total billed charges",""
"Imhistochem/Cytchm Ea Addl Antibody Slide","PX-31000499","CDM","88341","CPT","0312","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","87.48","147.61","84","98.5","154.55","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","519.00","389.25","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","427.19","427.19","1 through 10","230.7","1456.11","other","OPPS APC"
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","both","","","519.00","389.25","WELLPOINT [1015]","HB CH WELLPOINT","404.35","77.91","","1407.74","397.74","1912.74","22","230.7","1456.11","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","519.00","389.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","307.77","59.3","","295.93","284.34","295.93","1 through 10","204.8","926.86","percent of total billed charges",""
"Imhistochem/Cytchm Ea Multiplex Antibody Slide","PX-31000501","CDM","88344","CPT","0312","RC","","","","outpatient","","","519.00","389.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","407.16","78.45","","388.24","230.08","388.24","1 through 10","204.8","926.86","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","AETNA [1001]","HB CH AETNA HMO / PPO","210.46","58.3","","199.02","199.02","199.02","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.26","107.90","200.24","1 through 10","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","263.53","73","","248.93","248.93","248.93","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","210.46","58.3","","199.02","170.50","526.50","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","191.33","53","","186.03","186.03","186.03","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","MEDICARE [2001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","67.83","203.50","12","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","TRICARE [160005]","HB BWF TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","96.67","96.67","96.67","1 through 10","160.46","768.52","other","Tricare OPPS"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","81.79","81.79","200.24","1 through 10","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.46","44.45","","269.85","159.92","269.85","1 through 10","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","160.46","768.52","other","OPPS APC"
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","both","","","361.00","270.75","WELLPOINT [1015]","HB CH WELLPOINT","281.26","77.91","","978.45","276.45","2031.45","90","160.46","768.52","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","361.00","270.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","214.07","59.3","","205.69","205.53","592.01","60","180.5","489.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","361.00","270.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","283.20","78.45","","539.70","539.14","539.70","1 through 10","180.5","489.19","percent of total billed charges",""
"Imhistochem/Cytchm Init Antibody Stain Procedure","PX-31000500","CDM","88342","CPT","0312","RC","","","","outpatient","","","361.00","270.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.20","78.45","","269.85","159.92","351.00","67","180.5","489.19","percent of total billed charges",""
"Imm Admn Sarscov2 Vaccine Single Dose","PX-77100073","CDM","90480","CPT","0771","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.61","46.61","46.61","1 through 10","32.18","145.84","other","OPPS APC"
"IMMOBILIZER KNEE 22IN UNIVERSAL TIETEX FOAM TBAR CONTOURED POSTERIOR OPEN PATELLA","SUP-ITM-10042162","CDM","L1830","HCPCS","0274","RC","","","","both","","","37.62","28.21","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","23.85","63.4","","49.88","49.88","49.88","1 through 10","16.72","242.21","percent of total billed charges",""
"IMMOBILIZER KNEE 22IN UNIVERSAL TIETEX FOAM TBAR CONTOURED POSTERIOR OPEN PATELLA","SUP-ITM-10042162","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","37.62","28.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","22.31","59.3","","66.15","22.05","66.15","1 through 10","18.81","208.64","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Immts (Igm Monos Gm1 Titer)","PX-30003552","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","1 through 10","14.67","232.43","percent of total billed charges",""
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","both","","","33.00","24.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","40.90","40.90","40.90","1 through 10","14.67","232.43","other","OPPS APC"
"Immune Admin One Vacc Im/Sub-Q/ID","PX-77100003","CDM","90471","CPT","0771","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","73.20","36.60","73.20","1 through 10","16.5","154.78","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","AETNA [1001]","HB CH AETNA HMO / PPO","81.04","58.3","","76.55","76.55","76.55","11","11.3","101.47","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","both","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.79","44.45","","103.79","103.79","103.79","1 through 10","11.3","101.47","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.43","59.3","","79.11","79.11","237.33","38","11.81","109.05","percent of total billed charges",""
"Immuno Ql/Sq Multi","PX-30000521","CDM","83516","CPT","0301","RC","","","","outpatient","","","139.00","104.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.05","78.45","","207.58","103.79","207.58","1 through 10","11.81","109.05","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Immuno Qn Other","PX-30000526","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Immuno Qn Other","PX-30001463","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Immuno Qn Ria","PX-30000524","CDM","83519","CPT","0301","RC","","","","outpatient","","","113.00","84.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.65","78.45","","84.57","84.57","84.57","1 through 10","13.93","88.65","percent of total billed charges",""
"Immunoassay Infectious Antibody Qn","PX-30001435","CDM","86317","CPT","0302","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.34","53","","91.69","91.69","91.69","1 through 10","14.69","129.94","percent of total billed charges",""
"Immunoassay Infectious Antibody Qn","PX-30001435","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","15.46","139.64","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","74.84","74.84","74.84","1 through 10","16.2","99.28","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","136.00","102.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.65","59.3","","77.35","77.35","77.35","1 through 10","11.81","106.69","percent of total billed charges",""
"Immunoassay Optical Strep A","PX-30001357","CDM","87880","CPT","0306","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","60.14","101.48","1 through 10","11.81","106.69","percent of total billed charges",""
"Immunoassay Tumor Ag Other Ag Qn","PX-30000825","CDM","86316","CPT","0302","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","81.88","81.88","81.88","1 through 10","21.45","135.72","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","245.00","183.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","145.29","59.3","","139.47","139.47","139.47","1 through 10","21.45","192.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 125","PX-30000820","CDM","86304","CPT","0302","RC","","","","outpatient","","","245.00","183.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","192.20","78.45","","182.97","182.97","182.97","1 through 10","21.45","192.2","percent of total billed charges",""
"Immunoassay Tumor Antigen Ca 19-9","PX-30000819","CDM","86301","CPT","0302","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","73.25","73.25","73.25","1 through 10","21.45","131.19","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","17","21.89","135.78","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.58","53","","95.93","95.93","95.93","1 through 10","21.89","135.78","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.68","44.45","","81.27","81.27","81.27","1 through 10","21.89","135.78","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","186.00","139.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.30","59.3","","106.07","106.07","318.21","21","23.04","145.92","percent of total billed charges",""
"Immunofixation Electrophores Serum","PX-30000837","CDM","86334","CPT","0302","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","82.46","139.15","22","23.04","145.92","percent of total billed charges",""
"Immunofluorescent Giardia","PX-30001209","CDM","87269","CPT","0306","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","58.60","58.60","1 through 10","11.81","80.8","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","AETNA [1001]","HB CH AETNA HMO / PPO","84.54","58.3","","79.95","79.95","79.95","44","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","91.93","63.4","","93.49","93.49","186.97","14","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.85","53","","149.46","149.46","149.46","1 through 10","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.45","44.45","","63.31","63.31","63.31","1 through 10","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","both","","","145.00","108.75","WELLPOINT [1015]","HB CH WELLPOINT","112.97","77.91","","111.05","111.05","393.05","30","16.92","137.9","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.99","59.3","","82.63","82.63","247.88","38","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","83.67","57.7","","170.05","85.03","425.13","94","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","87.73","60.5","","89.26","89.26","178.51","34","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Light Chains Free Each","PX-30003759","CDM","83521","CPT","0301","RC","","","","outpatient","","","145.00","108.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.75","78.45","","108.40","64.24","216.80","40","26.77","113.75","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","58.00","43.50","AETNA [1001]","HB CH AETNA HMO / PPO","33.81","58.3","","31.75","31.75","31.75","24","7.86","47.31","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","58.00","43.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.74","53","","29.68","29.68","29.68","1 through 10","7.86","47.31","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","both","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.78","44.45","","25.15","25.15","25.15","1 through 10","7.86","47.31","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","58.00","43.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.39","59.3","","32.82","32.82","131.26","20","3.8","45.5","percent of total billed charges",""
"Immunoglobulin Subclasses Ea","PX-30000450","CDM","82787","CPT","0301","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.50","78.45","","43.05","25.51","43.05","26","3.8","45.5","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","AETNA [1001]","HB CH AETNA HMO / PPO","198.80","58.3","","199.02","199.02","199.02","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.26","107.90","200.24","1 through 10","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","248.93","73","","248.93","248.93","248.93","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.80","58.3","","199.02","170.50","526.50","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.73","53","","186.03","186.03","186.03","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","MEDICARE [2001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","67.83","203.50","12","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","TRICARE [160005]","HB BWF TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","96.67","96.67","96.67","1 through 10","151.57","768.52","other","Tricare OPPS"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","81.79","81.79","200.24","1 through 10","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.57","44.45","","269.85","159.92","269.85","1 through 10","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","199.43","199.43","199.43","1 through 10","151.57","768.52","other","OPPS APC"
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","both","","","341.00","255.75","WELLPOINT [1015]","HB CH WELLPOINT","265.67","77.91","","978.45","276.45","2031.45","90","151.57","768.52","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","341.00","255.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.21","59.3","","205.69","205.53","592.01","60","170.5","489.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","539.70","539.14","539.70","1 through 10","170.5","489.19","percent of total billed charges",""
"Immunoperoxidase","PX-31000158","CDM","88342","CPT","0312","RC","","","","outpatient","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","269.85","159.92","351.00","67","170.5","489.19","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","both","","","1145.00","858.75","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1088.9","other","OPPS APC"
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","561.85","49.07","","2115.00","2115.00","2115.00","1 through 10","508.95","898.25","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","573.65","50.1","","331.25","331.25","331.25","1 through 10","508.95","898.25","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Perm","PX-76001745","CDM","64999","CPT","0761","RC","","","","outpatient","","","1145.00","858.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","898.25","78.45","","282.15","282.15","282.15","1 through 10","508.95","898.25","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","both","","","1208.00","906.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1148.81","other","OPPS APC"
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1208.00","906.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","592.77","49.07","","2115.00","2115.00","2115.00","1 through 10","536.96","947.68","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1208.00","906.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","605.21","50.1","","331.25","331.25","331.25","1 through 10","536.96","947.68","percent of total billed charges",""
"Impl Elect Neurostim Array Sq Trial","PX-76001744","CDM","64999","CPT","0761","RC","","","","outpatient","","","1208.00","906.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","947.68","78.45","","282.15","282.15","282.15","1 through 10","536.96","947.68","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8027.65","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","8019.86","8019.86","8019.86","1 through 10","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7793.84","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3672.49","3672.49","3672.49","1 through 10","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7637.96","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3834.57","3834.57","7669.14","1 through 10","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5771.17","53","","10471.74","10471.74","10471.74","1 through 10","5381.58","8483.62","percent of total billed charges",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","MEDICARE [2001]","HB BWF MEDICARE","7793.84","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3896.92","3732.20","7793.84","23","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1013.50","1013.50","1013.50","1 through 10","5381.58","8483.62","per diem",""
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7637.96","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7639.96","7639.96","7639.96","1 through 10","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","both","","","10889.00","8166.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7637.96","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.47","3822.94","7793.84","1 through 10","5381.58","8483.62","other","OPPS APC"
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","10889.00","8166.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4936.99","4834.42","9668.83","1 through 10","4472.66","8542.42","other","ASC "
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","10889.00","8166.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","6837.93","","Case rate ($6,837.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4943.83","4841.26","9682.51","1 through 10","4472.66","8542.42","other","ASC "
"Impl Elect Neurostim Epidural Perc","PX-76001489","CDM","63650","CPT","0361","RC","","","","outpatient","","","10889.00","8166.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","5381.58","","Case rate ($5,381.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","13292.50","13292.50","13292.50","1 through 10","4472.66","8542.42","other","Multiple Surgery"
"Impl Elect Neurostim Peripher Perc","PX-76001555","CDM","64555","CPT","0761","RC","","","","both","","","15557.00","11667.75","MEDICARE [2001]","HB BWF MEDICARE","7793.84","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","5381.58","12120.46","other","OPPS APC"
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16397.00","12297.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8026.84","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","8026.86","8026.86","8026.86","1 through 10","5381.58","12774.9","other","OPPS APC"
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16397.00","12297.75","MEDICARE [2001]","HB BWF MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","5381.58","12774.9","other","OPPS APC"
"Impl Elect Neurostim Sacral Perc","PX-76001556","CDM","64561","CPT","0761","RC","","","","both","","","16397.00","12297.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.47","7645.47","7645.47","1 through 10","5381.58","12774.9","other","OPPS APC"
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","17681.62","17681.62","17681.62","1 through 10","795","1500","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T1","PX-27000141","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","74853.32","74853.32","74853.32","1 through 10","666.75","1176.75","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","both","","","32650.00","24487.50","WELLPOINT [1015]","HB CH WELLPOINT","25437.62","77.91","","17681.62","17681.62","17681.62","1 through 10","17304.5","32650","percent of total billed charges",""
"Impl Genrtor Neurostimulator Non Hi Freq Rechrgeable Bat and Chrging Sys T3","PX-27000142","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","32650.00","24487.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","19361.45","59.3","","74853.32","74853.32","74853.32","1 through 10","14512.93","25613.93","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","AETNA [1001]","HB CH AETNA HMO / PPO","3031.60","58.3","","1634.24","1004.95","1718.99","42","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3796.00","73","","2123.89","1900.92","2123.89","1 through 10","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3031.60","58.3","","3729.00","1254.19","3729.00","1 through 10","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2756.00","53","","939.37","939.37","5593.65","1 through 10","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4420.00","85","","2323.25","1864.50","2882.25","16","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5200.00","100","","2909.44","1772.40","10952.08","45","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5200.00","100","","2323.25","2323.25","2323.25","1 through 10","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5200.00","100","","2882.25","1772.40","10169.17","187","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3796.00","73","","1659.41","1659.41","1659.41","1 through 10","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","WELLPOINT [1015]","HB CH WELLPOINT","4051.32","77.91","","2050.91","1468.48","2902.83","52","2311.4","5200","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3083.60","59.3","","1548.60","1092.60","3613.79","82","2600","4079.4","percent of total billed charges",""
"IMPLANT 15MM 2.5X3.5 SYSTEM HEMICAP RESURFACING ARTICULAR COMPONENT DF OFFSET","SUP-ITM-10079697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4079.40","78.45","","2085.51","998.68","6202.11","56","2600","4079.4","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","AETNA [1001]","HB CH AETNA HMO / PPO","647.13","58.3","","1830.28","315.58","1830.28","1 through 10","493.4","1110","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","4170.85","4170.85","4170.85","1 through 10","493.4","1110","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","493.40","44.45","","649.55","649.55","649.55","1 through 10","493.4","1110","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","both","","","1110.00","832.50","WELLPOINT [1015]","HB CH WELLPOINT","864.80","77.91","","8998.38","2542.37","8998.38","20","493.4","1110","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","658.23","59.3","","1891.61","1609.14","3664.18","25","555","870.8","percent of total billed charges",""
"IMPLANT 2.0MM 29 6 SYSTEM FIXATION MINIPLATE TITANIUM DOUBLE BEND SPACING","SUP-ITM-10014030","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","1470.68","1310.06","2481.69","19","555","870.8","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1634.24","1004.95","1718.99","42","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2123.89","1900.92","2123.89","1 through 10","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","3729.00","1254.19","3729.00","1 through 10","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","939.37","939.37","5593.65","1 through 10","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","2323.25","1864.50","2882.25","16","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","2909.44","1772.40","10952.08","45","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","2323.25","2323.25","2323.25","1 through 10","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","2882.25","1772.40","10169.17","187","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","1659.41","1659.41","1659.41","1 through 10","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","2050.91","1468.48","2902.83","52","733.43","1650","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1548.60","1092.60","3613.79","82","825","1294.43","percent of total billed charges",""
"IMPLANT 35X39 10MM COMPONENT PATELLA TRIALTHLON TRITANIUM ASYMMETRIC METAL BACKED","SUP-ITM-10140069","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","2085.51","998.68","6202.11","56","825","1294.43","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","AETNA [1001]","HB CH AETNA HMO / PPO","2218.43","58.3","","1634.24","1004.95","1718.99","42","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2777.80","73","","2123.89","1900.92","2123.89","1 through 10","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2218.43","58.3","","3729.00","1254.19","3729.00","1 through 10","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2016.76","53","","939.37","939.37","5593.65","1 through 10","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3234.42","85","","2323.25","1864.50","2882.25","16","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3805.20","100","","2909.44","1772.40","10952.08","45","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3805.20","100","","2323.25","2323.25","2323.25","1 through 10","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3805.20","100","","2882.25","1772.40","10169.17","187","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2777.80","73","","1659.41","1659.41","1659.41","1 through 10","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","WELLPOINT [1015]","HB CH WELLPOINT","2964.63","77.91","","2050.91","1468.48","2902.83","52","1691.41","3805.2","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1548.60","1092.60","3613.79","82","1902.6","2985.18","percent of total billed charges",""
"IMPLANT 36MM GLENOSPHERE VERSADIAL COMPREHENSIVE TITANIUM","SUP-ITM-10137826","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2985.18","78.45","","2085.51","998.68","6202.11","56","1902.6","2985.18","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","AETNA [1001]","HB CH AETNA HMO / PPO","3119.52","58.3","","1634.24","1004.95","1718.99","42","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3906.08","73","","2123.89","1900.92","2123.89","1 through 10","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3119.52","58.3","","3729.00","1254.19","3729.00","1 through 10","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2835.92","53","","939.37","939.37","5593.65","1 through 10","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4548.18","85","","2323.25","1864.50","2882.25","16","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5350.80","100","","2909.44","1772.40","10952.08","45","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5350.80","100","","2323.25","2323.25","2323.25","1 through 10","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5350.80","100","","2882.25","1772.40","10169.17","187","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3906.08","73","","1659.41","1659.41","1659.41","1 through 10","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","WELLPOINT [1015]","HB CH WELLPOINT","4168.81","77.91","","2050.91","1468.48","2902.83","52","2378.43","5350.8","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5350.80","4013.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","3173.02","59.3","","1548.60","1092.60","3613.79","82","2675.4","4197.7","percent of total billed charges",""
"IMPLANT 42MM LG BODY PROXIMALIMAL COMPREHENSIVE SEGMENTAL REVISION SYSTEM","SUP-ITM-10122538","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5350.80","4013.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4197.70","78.45","","2085.51","998.68","6202.11","56","2675.4","4197.7","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","AETNA [1001]","HB CH AETNA HMO / PPO","1915.16","58.3","","1634.24","1004.95","1718.99","42","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","2123.89","1900.92","2123.89","1 through 10","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1915.16","58.3","","3729.00","1254.19","3729.00","1 through 10","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1741.05","53","","939.37","939.37","5593.65","1 through 10","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2792.25","85","","2323.25","1864.50","2882.25","16","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3285.00","100","","2909.44","1772.40","10952.08","45","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3285.00","100","","2323.25","2323.25","2323.25","1 through 10","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3285.00","100","","2882.25","1772.40","10169.17","187","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","1659.41","1659.41","1659.41","1 through 10","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","WELLPOINT [1015]","HB CH WELLPOINT","2559.34","77.91","","2050.91","1468.48","2902.83","52","1460.18","3285","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1948.01","59.3","","1548.60","1092.60","3613.79","82","1642.5","2577.08","percent of total billed charges",""
"IMPLANT 7X12MM FOOT ARTHRODESIS SUBTALAR PROSTOP","SUP-ITM-10042197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2577.08","78.45","","2085.51","998.68","6202.11","56","1642.5","2577.08","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","AETNA [1001]","HB CH AETNA HMO / PPO","585.92","58.3","","554.95","91.85","1421.75","94","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","2490.03","2490.03","2490.03","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","585.92","58.3","","750.00","750.00","750.00","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","532.65","53","","1192.50","120.84","4149.90","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","854.25","85","","750.00","75.00","750.00","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1005.00","100","","657.00","121.50","1971.00","14","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1005.00","100","","75.00","75.00","75.00","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1005.00","100","","366.00","144.00","1971.00","45","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","667.50","667.50","667.50","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.72","44.45","","123.77","123.77","123.77","1 through 10","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","WELLPOINT [1015]","HB CH WELLPOINT","783.00","77.91","","483.51","229.32","1316.08","96","446.72","1005","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.97","59.3","","439.50","225.34","1872.27","197","502.5","788.42","percent of total billed charges",""
"IMPLANT ACL TIGHTROPE FIBERTAG ABS NON BUTTON","SUP-ITM-10273504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","385.32","55.36","1815.62","58","502.5","788.42","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","AETNA [1001]","HB CH AETNA HMO / PPO","666.45","58.3","","554.95","91.85","1421.75","94","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","834.49","73","","2490.03","2490.03","2490.03","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","666.45","58.3","","750.00","750.00","750.00","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","605.86","53","","1192.50","120.84","4149.90","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","971.67","85","","750.00","75.00","750.00","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1143.14","100","","657.00","121.50","1971.00","14","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1143.14","100","","75.00","75.00","75.00","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1143.14","100","","366.00","144.00","1971.00","45","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","834.49","73","","667.50","667.50","667.50","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","508.13","44.45","","123.77","123.77","123.77","1 through 10","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.14","857.35","WELLPOINT [1015]","HB CH WELLPOINT","890.62","77.91","","483.51","229.32","1316.08","96","508.13","1143.14","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.14","857.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","677.88","59.3","","439.50","225.34","1872.27","197","571.57","896.79","percent of total billed charges",""
"Implant Anchor T1","PX-27000007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.14","857.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","896.79","78.45","","385.32","55.36","1815.62","58","571.57","896.79","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","AETNA [1001]","HB CH AETNA HMO / PPO","2331.84","58.3","","554.95","91.85","1421.75","94","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2919.80","73","","2490.03","2490.03","2490.03","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2331.84","58.3","","750.00","750.00","750.00","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2119.86","53","","1192.50","120.84","4149.90","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3399.77","85","","750.00","75.00","750.00","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3999.73","100","","657.00","121.50","1971.00","14","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3999.73","100","","75.00","75.00","75.00","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3999.73","100","","366.00","144.00","1971.00","45","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2919.80","73","","667.50","667.50","667.50","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1777.88","44.45","","123.77","123.77","123.77","1 through 10","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","both","","","3999.73","2999.80","WELLPOINT [1015]","HB CH WELLPOINT","3116.19","77.91","","483.51","229.32","1316.08","96","1777.88","3999.73","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3999.73","2999.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","2371.84","59.3","","439.50","225.34","1872.27","197","1999.87","3137.79","percent of total billed charges",""
"Implant Anchor T2","PX-27000008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3999.73","2999.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3137.79","78.45","","385.32","55.36","1815.62","58","1999.87","3137.79","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","AETNA [1001]","HB CH AETNA HMO / PPO","2513.70","58.3","","554.95","91.85","1421.75","94","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3147.52","73","","2490.03","2490.03","2490.03","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2513.70","58.3","","750.00","750.00","750.00","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2285.19","53","","1192.50","120.84","4149.90","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3664.92","85","","750.00","75.00","750.00","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4311.67","100","","657.00","121.50","1971.00","14","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4311.67","100","","75.00","75.00","75.00","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4311.67","100","","366.00","144.00","1971.00","45","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3147.52","73","","667.50","667.50","667.50","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1916.54","44.45","","123.77","123.77","123.77","1 through 10","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","both","","","4311.67","3233.75","WELLPOINT [1015]","HB CH WELLPOINT","3359.22","77.91","","483.51","229.32","1316.08","96","1916.54","4311.67","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4311.67","3233.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2556.82","59.3","","439.50","225.34","1872.27","197","2155.84","3382.51","percent of total billed charges",""
"Implant Anchor T3","PX-27000009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4311.67","3233.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3382.51","78.45","","385.32","55.36","1815.62","58","2155.84","3382.51","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","AETNA [1001]","HB CH AETNA HMO / PPO","981.19","58.3","","1634.24","1004.95","1718.99","42","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1228.59","73","","2123.89","1900.92","2123.89","1 through 10","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","981.19","58.3","","3729.00","1254.19","3729.00","1 through 10","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","891.99","53","","939.37","939.37","5593.65","1 through 10","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1430.55","85","","2323.25","1864.50","2882.25","16","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1683.00","100","","2909.44","1772.40","10952.08","45","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1683.00","100","","2323.25","2323.25","2323.25","1 through 10","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1683.00","100","","2882.25","1772.40","10169.17","187","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1228.59","73","","1659.41","1659.41","1659.41","1 through 10","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","both","","","1683.00","1262.25","WELLPOINT [1015]","HB CH WELLPOINT","1311.23","77.91","","2050.91","1468.48","2902.83","52","748.09","1683","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1683.00","1262.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","998.02","59.3","","1548.60","1092.60","3613.79","82","841.5","1320.31","percent of total billed charges",""
"Implant Ankle / Foot T1","PX-27000095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1683.00","1262.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1320.31","78.45","","2085.51","998.68","6202.11","56","841.5","1320.31","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","AETNA [1001]","HB CH AETNA HMO / PPO","2207.97","58.3","","1634.24","1004.95","1718.99","42","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","2123.89","1900.92","2123.89","1 through 10","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2207.97","58.3","","3729.00","1254.19","3729.00","1 through 10","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2007.24","53","","939.37","939.37","5593.65","1 through 10","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3219.16","85","","2323.25","1864.50","2882.25","16","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3787.25","100","","2909.44","1772.40","10952.08","45","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3787.25","100","","2323.25","2323.25","2323.25","1 through 10","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3787.25","100","","2882.25","1772.40","10169.17","187","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2764.69","73","","1659.41","1659.41","1659.41","1 through 10","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","both","","","3787.25","2840.44","WELLPOINT [1015]","HB CH WELLPOINT","2950.65","77.91","","2050.91","1468.48","2902.83","52","1683.43","3787.25","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2245.84","59.3","","1548.60","1092.60","3613.79","82","1893.63","2971.1","percent of total billed charges",""
"Implant Ankle / Foot T2","PX-27000096","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3787.25","2840.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2971.10","78.45","","2085.51","998.68","6202.11","56","1893.63","2971.1","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","AETNA [1001]","HB CH AETNA HMO / PPO","4028.10","58.3","","1634.24","1004.95","1718.99","42","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5043.77","73","","2123.89","1900.92","2123.89","1 through 10","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4028.10","58.3","","3729.00","1254.19","3729.00","1 through 10","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3661.91","53","","939.37","939.37","5593.65","1 through 10","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5872.88","85","","2323.25","1864.50","2882.25","16","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6909.27","100","","2909.44","1772.40","10952.08","45","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6909.27","100","","2323.25","2323.25","2323.25","1 through 10","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6909.27","100","","2882.25","1772.40","10169.17","187","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5043.77","73","","1659.41","1659.41","1659.41","1 through 10","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","both","","","6909.27","5181.95","WELLPOINT [1015]","HB CH WELLPOINT","5383.01","77.91","","2050.91","1468.48","2902.83","52","3071.17","6909.27","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6909.27","5181.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","4097.20","59.3","","1548.60","1092.60","3613.79","82","3454.64","5420.32","percent of total billed charges",""
"Implant Ankle / Foot T3","PX-27000097","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6909.27","5181.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5420.32","78.45","","2085.51","998.68","6202.11","56","3454.64","5420.32","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","AETNA [1001]","HB CH AETNA HMO / PPO","585.76","58.3","","554.95","91.85","1421.75","94","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","733.46","73","","2490.03","2490.03","2490.03","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","585.76","58.3","","750.00","750.00","750.00","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","532.51","53","","1192.50","120.84","4149.90","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","854.03","85","","750.00","75.00","750.00","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1004.74","100","","657.00","121.50","1971.00","14","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1004.74","100","","75.00","75.00","75.00","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1004.74","100","","366.00","144.00","1971.00","45","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.46","73","","667.50","667.50","667.50","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.61","44.45","","123.77","123.77","123.77","1 through 10","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","both","","","1004.74","753.55","WELLPOINT [1015]","HB CH WELLPOINT","782.79","77.91","","483.51","229.32","1316.08","96","446.61","1004.74","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.74","753.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.81","59.3","","439.50","225.34","1872.27","197","502.37","788.22","percent of total billed charges",""
"Implant Bone Void Filler T1","PX-27000010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1004.74","753.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.22","78.45","","385.32","55.36","1815.62","58","502.37","788.22","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","AETNA [1001]","HB CH AETNA HMO / PPO","2484.68","58.3","","554.95","91.85","1421.75","94","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3111.18","73","","2490.03","2490.03","2490.03","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2484.68","58.3","","750.00","750.00","750.00","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2258.80","53","","1192.50","120.84","4149.90","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3622.61","85","","750.00","75.00","750.00","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4261.89","100","","657.00","121.50","1971.00","14","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4261.89","100","","75.00","75.00","75.00","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4261.89","100","","366.00","144.00","1971.00","45","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3111.18","73","","667.50","667.50","667.50","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.41","44.45","","123.77","123.77","123.77","1 through 10","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","both","","","4261.89","3196.42","WELLPOINT [1015]","HB CH WELLPOINT","3320.44","77.91","","483.51","229.32","1316.08","96","1894.41","4261.89","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4261.89","3196.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","2527.30","59.3","","439.50","225.34","1872.27","197","2130.95","3343.45","percent of total billed charges",""
"Implant Bone Void Filler T2","PX-27000011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4261.89","3196.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3343.45","78.45","","385.32","55.36","1815.62","58","2130.95","3343.45","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","AETNA [1001]","HB CH AETNA HMO / PPO","3919.22","58.3","","554.95","91.85","1421.75","94","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4907.43","73","","2490.03","2490.03","2490.03","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3919.22","58.3","","750.00","750.00","750.00","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3562.93","53","","1192.50","120.84","4149.90","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5714.13","85","","750.00","75.00","750.00","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6722.50","100","","657.00","121.50","1971.00","14","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6722.50","100","","75.00","75.00","75.00","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6722.50","100","","366.00","144.00","1971.00","45","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4907.43","73","","667.50","667.50","667.50","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2988.15","44.45","","123.77","123.77","123.77","1 through 10","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","both","","","6722.50","5041.87","WELLPOINT [1015]","HB CH WELLPOINT","5237.50","77.91","","483.51","229.32","1316.08","96","2988.15","6722.5","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6722.50","5041.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","3986.44","59.3","","439.50","225.34","1872.27","197","3361.25","5273.8","percent of total billed charges",""
"Implant Bone Void Filler T3","PX-27000012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6722.50","5041.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5273.80","78.45","","385.32","55.36","1815.62","58","3361.25","5273.8","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2070.70","1553.02","AETNA [1001]","HB CH AETNA HMO / PPO","1207.22","58.3","","1770.74","1285.96","2571.91","24","920.43","2070.7","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","both","","","2070.70","1553.02","WELLPOINT [1015]","HB CH WELLPOINT","1613.28","77.91","","2459.68","1786.28","4054.28","11","920.43","2070.7","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2070.70","1553.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","1227.93","59.3","","4926.10","1830.08","18282.10","21","1035.35","1624.46","percent of total billed charges",""
"Implant Breast Prosthesis T1","PX-27000127","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","2070.70","1553.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1624.46","78.45","","1743.64","1033.30","4801.93","1 through 10","1035.35","1624.46","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","AETNA [1001]","HB CH AETNA HMO / PPO","3089.90","58.3","","1770.74","1285.96","2571.91","24","2355.85","5300","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","both","","","5300.00","3975.00","WELLPOINT [1015]","HB CH WELLPOINT","4129.23","77.91","","2459.68","1786.28","4054.28","11","2355.85","5300","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3142.90","59.3","","4926.10","1830.08","18282.10","21","2650","4157.85","percent of total billed charges",""
"Implant Breast Prosthesis T3","PX-27000128","CDM","C1789","HCPCS","0278","RC","","","","outpatient","","","5300.00","3975.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4157.85","78.45","","1743.64","1033.30","4801.93","1 through 10","2650","4157.85","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","AETNA [1001]","HB CH AETNA HMO / PPO","476.84","58.3","","554.95","91.85","1421.75","94","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","597.07","73","","2490.03","2490.03","2490.03","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","476.84","58.3","","750.00","750.00","750.00","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","433.49","53","","1192.50","120.84","4149.90","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","695.22","85","","750.00","75.00","750.00","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","817.90","100","","657.00","121.50","1971.00","14","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","817.90","100","","75.00","75.00","75.00","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","817.90","100","","366.00","144.00","1971.00","45","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","597.07","73","","667.50","667.50","667.50","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","363.56","44.45","","123.77","123.77","123.77","1 through 10","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","both","","","817.90","613.42","WELLPOINT [1015]","HB CH WELLPOINT","637.23","77.91","","483.51","229.32","1316.08","96","363.56","817.9","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","817.90","613.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","485.01","59.3","","439.50","225.34","1872.27","197","408.95","641.64","percent of total billed charges",""
"Implant Cable T1","PX-27000013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","817.90","613.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","641.64","78.45","","385.32","55.36","1815.62","58","408.95","641.64","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","AETNA [1001]","HB CH AETNA HMO / PPO","1938.71","58.3","","554.95","91.85","1421.75","94","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2427.54","73","","2490.03","2490.03","2490.03","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1938.71","58.3","","750.00","750.00","750.00","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1762.46","53","","1192.50","120.84","4149.90","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2826.59","85","","750.00","75.00","750.00","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3325.40","100","","657.00","121.50","1971.00","14","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3325.40","100","","75.00","75.00","75.00","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3325.40","100","","366.00","144.00","1971.00","45","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2427.54","73","","667.50","667.50","667.50","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1478.14","44.45","","123.77","123.77","123.77","1 through 10","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","both","","","3325.40","2494.05","WELLPOINT [1015]","HB CH WELLPOINT","2590.82","77.91","","483.51","229.32","1316.08","96","1478.14","3325.4","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.40","2494.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1971.96","59.3","","439.50","225.34","1872.27","197","1662.7","2608.78","percent of total billed charges",""
"Implant Cable T2","PX-27000014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3325.40","2494.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2608.78","78.45","","385.32","55.36","1815.62","58","1662.7","2608.78","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","AETNA [1001]","HB CH AETNA HMO / PPO","2553.82","58.3","","554.95","91.85","1421.75","94","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3197.75","73","","2490.03","2490.03","2490.03","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2553.82","58.3","","750.00","750.00","750.00","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2321.65","53","","1192.50","120.84","4149.90","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3723.41","85","","750.00","75.00","750.00","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4380.48","100","","657.00","121.50","1971.00","14","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4380.48","100","","75.00","75.00","75.00","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4380.48","100","","366.00","144.00","1971.00","45","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3197.75","73","","667.50","667.50","667.50","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1947.12","44.45","","123.77","123.77","123.77","1 through 10","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","both","","","4380.48","3285.36","WELLPOINT [1015]","HB CH WELLPOINT","3412.83","77.91","","483.51","229.32","1316.08","96","1947.12","4380.48","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.48","3285.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","2597.62","59.3","","439.50","225.34","1872.27","197","2190.24","3436.49","percent of total billed charges",""
"Implant Cable T3","PX-27000015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4380.48","3285.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3436.49","78.45","","385.32","55.36","1815.62","58","2190.24","3436.49","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","AETNA [1001]","HB CH AETNA HMO / PPO","1764.94","58.3","","1634.24","1004.95","1718.99","42","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2209.96","73","","2123.89","1900.92","2123.89","1 through 10","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1764.94","58.3","","3729.00","1254.19","3729.00","1 through 10","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1604.49","53","","939.37","939.37","5593.65","1 through 10","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2573.24","85","","2323.25","1864.50","2882.25","16","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3027.34","100","","2909.44","1772.40","10952.08","45","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3027.34","100","","2323.25","2323.25","2323.25","1 through 10","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3027.34","100","","2882.25","1772.40","10169.17","187","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2209.96","73","","1659.41","1659.41","1659.41","1 through 10","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3027.34","2270.50","WELLPOINT [1015]","HB CH WELLPOINT","2358.60","77.91","","2050.91","1468.48","2902.83","52","1345.65","3027.34","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.34","2270.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1795.21","59.3","","1548.60","1092.60","3613.79","82","1513.67","2374.95","percent of total billed charges",""
"Implant Elbow T1","PX-27000098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3027.34","2270.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2374.95","78.45","","2085.51","998.68","6202.11","56","1513.67","2374.95","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","AETNA [1001]","HB CH AETNA HMO / PPO","2202.57","58.3","","1634.24","1004.95","1718.99","42","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2757.94","73","","2123.89","1900.92","2123.89","1 through 10","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2202.57","58.3","","3729.00","1254.19","3729.00","1 through 10","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2002.34","53","","939.37","939.37","5593.65","1 through 10","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3211.30","85","","2323.25","1864.50","2882.25","16","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3778.00","100","","2909.44","1772.40","10952.08","45","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3778.00","100","","2323.25","2323.25","2323.25","1 through 10","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3778.00","100","","2882.25","1772.40","10169.17","187","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2757.94","73","","1659.41","1659.41","1659.41","1 through 10","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","both","","","3778.00","2833.50","WELLPOINT [1015]","HB CH WELLPOINT","2943.44","77.91","","2050.91","1468.48","2902.83","52","1679.32","3778","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3778.00","2833.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2240.35","59.3","","1548.60","1092.60","3613.79","82","1889","2963.84","percent of total billed charges",""
"Implant Elbow T2","PX-27000099","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3778.00","2833.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2963.84","78.45","","2085.51","998.68","6202.11","56","1889","2963.84","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","AETNA [1001]","HB CH AETNA HMO / PPO","3596.54","58.3","","1634.24","1004.95","1718.99","42","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4503.38","73","","2123.89","1900.92","2123.89","1 through 10","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3596.54","58.3","","3729.00","1254.19","3729.00","1 through 10","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3269.58","53","","939.37","939.37","5593.65","1 through 10","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5243.67","85","","2323.25","1864.50","2882.25","16","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6169.02","100","","2909.44","1772.40","10952.08","45","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6169.02","100","","2323.25","2323.25","2323.25","1 through 10","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6169.02","100","","2882.25","1772.40","10169.17","187","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4503.38","73","","1659.41","1659.41","1659.41","1 through 10","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","both","","","6169.02","4626.76","WELLPOINT [1015]","HB CH WELLPOINT","4806.28","77.91","","2050.91","1468.48","2902.83","52","2742.13","6169.02","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6169.02","4626.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","3658.23","59.3","","1548.60","1092.60","3613.79","82","3084.51","4839.6","percent of total billed charges",""
"Implant Elbow T3","PX-27000100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6169.02","4626.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4839.60","78.45","","2085.51","998.68","6202.11","56","3084.51","4839.6","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","AETNA [1001]","HB CH AETNA HMO / PPO","365.38","58.3","","554.95","91.85","1421.75","94","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","457.51","73","","2490.03","2490.03","2490.03","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","365.38","58.3","","750.00","750.00","750.00","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","332.17","53","","1192.50","120.84","4149.90","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","532.72","85","","750.00","75.00","750.00","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","626.73","100","","657.00","121.50","1971.00","14","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","626.73","100","","75.00","75.00","75.00","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","626.73","100","","366.00","144.00","1971.00","45","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","457.51","73","","667.50","667.50","667.50","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.58","44.45","","123.77","123.77","123.77","1 through 10","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.73","470.05","WELLPOINT [1015]","HB CH WELLPOINT","488.29","77.91","","483.51","229.32","1316.08","96","278.58","626.73","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.73","470.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.65","59.3","","439.50","225.34","1872.27","197","313.37","491.67","percent of total billed charges",""
"Implant Endobutton T1","PX-27000016","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.73","470.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.67","78.45","","385.32","55.36","1815.62","58","313.37","491.67","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","AETNA [1001]","HB CH AETNA HMO / PPO","2042.10","58.3","","1634.24","1004.95","1718.99","42","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2557.00","73","","2123.89","1900.92","2123.89","1 through 10","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2042.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.45","53","","939.37","939.37","5593.65","1 through 10","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2977.33","85","","2323.25","1864.50","2882.25","16","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3502.74","100","","2909.44","1772.40","10952.08","45","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3502.74","100","","2323.25","2323.25","2323.25","1 through 10","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3502.74","100","","2882.25","1772.40","10169.17","187","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2557.00","73","","1659.41","1659.41","1659.41","1 through 10","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.74","2627.05","WELLPOINT [1015]","HB CH WELLPOINT","2728.98","77.91","","2050.91","1468.48","2902.83","52","1556.97","3502.74","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.74","2627.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.12","59.3","","1548.60","1092.60","3613.79","82","1751.37","2747.9","percent of total billed charges",""
"IMPLANT FINGER 19.3X15.6X11.3MM SZ 10 ASCENSION METACARPOPHALANGEAL SILICONE","SUP-ITM-10050571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.74","2627.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.90","78.45","","2085.51","998.68","6202.11","56","1751.37","2747.9","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","AETNA [1001]","HB CH AETNA HMO / PPO","1954.59","58.3","","1634.24","1004.95","1718.99","42","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","2123.89","1900.92","2123.89","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1954.59","58.3","","3729.00","1254.19","3729.00","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1776.90","53","","939.37","939.37","5593.65","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2849.75","85","","2323.25","1864.50","2882.25","16","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3352.65","100","","2909.44","1772.40","10952.08","45","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3352.65","100","","2323.25","2323.25","2323.25","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3352.65","100","","2882.25","1772.40","10169.17","187","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","1659.41","1659.41","1659.41","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","WELLPOINT [1015]","HB CH WELLPOINT","2612.05","77.91","","2050.91","1468.48","2902.83","52","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1988.12","59.3","","1548.60","1092.60","3613.79","82","1676.33","2630.15","percent of total billed charges",""
"IMPLANT FINGER SZ 0 SILICONE PIP","SUP-ITM-10086340","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2630.15","78.45","","2085.51","998.68","6202.11","56","1676.33","2630.15","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","AETNA [1001]","HB CH AETNA HMO / PPO","1954.59","58.3","","1634.24","1004.95","1718.99","42","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","2123.89","1900.92","2123.89","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1954.59","58.3","","3729.00","1254.19","3729.00","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1776.90","53","","939.37","939.37","5593.65","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2849.75","85","","2323.25","1864.50","2882.25","16","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3352.65","100","","2909.44","1772.40","10952.08","45","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3352.65","100","","2323.25","2323.25","2323.25","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3352.65","100","","2882.25","1772.40","10169.17","187","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","1659.41","1659.41","1659.41","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","WELLPOINT [1015]","HB CH WELLPOINT","2612.05","77.91","","2050.91","1468.48","2902.83","52","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1988.12","59.3","","1548.60","1092.60","3613.79","82","1676.33","2630.15","percent of total billed charges",""
"IMPLANT FINGER SZ 2 SILICONE PIP","SUP-ITM-10117440","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2630.15","78.45","","2085.51","998.68","6202.11","56","1676.33","2630.15","percent of total billed charges",""
"IMPLANT FINGER SZ 4 SILICONE PIP","SUP-ITM-10117442","CDM","C1889","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","AETNA [1001]","HB CH AETNA HMO / PPO","1954.59","58.3","","1830.28","315.58","1830.28","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 4 SILICONE PIP","SUP-ITM-10117442","CDM","C1889","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2447.43","73","","4170.85","4170.85","4170.85","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 4 SILICONE PIP","SUP-ITM-10117442","CDM","C1889","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1490.25","44.45","","649.55","649.55","649.55","1 through 10","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 4 SILICONE PIP","SUP-ITM-10117442","CDM","C1889","HCPCS","0278","RC","","","","both","","","3352.65","2514.49","WELLPOINT [1015]","HB CH WELLPOINT","2612.05","77.91","","8998.38","2542.37","8998.38","20","1490.25","3352.65","percent of total billed charges",""
"IMPLANT FINGER SZ 4 SILICONE PIP","SUP-ITM-10117442","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1988.12","59.3","","1891.61","1609.14","3664.18","25","1676.33","2630.15","percent of total billed charges",""
"IMPLANT FINGER SZ 4 SILICONE PIP","SUP-ITM-10117442","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3352.65","2514.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2630.15","78.45","","1470.68","1310.06","2481.69","19","1676.33","2630.15","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","AETNA [1001]","HB CH AETNA HMO / PPO","3623.93","58.3","","1634.24","1004.95","1718.99","42","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4537.68","73","","2123.89","1900.92","2123.89","1 through 10","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3623.93","58.3","","3729.00","1254.19","3729.00","1 through 10","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3294.48","53","","939.37","939.37","5593.65","1 through 10","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5283.60","85","","2323.25","1864.50","2882.25","16","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6216.00","100","","2909.44","1772.40","10952.08","45","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6216.00","100","","2323.25","2323.25","2323.25","1 through 10","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6216.00","100","","2882.25","1772.40","10169.17","187","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4537.68","73","","1659.41","1659.41","1659.41","1 through 10","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","both","","","6216.00","4662.00","WELLPOINT [1015]","HB CH WELLPOINT","4842.89","77.91","","2050.91","1468.48","2902.83","52","2763.01","6216","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3686.09","59.3","","1548.60","1092.60","3613.79","82","3108","4876.45","percent of total billed charges",""
"IMPLANT FINGER SZ 5 PYROCARBON PROXIMAL MCP WW","SUP-ITM-10117435","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6216.00","4662.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4876.45","78.45","","2085.51","998.68","6202.11","56","3108","4876.45","percent of total billed charges",""
"IMPLANT GENERATOR INTRSTM PLS NEUROSTIMULATORX 97800 X INCONTINENCE","SUP-ITM-10295475","CDM","C1820","HCPCS","0278","RC","","","","both","","","22450.00","16837.50","WELLPOINT [1015]","HB CH WELLPOINT","17490.80","77.91","","17681.62","17681.62","17681.62","1 through 10","11898.5","22450","percent of total billed charges",""
"IMPLANT GENERATOR INTRSTM PLS NEUROSTIMULATORX 97800 X INCONTINENCE","SUP-ITM-10295475","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","22450.00","16837.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","13312.85","59.3","","74853.32","74853.32","74853.32","1 through 10","9979.03","17612.03","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","AETNA [1001]","HB CH AETNA HMO / PPO","1747.25","58.3","","554.95","91.85","1421.75","94","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2187.81","73","","2490.03","2490.03","2490.03","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1747.25","58.3","","750.00","750.00","750.00","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1588.41","53","","1192.50","120.84","4149.90","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2547.45","85","","750.00","75.00","750.00","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2997.00","100","","657.00","121.50","1971.00","14","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2997.00","100","","75.00","75.00","75.00","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2997.00","100","","366.00","144.00","1971.00","45","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2187.81","73","","667.50","667.50","667.50","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1332.17","44.45","","123.77","123.77","123.77","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","WELLPOINT [1015]","HB CH WELLPOINT","2334.96","77.91","","483.51","229.32","1316.08","96","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2997.00","2247.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1777.22","59.3","","439.50","225.34","1872.27","197","1498.5","2351.15","percent of total billed charges",""
"IMPLANT HAMMERTOE LG CONTINUOUS COMPRESSION","SUP-ITM-10277688","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2997.00","2247.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2351.15","78.45","","385.32","55.36","1815.62","58","1498.5","2351.15","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","AETNA [1001]","HB CH AETNA HMO / PPO","1747.25","58.3","","1634.24","1004.95","1718.99","42","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2187.81","73","","2123.89","1900.92","2123.89","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1747.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1588.41","53","","939.37","939.37","5593.65","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2547.45","85","","2323.25","1864.50","2882.25","16","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2997.00","100","","2909.44","1772.40","10952.08","45","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2997.00","100","","2323.25","2323.25","2323.25","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2997.00","100","","2882.25","1772.40","10169.17","187","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2187.81","73","","1659.41","1659.41","1659.41","1 through 10","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","both","","","2997.00","2247.75","WELLPOINT [1015]","HB CH WELLPOINT","2334.96","77.91","","2050.91","1468.48","2902.83","52","1332.17","2997","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2997.00","2247.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1777.22","59.3","","1548.60","1092.60","3613.79","82","1498.5","2351.15","percent of total billed charges",""
"IMPLANT HAMMERTOE STANDARD CONTINUOUS COMPRESSION","SUP-ITM-10277687","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2997.00","2247.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2351.15","78.45","","2085.51","998.68","6202.11","56","1498.5","2351.15","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","AETNA [1001]","HB CH AETNA HMO / PPO","102025.00","58.3","","1830.28","315.58","1830.28","1 through 10","77787.5","175000","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","127750.00","73","","4170.85","4170.85","4170.85","1 through 10","77787.5","175000","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77787.50","44.45","","649.55","649.55","649.55","1 through 10","77787.5","175000","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","both","","","175000.00","131250.00","WELLPOINT [1015]","HB CH WELLPOINT","136342.50","77.91","","8998.38","2542.37","8998.38","20","77787.5","175000","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175000.00","131250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","103775.00","59.3","","1891.61","1609.14","3664.18","25","87500","137287.5","percent of total billed charges",""
"Implant Heart T3","PX-27000695","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","175000.00","131250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137287.50","78.45","","1470.68","1310.06","2481.69","19","87500","137287.5","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","AETNA [1001]","HB CH AETNA HMO / PPO","957.96","58.3","","1634.24","1004.95","1718.99","42","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1199.51","73","","2123.89","1900.92","2123.89","1 through 10","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","957.96","58.3","","3729.00","1254.19","3729.00","1 through 10","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","870.87","53","","939.37","939.37","5593.65","1 through 10","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1396.69","85","","2323.25","1864.50","2882.25","16","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1643.16","100","","2909.44","1772.40","10952.08","45","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1643.16","100","","2323.25","2323.25","2323.25","1 through 10","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1643.16","100","","2882.25","1772.40","10169.17","187","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1199.51","73","","1659.41","1659.41","1659.41","1 through 10","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","both","","","1643.16","1232.37","WELLPOINT [1015]","HB CH WELLPOINT","1280.19","77.91","","2050.91","1468.48","2902.83","52","730.38","1643.16","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1643.16","1232.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","974.39","59.3","","1548.60","1092.60","3613.79","82","821.58","1289.06","percent of total billed charges",""
"Implant Hip T1","PX-27000101","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1643.16","1232.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1289.06","78.45","","2085.51","998.68","6202.11","56","821.58","1289.06","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","AETNA [1001]","HB CH AETNA HMO / PPO","2325.66","58.3","","1634.24","1004.95","1718.99","42","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2912.06","73","","2123.89","1900.92","2123.89","1 through 10","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2325.66","58.3","","3729.00","1254.19","3729.00","1 through 10","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.24","53","","939.37","939.37","5593.65","1 through 10","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3390.76","85","","2323.25","1864.50","2882.25","16","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3989.13","100","","2909.44","1772.40","10952.08","45","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3989.13","100","","2323.25","2323.25","2323.25","1 through 10","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3989.13","100","","2882.25","1772.40","10169.17","187","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2912.06","73","","1659.41","1659.41","1659.41","1 through 10","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","both","","","3989.13","2991.85","WELLPOINT [1015]","HB CH WELLPOINT","3107.93","77.91","","2050.91","1468.48","2902.83","52","1773.17","3989.13","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3989.13","2991.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","2365.55","59.3","","1548.60","1092.60","3613.79","82","1994.57","3129.47","percent of total billed charges",""
"Implant Hip T2","PX-27000102","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3989.13","2991.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3129.47","78.45","","2085.51","998.68","6202.11","56","1994.57","3129.47","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","AETNA [1001]","HB CH AETNA HMO / PPO","2544.85","58.3","","1634.24","1004.95","1718.99","42","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3186.52","73","","2123.89","1900.92","2123.89","1 through 10","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2544.85","58.3","","3729.00","1254.19","3729.00","1 through 10","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2313.50","53","","939.37","939.37","5593.65","1 through 10","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3710.33","85","","2323.25","1864.50","2882.25","16","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4365.09","100","","2909.44","1772.40","10952.08","45","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4365.09","100","","2323.25","2323.25","2323.25","1 through 10","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4365.09","100","","2882.25","1772.40","10169.17","187","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3186.52","73","","1659.41","1659.41","1659.41","1 through 10","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","both","","","4365.09","3273.82","WELLPOINT [1015]","HB CH WELLPOINT","3400.84","77.91","","2050.91","1468.48","2902.83","52","1940.28","4365.09","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4365.09","3273.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","2588.50","59.3","","1548.60","1092.60","3613.79","82","2182.55","3424.41","percent of total billed charges",""
"Implant Hip T3","PX-27000103","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4365.09","3273.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3424.41","78.45","","2085.51","998.68","6202.11","56","2182.55","3424.41","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","AETNA [1001]","HB CH AETNA HMO / PPO","1112.90","58.3","","1634.24","1004.95","1718.99","42","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1393.51","73","","2123.89","1900.92","2123.89","1 through 10","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1112.90","58.3","","3729.00","1254.19","3729.00","1 through 10","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1011.73","53","","939.37","939.37","5593.65","1 through 10","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1622.58","85","","2323.25","1864.50","2882.25","16","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1908.92","100","","2909.44","1772.40","10952.08","45","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1908.92","100","","2323.25","2323.25","2323.25","1 through 10","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1908.92","100","","2882.25","1772.40","10169.17","187","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1393.51","73","","1659.41","1659.41","1659.41","1 through 10","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","both","","","1908.92","1431.69","WELLPOINT [1015]","HB CH WELLPOINT","1487.24","77.91","","2050.91","1468.48","2902.83","52","848.51","1908.92","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1908.92","1431.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","1131.99","59.3","","1548.60","1092.60","3613.79","82","954.46","1497.55","percent of total billed charges",""
"Implant Knee T1","PX-27000104","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1908.92","1431.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1497.55","78.45","","2085.51","998.68","6202.11","56","954.46","1497.55","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","AETNA [1001]","HB CH AETNA HMO / PPO","2138.99","58.3","","1634.24","1004.95","1718.99","42","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2678.32","73","","2123.89","1900.92","2123.89","1 through 10","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2138.99","58.3","","3729.00","1254.19","3729.00","1 through 10","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1944.53","53","","939.37","939.37","5593.65","1 through 10","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3118.59","85","","2323.25","1864.50","2882.25","16","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3668.93","100","","2909.44","1772.40","10952.08","45","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3668.93","100","","2323.25","2323.25","2323.25","1 through 10","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3668.93","100","","2882.25","1772.40","10169.17","187","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2678.32","73","","1659.41","1659.41","1659.41","1 through 10","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","both","","","3668.93","2751.70","WELLPOINT [1015]","HB CH WELLPOINT","2858.46","77.91","","2050.91","1468.48","2902.83","52","1630.84","3668.93","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3668.93","2751.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2175.68","59.3","","1548.60","1092.60","3613.79","82","1834.47","2878.28","percent of total billed charges",""
"Implant Knee T2","PX-27000105","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3668.93","2751.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2878.28","78.45","","2085.51","998.68","6202.11","56","1834.47","2878.28","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","AETNA [1001]","HB CH AETNA HMO / PPO","3564.82","58.3","","1634.24","1004.95","1718.99","42","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4463.67","73","","2123.89","1900.92","2123.89","1 through 10","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3564.82","58.3","","3729.00","1254.19","3729.00","1 through 10","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3240.75","53","","939.37","939.37","5593.65","1 through 10","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5197.43","85","","2323.25","1864.50","2882.25","16","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6114.62","100","","2909.44","1772.40","10952.08","45","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6114.62","100","","2323.25","2323.25","2323.25","1 through 10","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6114.62","100","","2882.25","1772.40","10169.17","187","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4463.67","73","","1659.41","1659.41","1659.41","1 through 10","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","both","","","6114.62","4585.96","WELLPOINT [1015]","HB CH WELLPOINT","4763.90","77.91","","2050.91","1468.48","2902.83","52","2717.95","6114.62","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6114.62","4585.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","3625.97","59.3","","1548.60","1092.60","3613.79","82","3057.31","4796.92","percent of total billed charges",""
"Implant Knee T3","PX-27000106","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6114.62","4585.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4796.92","78.45","","2085.51","998.68","6202.11","56","3057.31","4796.92","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","AETNA [1001]","HB CH AETNA HMO / PPO","6636.69","58.3","","554.95","91.85","1421.75","94","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8310.09","73","","2490.03","2490.03","2490.03","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6636.69","58.3","","750.00","750.00","750.00","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6033.35","53","","1192.50","120.84","4149.90","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9676.13","85","","750.00","75.00","750.00","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11383.68","100","","657.00","121.50","1971.00","14","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11383.68","100","","75.00","75.00","75.00","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11383.68","100","","366.00","144.00","1971.00","45","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8310.09","73","","667.50","667.50","667.50","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5060.05","44.45","","123.77","123.77","123.77","1 through 10","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","both","","","11383.68","8537.76","WELLPOINT [1015]","HB CH WELLPOINT","8869.03","77.91","","483.51","229.32","1316.08","96","5060.05","11383.68","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11383.68","8537.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","6750.52","59.3","","439.50","225.34","1872.27","197","5691.84","8930.5","percent of total billed charges",""
"IMPLANT MANDIBLE SM PRINTED 3D TI TRUMATCH MIDFACE SD980.106","SUP-ITM-10239696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11383.68","8537.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8930.50","78.45","","385.32","55.36","1815.62","58","5691.84","8930.5","percent of total billed charges",""
"IMPLANT MESH LG REGENETEN BIOINDUCTIVE WITH DELIVERY SYSTEM","SUP-ITM-10261483","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3608.70","78.45","","555.84","555.84","555.84","1 through 10","2300","3608.7","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","AETNA [1001]","HB CH AETNA HMO / PPO","207.12","58.3","","554.95","91.85","1421.75","94","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","259.34","73","","2490.03","2490.03","2490.03","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","207.12","58.3","","750.00","750.00","750.00","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","188.29","53","","1192.50","120.84","4149.90","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","301.97","85","","750.00","75.00","750.00","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","355.26","100","","657.00","121.50","1971.00","14","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","355.26","100","","75.00","75.00","75.00","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","355.26","100","","366.00","144.00","1971.00","45","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","259.34","73","","667.50","667.50","667.50","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.91","44.45","","123.77","123.77","123.77","1 through 10","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","both","","","355.26","266.44","WELLPOINT [1015]","HB CH WELLPOINT","276.78","77.91","","483.51","229.32","1316.08","96","157.91","355.26","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.26","266.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","210.67","59.3","","439.50","225.34","1872.27","197","177.63","278.7","percent of total billed charges",""
"Implant Nail / Screw T1","PX-27000017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","355.26","266.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.70","78.45","","385.32","55.36","1815.62","58","177.63","278.7","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","AETNA [1001]","HB CH AETNA HMO / PPO","2237.31","58.3","","554.95","91.85","1421.75","94","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2801.44","73","","2490.03","2490.03","2490.03","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2237.31","58.3","","750.00","750.00","750.00","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2033.92","53","","1192.50","120.84","4149.90","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3261.95","85","","750.00","75.00","750.00","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3837.59","100","","657.00","121.50","1971.00","14","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3837.59","100","","75.00","75.00","75.00","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3837.59","100","","366.00","144.00","1971.00","45","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2801.44","73","","667.50","667.50","667.50","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1705.81","44.45","","123.77","123.77","123.77","1 through 10","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","both","","","3837.59","2878.19","WELLPOINT [1015]","HB CH WELLPOINT","2989.87","77.91","","483.51","229.32","1316.08","96","1705.81","3837.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3837.59","2878.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2275.69","59.3","","439.50","225.34","1872.27","197","1918.8","3010.59","percent of total billed charges",""
"Implant Nail / Screw T2","PX-27000018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3837.59","2878.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3010.59","78.45","","385.32","55.36","1815.62","58","1918.8","3010.59","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","AETNA [1001]","HB CH AETNA HMO / PPO","2647.60","58.3","","554.95","91.85","1421.75","94","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3315.17","73","","2490.03","2490.03","2490.03","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2647.60","58.3","","750.00","750.00","750.00","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2406.90","53","","1192.50","120.84","4149.90","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3860.13","85","","750.00","75.00","750.00","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4541.33","100","","657.00","121.50","1971.00","14","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4541.33","100","","75.00","75.00","75.00","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4541.33","100","","366.00","144.00","1971.00","45","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3315.17","73","","667.50","667.50","667.50","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2018.62","44.45","","123.77","123.77","123.77","1 through 10","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","both","","","4541.33","3406.00","WELLPOINT [1015]","HB CH WELLPOINT","3538.15","77.91","","483.51","229.32","1316.08","96","2018.62","4541.33","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4541.33","3406.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2693.01","59.3","","439.50","225.34","1872.27","197","2270.67","3562.67","percent of total billed charges",""
"Implant Nail / Screw T3","PX-27000019","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4541.33","3406.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3562.67","78.45","","385.32","55.36","1815.62","58","2270.67","3562.67","percent of total billed charges",""
"IMPLANT NASAL 24MM LATERA PLLA POLYMER ABSORBABLE- ORDER IN QUANTITIES OF 3 OR 6 FOR PRICE DISCOUNTS","SUP-ITM-10216606","CDM","C1889","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","AETNA [1001]","HB CH AETNA HMO / PPO","2326.17","58.3","","1830.28","315.58","1830.28","1 through 10","1773.56","3990","percent of total billed charges",""
"IMPLANT NASAL 24MM LATERA PLLA POLYMER ABSORBABLE- ORDER IN QUANTITIES OF 3 OR 6 FOR PRICE DISCOUNTS","SUP-ITM-10216606","CDM","C1889","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","4170.85","4170.85","4170.85","1 through 10","1773.56","3990","percent of total billed charges",""
"IMPLANT NASAL 24MM LATERA PLLA POLYMER ABSORBABLE- ORDER IN QUANTITIES OF 3 OR 6 FOR PRICE DISCOUNTS","SUP-ITM-10216606","CDM","C1889","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.56","44.45","","649.55","649.55","649.55","1 through 10","1773.56","3990","percent of total billed charges",""
"IMPLANT NASAL 24MM LATERA PLLA POLYMER ABSORBABLE- ORDER IN QUANTITIES OF 3 OR 6 FOR PRICE DISCOUNTS","SUP-ITM-10216606","CDM","C1889","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB CH WELLPOINT","3108.61","77.91","","8998.38","2542.37","8998.38","20","1773.56","3990","percent of total billed charges",""
"IMPLANT NASAL 24MM LATERA PLLA POLYMER ABSORBABLE- ORDER IN QUANTITIES OF 3 OR 6 FOR PRICE DISCOUNTS","SUP-ITM-10216606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.07","59.3","","1891.61","1609.14","3664.18","25","1995","3130.16","percent of total billed charges",""
"IMPLANT NASAL 24MM LATERA PLLA POLYMER ABSORBABLE- ORDER IN QUANTITIES OF 3 OR 6 FOR PRICE DISCOUNTS","SUP-ITM-10216606","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","1470.68","1310.06","2481.69","19","1995","3130.16","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","AETNA [1001]","HB CH AETNA HMO / PPO","184.86","58.3","","554.95","91.85","1421.75","94","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","231.48","73","","2490.03","2490.03","2490.03","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","184.86","58.3","","750.00","750.00","750.00","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.06","53","","1192.50","120.84","4149.90","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","269.53","85","","750.00","75.00","750.00","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","317.09","100","","657.00","121.50","1971.00","14","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","317.09","100","","75.00","75.00","75.00","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","317.09","100","","366.00","144.00","1971.00","45","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","231.48","73","","667.50","667.50","667.50","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.95","44.45","","123.77","123.77","123.77","1 through 10","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","both","","","317.09","237.82","WELLPOINT [1015]","HB CH WELLPOINT","247.04","77.91","","483.51","229.32","1316.08","96","140.95","317.09","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.09","237.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.03","59.3","","439.50","225.34","1872.27","197","158.55","248.76","percent of total billed charges",""
"Implant Pin/Wire/Peg T1","PX-27000020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","317.09","237.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","248.76","78.45","","385.32","55.36","1815.62","58","158.55","248.76","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","AETNA [1001]","HB CH AETNA HMO / PPO","2031.61","58.3","","554.95","91.85","1421.75","94","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2543.87","73","","2490.03","2490.03","2490.03","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.61","58.3","","750.00","750.00","750.00","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.92","53","","1192.50","120.84","4149.90","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2962.04","85","","750.00","75.00","750.00","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3484.75","100","","657.00","121.50","1971.00","14","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3484.75","100","","75.00","75.00","75.00","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3484.75","100","","366.00","144.00","1971.00","45","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2543.87","73","","667.50","667.50","667.50","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1548.97","44.45","","123.77","123.77","123.77","1 through 10","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","both","","","3484.75","2613.56","WELLPOINT [1015]","HB CH WELLPOINT","2714.97","77.91","","483.51","229.32","1316.08","96","1548.97","3484.75","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.75","2613.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2066.46","59.3","","439.50","225.34","1872.27","197","1742.38","2733.79","percent of total billed charges",""
"Implant Pin/Wire/Peg T2","PX-27000021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3484.75","2613.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.79","78.45","","385.32","55.36","1815.62","58","1742.38","2733.79","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","AETNA [1001]","HB CH AETNA HMO / PPO","2840.38","58.3","","554.95","91.85","1421.75","94","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3556.56","73","","2490.03","2490.03","2490.03","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2840.38","58.3","","750.00","750.00","750.00","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2582.16","53","","1192.50","120.84","4149.90","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4141.20","85","","750.00","75.00","750.00","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4872.00","100","","657.00","121.50","1971.00","14","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4872.00","100","","75.00","75.00","75.00","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4872.00","100","","366.00","144.00","1971.00","45","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3556.56","73","","667.50","667.50","667.50","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2165.60","44.45","","123.77","123.77","123.77","1 through 10","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","both","","","4872.00","3654.00","WELLPOINT [1015]","HB CH WELLPOINT","3795.78","77.91","","483.51","229.32","1316.08","96","2165.6","4872","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.00","3654.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2889.10","59.3","","439.50","225.34","1872.27","197","2436","3822.08","percent of total billed charges",""
"Implant Pin/Wire/Peg T3","PX-27000022","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4872.00","3654.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3822.08","78.45","","385.32","55.36","1815.62","58","2436","3822.08","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","AETNA [1001]","HB CH AETNA HMO / PPO","536.48","58.3","","554.95","91.85","1421.75","94","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","671.75","73","","2490.03","2490.03","2490.03","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","536.48","58.3","","750.00","750.00","750.00","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","487.71","53","","1192.50","120.84","4149.90","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","782.18","85","","750.00","75.00","750.00","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","920.21","100","","657.00","121.50","1971.00","14","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","920.21","100","","75.00","75.00","75.00","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","920.21","100","","366.00","144.00","1971.00","45","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","671.75","73","","667.50","667.50","667.50","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.03","44.45","","123.77","123.77","123.77","1 through 10","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","both","","","920.21","690.16","WELLPOINT [1015]","HB CH WELLPOINT","716.94","77.91","","483.51","229.32","1316.08","96","409.03","920.21","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","920.21","690.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","545.68","59.3","","439.50","225.34","1872.27","197","460.11","721.9","percent of total billed charges",""
"Implant Plate T1","PX-27000023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","920.21","690.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","721.90","78.45","","385.32","55.36","1815.62","58","460.11","721.9","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","AETNA [1001]","HB CH AETNA HMO / PPO","2060.74","58.3","","554.95","91.85","1421.75","94","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2580.35","73","","2490.03","2490.03","2490.03","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2060.74","58.3","","750.00","750.00","750.00","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1873.40","53","","1192.50","120.84","4149.90","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3004.51","85","","750.00","75.00","750.00","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3534.72","100","","657.00","121.50","1971.00","14","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3534.72","100","","75.00","75.00","75.00","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3534.72","100","","366.00","144.00","1971.00","45","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2580.35","73","","667.50","667.50","667.50","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.18","44.45","","123.77","123.77","123.77","1 through 10","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.72","2651.04","WELLPOINT [1015]","HB CH WELLPOINT","2753.90","77.91","","483.51","229.32","1316.08","96","1571.18","3534.72","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.72","2651.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","2096.09","59.3","","439.50","225.34","1872.27","197","1767.36","2772.99","percent of total billed charges",""
"Implant Plate T2","PX-27000024","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.72","2651.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2772.99","78.45","","385.32","55.36","1815.62","58","1767.36","2772.99","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","AETNA [1001]","HB CH AETNA HMO / PPO","3405.02","58.3","","554.95","91.85","1421.75","94","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4263.57","73","","2490.03","2490.03","2490.03","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3405.02","58.3","","750.00","750.00","750.00","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3095.47","53","","1192.50","120.84","4149.90","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4964.43","85","","750.00","75.00","750.00","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5840.51","100","","657.00","121.50","1971.00","14","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5840.51","100","","75.00","75.00","75.00","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5840.51","100","","366.00","144.00","1971.00","45","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4263.57","73","","667.50","667.50","667.50","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2596.11","44.45","","123.77","123.77","123.77","1 through 10","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","both","","","5840.51","4380.38","WELLPOINT [1015]","HB CH WELLPOINT","4550.34","77.91","","483.51","229.32","1316.08","96","2596.11","5840.51","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5840.51","4380.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","3463.42","59.3","","439.50","225.34","1872.27","197","2920.26","4581.88","percent of total billed charges",""
"Implant Plate T3","PX-27000025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5840.51","4380.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4581.88","78.45","","385.32","55.36","1815.62","58","2920.26","4581.88","percent of total billed charges",""
"Implant Pump Infus Programmable","PX-76001481","CDM","62362","CPT","0761","RC","","","","both","","","49250.00","36937.50","MEDICARE [2001]","HB BWF MEDICARE","20986.96","","APC Price ($20,986.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20989.08","20989.08","20989.08","1 through 10","10443.8","38370.68","other","OPPS APC"
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","AETNA [1001]","HB CH AETNA HMO / PPO","1379.61","58.3","","1634.24","1004.95","1718.99","42","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1727.47","73","","2123.89","1900.92","2123.89","1 through 10","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1379.61","58.3","","3729.00","1254.19","3729.00","1 through 10","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1254.19","53","","939.37","939.37","5593.65","1 through 10","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2011.44","85","","2323.25","1864.50","2882.25","16","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2366.40","100","","2909.44","1772.40","10952.08","45","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2366.40","100","","2323.25","2323.25","2323.25","1 through 10","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2366.40","100","","2882.25","1772.40","10169.17","187","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1727.47","73","","1659.41","1659.41","1659.41","1 through 10","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","both","","","2366.40","1774.80","WELLPOINT [1015]","HB CH WELLPOINT","1843.66","77.91","","2050.91","1468.48","2902.83","52","1051.86","2366.4","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2366.40","1774.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","1403.28","59.3","","1548.60","1092.60","3613.79","82","1183.2","1856.44","percent of total billed charges",""
"Implant Shoulder T1","PX-27000107","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2366.40","1774.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1856.44","78.45","","2085.51","998.68","6202.11","56","1183.2","1856.44","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","AETNA [1001]","HB CH AETNA HMO / PPO","2335.33","58.3","","1634.24","1004.95","1718.99","42","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2924.18","73","","2123.89","1900.92","2123.89","1 through 10","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2335.33","58.3","","3729.00","1254.19","3729.00","1 through 10","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2123.03","53","","939.37","939.37","5593.65","1 through 10","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3404.86","85","","2323.25","1864.50","2882.25","16","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4005.72","100","","2909.44","1772.40","10952.08","45","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4005.72","100","","2323.25","2323.25","2323.25","1 through 10","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4005.72","100","","2882.25","1772.40","10169.17","187","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2924.18","73","","1659.41","1659.41","1659.41","1 through 10","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","both","","","4005.72","3004.29","WELLPOINT [1015]","HB CH WELLPOINT","3120.86","77.91","","2050.91","1468.48","2902.83","52","1780.54","4005.72","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4005.72","3004.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","2375.39","59.3","","1548.60","1092.60","3613.79","82","2002.86","3142.49","percent of total billed charges",""
"Implant Shoulder T2","PX-27000108","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4005.72","3004.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3142.49","78.45","","2085.51","998.68","6202.11","56","2002.86","3142.49","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","AETNA [1001]","HB CH AETNA HMO / PPO","2965.15","58.3","","1634.24","1004.95","1718.99","42","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3712.79","73","","2123.89","1900.92","2123.89","1 through 10","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2965.15","58.3","","3729.00","1254.19","3729.00","1 through 10","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2695.59","53","","939.37","939.37","5593.65","1 through 10","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4323.12","85","","2323.25","1864.50","2882.25","16","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5086.02","100","","2909.44","1772.40","10952.08","45","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5086.02","100","","2323.25","2323.25","2323.25","1 through 10","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5086.02","100","","2882.25","1772.40","10169.17","187","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3712.79","73","","1659.41","1659.41","1659.41","1 through 10","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","both","","","5086.02","3814.51","WELLPOINT [1015]","HB CH WELLPOINT","3962.52","77.91","","2050.91","1468.48","2902.83","52","2260.74","5086.02","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5086.02","3814.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","3016.01","59.3","","1548.60","1092.60","3613.79","82","2543.01","3989.98","percent of total billed charges",""
"Implant Shoulder T3","PX-27000109","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5086.02","3814.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3989.98","78.45","","2085.51","998.68","6202.11","56","2543.01","3989.98","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","AETNA [1001]","HB CH AETNA HMO / PPO","582.36","58.3","","1830.28","315.58","1830.28","1 through 10","444.02","998.91","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","729.20","73","","4170.85","4170.85","4170.85","1 through 10","444.02","998.91","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","444.02","44.45","","649.55","649.55","649.55","1 through 10","444.02","998.91","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","both","","","998.91","749.18","WELLPOINT [1015]","HB CH WELLPOINT","778.25","77.91","","8998.38","2542.37","8998.38","20","444.02","998.91","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","998.91","749.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","592.35","59.3","","1891.61","1609.14","3664.18","25","499.46","783.64","percent of total billed charges",""
"Implant Spinal T1","PX-27000700","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","998.91","749.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","783.64","78.45","","1470.68","1310.06","2481.69","19","499.46","783.64","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","AETNA [1001]","HB CH AETNA HMO / PPO","2226.65","58.3","","1830.28","315.58","1830.28","1 through 10","1697.67","3819.29","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2788.08","73","","4170.85","4170.85","4170.85","1 through 10","1697.67","3819.29","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1697.67","44.45","","649.55","649.55","649.55","1 through 10","1697.67","3819.29","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","both","","","3819.29","2864.47","WELLPOINT [1015]","HB CH WELLPOINT","2975.61","77.91","","8998.38","2542.37","8998.38","20","1697.67","3819.29","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3819.29","2864.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","2264.84","59.3","","1891.61","1609.14","3664.18","25","1909.65","2996.23","percent of total billed charges",""
"Implant Spinal T2","PX-27000701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3819.29","2864.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2996.23","78.45","","1470.68","1310.06","2481.69","19","1909.65","2996.23","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","AETNA [1001]","HB CH AETNA HMO / PPO","3545.23","58.3","","1830.28","315.58","1830.28","1 through 10","2703.01","6081.01","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4439.14","73","","4170.85","4170.85","4170.85","1 through 10","2703.01","6081.01","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2703.01","44.45","","649.55","649.55","649.55","1 through 10","2703.01","6081.01","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","both","","","6081.01","4560.76","WELLPOINT [1015]","HB CH WELLPOINT","4737.71","77.91","","8998.38","2542.37","8998.38","20","2703.01","6081.01","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6081.01","4560.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","3606.04","59.3","","1891.61","1609.14","3664.18","25","3040.51","4770.55","percent of total billed charges",""
"Implant Spinal T3","PX-27000702","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6081.01","4560.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4770.55","78.45","","1470.68","1310.06","2481.69","19","3040.51","4770.55","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","AETNA [1001]","HB CH AETNA HMO / PPO","138.17","58.3","","554.95","91.85","1421.75","94","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","2490.03","2490.03","2490.03","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.17","58.3","","750.00","750.00","750.00","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.61","53","","1192.50","120.84","4149.90","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.45","85","","750.00","75.00","750.00","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.00","100","","657.00","121.50","1971.00","14","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.00","100","","75.00","75.00","75.00","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.00","100","","366.00","144.00","1971.00","45","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","667.50","667.50","667.50","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","123.77","123.77","123.77","1 through 10","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","WELLPOINT [1015]","HB CH WELLPOINT","184.65","77.91","","483.51","229.32","1316.08","96","105.35","237","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.54","59.3","","439.50","225.34","1872.27","197","118.5","185.93","percent of total billed charges",""
"Implant Staple Bone T1","PX-27000026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","385.32","55.36","1815.62","58","118.5","185.93","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","AETNA [1001]","HB CH AETNA HMO / PPO","2403.42","58.3","","554.95","91.85","1421.75","94","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3009.43","73","","2490.03","2490.03","2490.03","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2403.42","58.3","","750.00","750.00","750.00","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2184.93","53","","1192.50","120.84","4149.90","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3504.13","85","","750.00","75.00","750.00","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4122.50","100","","657.00","121.50","1971.00","14","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4122.50","100","","75.00","75.00","75.00","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4122.50","100","","366.00","144.00","1971.00","45","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3009.43","73","","667.50","667.50","667.50","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1832.45","44.45","","123.77","123.77","123.77","1 through 10","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","both","","","4122.50","3091.87","WELLPOINT [1015]","HB CH WELLPOINT","3211.84","77.91","","483.51","229.32","1316.08","96","1832.45","4122.5","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.50","3091.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2444.64","59.3","","439.50","225.34","1872.27","197","2061.25","3234.1","percent of total billed charges",""
"Implant Staple Bone Tier2","PX-27001091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4122.50","3091.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3234.10","78.45","","385.32","55.36","1815.62","58","2061.25","3234.1","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","554.95","91.85","1421.75","94","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","2490.03","2490.03","2490.03","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","750.00","750.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","1192.50","120.84","4149.90","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3176.88","85","","750.00","75.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3737.50","100","","657.00","121.50","1971.00","14","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3737.50","100","","75.00","75.00","75.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3737.50","100","","366.00","144.00","1971.00","45","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","667.50","667.50","667.50","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","123.77","123.77","123.77","1 through 10","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","483.51","229.32","1316.08","96","1661.32","3737.5","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","439.50","225.34","1872.27","197","1868.75","2932.07","percent of total billed charges",""
"IMPLANT SYNDESMOSIS TIGHTROPE XP KNOTLESS DRIVER DISPOSABLE","SUP-ITM-10267742","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","385.32","55.36","1815.62","58","1868.75","2932.07","percent of total billed charges",""
"IMPLANT TENDON REGENETEN COLLAGEN ROTATOR CUFF WITH DELIVERY SYSTEM MEDIUM","SUP-ITM-10269007","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3608.70","78.45","","555.84","555.84","555.84","1 through 10","2300","3608.7","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1830.28","315.58","1830.28","1 through 10","1944.69","4375","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","4170.85","4170.85","4170.85","1 through 10","1944.69","4375","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","649.55","649.55","649.55","1 through 10","1944.69","4375","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","8998.38","2542.37","8998.38","20","1944.69","4375","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1891.61","1609.14","3664.18","25","2187.5","3432.19","percent of total billed charges",""
"Implant Testicular T2","PX-27000704","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1470.68","1310.06","2481.69","19","2187.5","3432.19","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","AETNA [1001]","HB CH AETNA HMO / PPO","1781.50","58.3","","1830.28","315.58","1830.28","1 through 10","1358.28","3055.75","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2230.70","73","","4170.85","4170.85","4170.85","1 through 10","1358.28","3055.75","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1358.28","44.45","","649.55","649.55","649.55","1 through 10","1358.28","3055.75","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","both","","","3055.75","2291.81","WELLPOINT [1015]","HB CH WELLPOINT","2380.73","77.91","","8998.38","2542.37","8998.38","20","1358.28","3055.75","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3055.75","2291.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1812.06","59.3","","1891.61","1609.14","3664.18","25","1527.88","2397.24","percent of total billed charges",""
"Implant Tissue Expander T1","PX-27000129","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3055.75","2291.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2397.24","78.45","","1470.68","1310.06","2481.69","19","1527.88","2397.24","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2137.67","58.3","","1830.28","315.58","1830.28","1 through 10","1629.83","3666.67","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2676.67","73","","4170.85","4170.85","4170.85","1 through 10","1629.83","3666.67","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1629.83","44.45","","649.55","649.55","649.55","1 through 10","1629.83","3666.67","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","both","","","3666.67","2750.00","WELLPOINT [1015]","HB CH WELLPOINT","2856.70","77.91","","8998.38","2542.37","8998.38","20","1629.83","3666.67","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3666.67","2750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2174.34","59.3","","1891.61","1609.14","3664.18","25","1833.34","2876.5","percent of total billed charges",""
"Implant Tissue Expander T2","PX-27000130","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3666.67","2750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2876.50","78.45","","1470.68","1310.06","2481.69","19","1833.34","2876.5","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","AETNA [1001]","HB CH AETNA HMO / PPO","51.62","58.3","","554.95","91.85","1421.75","94","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","64.64","73","","2490.03","2490.03","2490.03","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","51.62","58.3","","750.00","750.00","750.00","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.93","53","","1192.50","120.84","4149.90","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","75.27","85","","750.00","75.00","750.00","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","88.55","100","","657.00","121.50","1971.00","14","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","88.55","100","","75.00","75.00","75.00","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","88.55","100","","366.00","144.00","1971.00","45","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","64.64","73","","667.50","667.50","667.50","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.36","44.45","","123.77","123.77","123.77","1 through 10","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.55","66.41","WELLPOINT [1015]","HB CH WELLPOINT","68.99","77.91","","483.51","229.32","1316.08","96","39.36","88.55","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.55","66.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.51","59.3","","439.50","225.34","1872.27","197","44.28","69.47","percent of total billed charges",""
"Implant Washer / Nut T1","PX-27000027","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.55","66.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.47","78.45","","385.32","55.36","1815.62","58","44.28","69.47","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","AETNA [1001]","HB CH AETNA HMO / PPO","1461.91","58.3","","1634.24","1004.95","1718.99","42","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1830.52","73","","2123.89","1900.92","2123.89","1 through 10","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1461.91","58.3","","3729.00","1254.19","3729.00","1 through 10","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1329.01","53","","939.37","939.37","5593.65","1 through 10","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2131.43","85","","2323.25","1864.50","2882.25","16","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2507.56","100","","2909.44","1772.40","10952.08","45","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2507.56","100","","2323.25","2323.25","2323.25","1 through 10","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2507.56","100","","2882.25","1772.40","10169.17","187","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1830.52","73","","1659.41","1659.41","1659.41","1 through 10","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","both","","","2507.56","1880.67","WELLPOINT [1015]","HB CH WELLPOINT","1953.64","77.91","","2050.91","1468.48","2902.83","52","1114.61","2507.56","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2507.56","1880.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1486.98","59.3","","1548.60","1092.60","3613.79","82","1253.78","1967.18","percent of total billed charges",""
"Implant Wrist / Finger T1","PX-27000110","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2507.56","1880.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1967.18","78.45","","2085.51","998.68","6202.11","56","1253.78","1967.18","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","AETNA [1001]","HB CH AETNA HMO / PPO","2151.27","58.3","","1634.24","1004.95","1718.99","42","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2693.70","73","","2123.89","1900.92","2123.89","1 through 10","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2151.27","58.3","","3729.00","1254.19","3729.00","1 through 10","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1955.70","53","","939.37","939.37","5593.65","1 through 10","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3136.50","85","","2323.25","1864.50","2882.25","16","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3690.00","100","","2909.44","1772.40","10952.08","45","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3690.00","100","","2323.25","2323.25","2323.25","1 through 10","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3690.00","100","","2882.25","1772.40","10169.17","187","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2693.70","73","","1659.41","1659.41","1659.41","1 through 10","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","both","","","3690.00","2767.50","WELLPOINT [1015]","HB CH WELLPOINT","2874.88","77.91","","2050.91","1468.48","2902.83","52","1640.21","3690","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3690.00","2767.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2188.17","59.3","","1548.60","1092.60","3613.79","82","1845","2894.81","percent of total billed charges",""
"Implant Wrist / Finger T2","PX-27000111","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3690.00","2767.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2894.81","78.45","","2085.51","998.68","6202.11","56","1845","2894.81","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","AETNA [1001]","HB CH AETNA HMO / PPO","2915.82","58.3","","1634.24","1004.95","1718.99","42","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3651.02","73","","2123.89","1900.92","2123.89","1 through 10","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2915.82","58.3","","3729.00","1254.19","3729.00","1 through 10","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.74","53","","939.37","939.37","5593.65","1 through 10","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4251.19","85","","2323.25","1864.50","2882.25","16","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5001.40","100","","2909.44","1772.40","10952.08","45","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5001.40","100","","2323.25","2323.25","2323.25","1 through 10","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5001.40","100","","2882.25","1772.40","10169.17","187","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3651.02","73","","1659.41","1659.41","1659.41","1 through 10","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","both","","","5001.40","3751.05","WELLPOINT [1015]","HB CH WELLPOINT","3896.59","77.91","","2050.91","1468.48","2902.83","52","2223.12","5001.4","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5001.40","3751.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.83","59.3","","1548.60","1092.60","3613.79","82","2500.7","3923.6","percent of total billed charges",""
"Implant Wrist / Finger T3","PX-27000112","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5001.40","3751.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3923.60","78.45","","2085.51","998.68","6202.11","56","2500.7","3923.6","percent of total billed charges",""
"IMPLANTABLE PULSE GENERATOR CLOSED LOOP INS NGRC-ECAPS MRI","SUP-ITM-10327771","CDM","C1820","HCPCS","0278","RC","","","","both","","","43000.00","32250.00","WELLPOINT [1015]","HB CH WELLPOINT","33501.30","77.91","","17681.62","17681.62","17681.62","1 through 10","22790","43000","percent of total billed charges",""
"IMPLANTABLE PULSE GENERATOR CLOSED LOOP INS NGRC-ECAPS MRI","SUP-ITM-10327771","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","43000.00","32250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","25499.00","59.3","","74853.32","74853.32","74853.32","1 through 10","19113.5","33733.5","percent of total billed charges",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","both","","","1171.00","878.25","AETNA [1001]","HB CH AETNA HMO / PPO","682.69","58.3","","8511.80","5367.68","8511.80","1 through 10","502.36","912.33","percent of total billed charges",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2460.00","2460.00","2460.00","1 through 10","502.36","912.33","per diem",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","492.00","492.00","492.00","1 through 10","502.36","912.33","per diem",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","554.00","554.00","554.00","1 through 10","502.36","912.33","per diem",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","both","","","1171.00","878.25","WELLPOINT [1015]","HB CH WELLPOINT","912.33","77.91","","15443.26","7456.05","24096.85","1 through 10","502.36","912.33","percent of total billed charges",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","outpatient","","","1171.00","878.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","694.40","59.3","","13410.72","4221.29","30769.13","19","468.4","918.65","percent of total billed charges",""
"Impltj Biologic Implnt St Rnfcmtn","PX-76000197","CDM","15777","CPT","0761","RC","","","","outpatient","","","1171.00","878.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","918.65","78.45","","11309.64","3475.50","11309.64","1 through 10","468.4","918.65","percent of total billed charges",""
"Impltj Biologic Implnt St Rnfcmtn|BILATERAL PROCEDURE","PX-76000197","CDM","15777","CPT","0761","RC","","","50","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,040.50). Procedure 2, Per diem ($1,520.25). Procedures 3 - 9999, Per diem ($760.13).","1938.33","1938.33","1938.33","1 through 10","","","per diem",""
"Impltj Biologic Implnt St Rnfcmtn|BILATERAL PROCEDURE","PX-76000197","CDM","15777","CPT","0761","RC","","","50","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,040.50). Procedure 2, Per diem ($1,520.25). Procedures 3 - 9999, Per diem ($760.13).","3040.50","3040.50","3040.50","1 through 10","","","per diem",""
"Impltj Biologic Implnt St Rnfcmtn|BILATERAL PROCEDURE","PX-76000197","CDM","15777","CPT","0761","RC","","","50","both","","","1171.00","878.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,324). Procedure 2, Per diem ($1,662). Procedures 3 - 9999, Per diem ($831).","806.63","806.63","831.00","1 through 10","","","per diem",""
"In Situ Hybridization (Fish)","PX-31000051","CDM","88365","CPT","0310","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.04","78.45","","461.28","461.28","461.28","1 through 10","204.8","489.19","percent of total billed charges",""
"In Situ Hybridization 1st Probe Stain","PX-31000490","CDM","88365","CPT","0310","RC","","","","outpatient","","","617.00","462.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","484.04","78.45","","461.28","461.28","461.28","1 through 10","204.8","489.19","percent of total billed charges",""
"Inborn And Other Disorders Of Metabolism","642","MS-DRG","","","","","","","","inpatient","","","39691.26","29768.44","MEDICARE [2001]","HB BWF MEDICARE","14685.08","","Case rate ($14,685.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,454.52, add-ons for qualifying new technology services are included. If operating cost exceeds $58,978.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,566.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $13,340.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,115.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,005.37. The transfer capital threshold is the transfer adjustment factor * $1,005.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12592.00","12592.00","12592.00","1 through 10","12273.2379","14685.08","other","Inpatient DRG"
"Inborn Errors Of Metabolism,MODERATE","423","DRG","","","","","","","","inpatient","","","17747.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8733.3198","","Fee schedule rate ($14,322.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8733.3198","14322.34","14322.34","1 through 10","6930.73","59767.48","case rate",""
"Incision/Remove FB Subq Complex","PX-76000009","CDM","10121","CPT","0761","RC","","","","both","","","2835.00","2126.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1216.22","2224.06","per diem",""
"Incision/Remove FB Subq Complex","PX-76000009","CDM","10121","CPT","0761","RC","","","","both","","","2835.00","2126.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2019.33","","APC Price ($2,060.54). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1885.65","1885.65","1885.65","1 through 10","1216.22","2224.06","other","OPPS APC"
"Incision/Remove FB Subq Smp","PX-76000008","CDM","10120","CPT","0761","RC","","","","outpatient","","","657.00","492.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","508.58","508.58","508.58","1 through 10","281.85","567.68","other","ASC "
"Inf Nucleic Acid Virus 12-25 Target","PX-30001404","CDM","87633","CPT","0306","RC","","","","both","","","3270.00","2452.50","AETNA [1001]","HB CH AETNA HMO / PPO","1906.41","58.3","","1189.00","1189.00","1189.00","1 through 10","408.44","2547.66","percent of total billed charges",""
"Inf Nucleic Acid Virus 12-25 Target","PX-30001404","CDM","87633","CPT","0306","RC","","","","outpatient","","","3270.00","2452.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2565.32","78.45","","1448.81","1448.81","1448.81","1 through 10","219.28","2565.32","percent of total billed charges",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","24102.53","","MASSHEALTH [3001]","HB BWF MEDICAID","19122.06","","Case rate ($21,142.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $63,572.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21137.54","21137.54","21137.54","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,EXTREME","113","DRG","","","","","","","","inpatient","","","24102.53","","MOLINA [1014]","HB BWF MEDICAID","19122.06","","Case rate ($21,142.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $63,572.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12241.05","12241.05","12241.05","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","31111.13","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7234.4484","","Fee schedule rate ($23,358.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7234.4484","15297.48","15297.48","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","31111.13","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($23,358.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","15297.48","15297.48","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","31111.13","","MASSHEALTH [3001]","HB BWF MEDICAID","8563.18","","Case rate ($9,468.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,898.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,572.85 and the sum of the standard inlier and any outlier amount.","9465.74","9465.74","9465.74","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","31111.13","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","8563.18","","Case rate ($9,468.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,898.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,572.85 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","31111.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8563.18","","Case rate ($9,468.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,898.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,572.85 and the sum of the standard inlier and any outlier amount.","9465.74","9465.74","9465.74","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MAJOR","113","DRG","","","","","","","","inpatient","","","31111.13","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8563.18","","Case rate ($9,468.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,898.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,572.85 and the sum of the standard inlier and any outlier amount.","9465.74","695.29","9465.74","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","21523.52","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7234.4484","","Fee schedule rate ($7,234.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7234.4484","7234.44","7234.44","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","21523.52","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($7,234.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","7234.44","7234.44","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MINOR","113","DRG","","","","","","","","inpatient","","","21523.52","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","3270.59","","Case rate ($3,616.20). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,046.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3615.32","3615.32","3615.32","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16212.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","7864.412","","Standard inlier is a Case rate ($11,605.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $19,716, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,647.43) for the length of stay and the standard reimbursement.","7864.412","11605.40","11605.40","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16212.34","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8447.9472","","Standard inlier is a Case rate ($12,466.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,555, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,769.57) for the length of stay and the standard reimbursement.","8447.9472","11899.85","11899.85","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16212.34","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4909.89","","Case rate ($5,428.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,858.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5427.39","5427.39","5427.39","1 through 10","3270.59","38541.25","case rate",""
"Infections Of Upper Respiratory Tract,MODERATE","113","DRG","","","","","","","","inpatient","","","16212.34","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4909.89","","Case rate ($5,428.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,858.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5427.39","1460.80","5427.39","1 through 10","3270.59","38541.25","case rate",""
"Infections, Female Reproductive System With Cc","758","MS-DRG","","","","","","","","inpatient","","","25459.59","19094.69","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9166.27","","Case rate ($9,353.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,368.04, add-ons for qualifying new technology services are included. If operating cost exceeds $54,891.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,252.89, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,322.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,028.80 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $692.11. The transfer capital threshold is the transfer adjustment factor * $692.11. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9374.87","9374.87","9374.87","1 through 10","9166.27","10049.44","other","Inpatient DRG"
"Infections, Female Reproductive System With McC","757","MS-DRG","","","","","","","","inpatient","","","20095.25","15071.44","MEDICARE [2001]","HB BWF MEDICARE","13523.42","","Case rate ($13,523.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,544.90, add-ons for qualifying new technology services are included. If operating cost exceeds $59,068.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,573.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $12,171.88 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,205.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,012.30. The transfer capital threshold is the transfer adjustment factor * $1,012.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14229.25","14229.25","14229.25","1 through 10","13252.95","14698.45","other","Inpatient Replacement Plans DRG"
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","142701.76","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","115032.18","","Standard inlier is a Case rate ($115,032.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $121,507, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,328.33) for the length of stay and the standard reimbursement.","114298.32","114298.32","114298.32","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","142701.76","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7823.00","","Per diem ($7,823). If length of stay < 18, first 1 days paid at a per diem of $15,646 instead.","140813.78","140813.78","140813.78","1 through 10","3356","115032.18","per diem","Estimated amount calculated based on 7 day length of stay."
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,EXTREME","710","DRG","","","","","","","","inpatient","","","142701.76","","MASSHEALTH [3001]","HB BWF MEDICAID","50235.54","","Case rate ($55,544.03). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $97,974.03, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,169.97 and the sum of the standard inlier and any outlier amount.","55530.40","55530.40","55530.40","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","70987.17","","MASSHEALTH [3001]","HB BWF MEDICAID","20367.24","","Case rate ($22,519.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,949.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22513.97","22513.97","22513.97","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","70987.17","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","20367.24","","Case rate ($22,519.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,949.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4431.58","4431.58","4431.58","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","70987.17","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","39897.01","","Fee schedule rate ($39,897.01). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","61024.66","61024.66","61024.66","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases Including Hiv With O.R. Procedure,MAJOR","710","DRG","","","","","","","","inpatient","","","70987.17","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","20367.24","","Case rate ($22,519.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,949.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22513.96","22513.96","22513.96","1 through 10","3356","115032.18","case rate",""
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","49069.78","36802.33","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","18361.95","","Case rate ($18,736.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,766.67, add-ons for qualifying new technology services are included. If operating cost exceeds $64,290.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,973.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,984.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,427.42 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,412.58. The transfer capital threshold is the transfer adjustment factor * $1,412.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18185.28","18185.28","18185.28","1 through 10","18361.95","20495.64","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","49069.78","36802.33","MEDICARE [2001]","HB BWF MEDICARE","20495.64","","Case rate ($20,495.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,766.67, add-ons for qualifying new technology services are included. If operating cost exceeds $64,290.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,973.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $18,743.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,427.42 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,412.58. The transfer capital threshold is the transfer adjustment factor * $1,412.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19985.23","19985.23","20119.22","1 through 10","18361.95","20495.64","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With Cc","854","MS-DRG","","","","","","","","inpatient","","","49069.78","36802.33","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","18361.95","","Case rate ($18,736.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,766.67, add-ons for qualifying new technology services are included. If operating cost exceeds $64,290.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,973.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $16,984.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,427.42 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,412.58. The transfer capital threshold is the transfer adjustment factor * $1,412.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18096.97","18096.97","18096.97","1 through 10","18361.95","20495.64","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","89654.86","67241.14","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","50158.75","","Case rate ($50,158.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $45,885.35, add-ons for qualifying new technology services are included. If operating cost exceeds $91,409.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,052.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $46,328.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $45,546.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,491.39. The transfer capital threshold is the transfer adjustment factor * $3,491.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17842.43","17842.43","17842.43","1 through 10","44895.01","50694.73","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","89654.86","67241.14","MEDICARE [2001]","HB BWF MEDICARE","50158.75","","Case rate ($50,158.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $45,885.35, add-ons for qualifying new technology services are included. If operating cost exceeds $91,409.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,052.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $46,328.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $45,546.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,491.39. The transfer capital threshold is the transfer adjustment factor * $3,491.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","36269.93","0.02","49981.40","13","44895.01","50694.73","other","Inpatient DRG"
"Infectious And Parasitic Diseases With O.R. Procedures With McC","853","MS-DRG","","","","","","","","inpatient","","","89654.86","67241.14","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","44895.01","","Case rate ($45,811.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $45,885.35, add-ons for qualifying new technology services are included. If operating cost exceeds $91,409.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,052.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.3. The base transfer operating payment is the transfer adjustment factor * $41,980.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $45,546.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,491.39. The transfer capital threshold is the transfer adjustment factor * $3,491.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","23438.42","23438.42","23438.42","1 through 10","44895.01","50694.73","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System With McC","727","MS-DRG","","","","","","","","inpatient","","","20681.70","15511.27","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13713.11","","Case rate ($13,992.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,015.24, add-ons for qualifying new technology services are included. If operating cost exceeds $59,538.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,609.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,605.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,676.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,048.35. The transfer capital threshold is the transfer adjustment factor * $1,048.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13312.00","13312.00","13312.00","1 through 10","13713.11","14530.8966","other","Inpatient DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","22606.50","16954.87","MEDICARE [2001]","HB BWF MEDICARE","7808.33","","Case rate ($7,808.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $53,344.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,134.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,895.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,481.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $573.49. The transfer capital threshold is the transfer adjustment factor * $573.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8375.99","8375.99","8375.99","1 through 10","7652.16","8080.3019","other","Inpatient Replacement Plans DRG"
"Inflammation Of The Male Reproductive System Without McC","728","MS-DRG","","","","","","","","inpatient","","","22606.50","16954.87","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7652.16","","Case rate ($7,808.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,820.51, add-ons for qualifying new technology services are included. If operating cost exceeds $53,344.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,134.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $6,895.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,481.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $573.49. The transfer capital threshold is the transfer adjustment factor * $573.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7568.82","7568.82","7568.82","1 through 10","7652.16","8080.3019","other","Inpatient DRG"
"Inflammatory Bowel Disease With Cc","386","MS-DRG","","","","","","","","inpatient","","","37325.48","27994.11","MEDICARE [2001]","HB BWF MEDICARE","9328.48","","Case rate ($9,328.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,343.14, add-ons for qualifying new technology services are included. If operating cost exceeds $54,866.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,299.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,003.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $690.20. The transfer capital threshold is the transfer adjustment factor * $690.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10053.50","0.03","10053.50","1 through 10","9141.91","9814.8325","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","37163.98","27872.98","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14610.05","","Case rate ($14,908.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,931.96, add-ons for qualifying new technology services are included. If operating cost exceeds $60,455.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,679.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,450.35 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,592.72 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,118.62. The transfer capital threshold is the transfer adjustment factor * $1,118.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","29989.29","29989.29","29989.29","1 through 10","14610.05","16067.6472","other","Inpatient DRG"
"Inflammatory Bowel Disease With McC","385","MS-DRG","","","","","","","","inpatient","","","37163.98","27872.98","MEDICARE [2001]","HB BWF MEDICARE","14908.21","","Case rate ($14,908.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,931.96, add-ons for qualifying new technology services are included. If operating cost exceeds $60,455.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,679.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $13,450.35 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,592.72 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,118.62. The transfer capital threshold is the transfer adjustment factor * $1,118.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16407.31","16298.36","44785.77","1 through 10","14610.05","16067.6472","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","22283.53","16712.65","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6810.65","","Case rate ($6,612.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,622.51, add-ons for qualifying new technology services are included. If operating cost exceeds $52,146.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,042.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,791.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,283.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.65. The transfer capital threshold is the transfer adjustment factor * $481.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","6516.75","6516.75","6516.75","1 through 10","6480.03","6810.65","other","Inpatient DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","22283.53","16712.65","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","6612.28","","Case rate ($6,612.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,622.51, add-ons for qualifying new technology services are included. If operating cost exceeds $52,146.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,042.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,791.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,283.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.65. The transfer capital threshold is the transfer adjustment factor * $481.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6805.62","6805.62","6805.62","1 through 10","6480.03","6810.65","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease Without Cc/McC","387","MS-DRG","","","","","","","","inpatient","","","22283.53","16712.65","MEDICARE [2001]","HB BWF MEDICARE","6612.28","","Case rate ($6,612.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,622.51, add-ons for qualifying new technology services are included. If operating cost exceeds $52,146.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,042.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $5,791.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,283.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $481.65. The transfer capital threshold is the transfer adjustment factor * $481.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6916.28","6916.28","6916.28","1 through 10","6480.03","6810.65","other","Inpatient Replacement Plans DRG"
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24488.03","","Standard inlier is a Case rate ($24,488.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,476.17) for the length of stay and the standard reimbursement.","23375.25","23375.25","24488.03","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26305.03","","Standard inlier is a Case rate ($26,305.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,770, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,733.89) for the length of stay and the standard reimbursement.","26305.03","25109.34","26305.03","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","MASSHEALTH [3001]","HB BWF MEDICAID","12747.66","","Case rate ($14,094.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,524.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2911.42","2911.42","2911.42","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12688.60","","Fee schedule rate ($12,688.60). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10111.33","10111.33","10111.33","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","27045.13","","Fee schedule rate ($27,045.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","27045.13","27045.13","27045.13","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12747.66","","Case rate ($14,094.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,524.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14091.27","14091.27","16386.92","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MAJOR","245","DRG","","","","","","","","inpatient","","","42982.71","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","12747.66","","Case rate ($14,094.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,524.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14091.27","478.55","14091.27","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","13461.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13385.19","","Standard inlier is a Case rate ($13,385.19). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,378, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,900.08) for the length of stay and the standard reimbursement.","12776.94","12776.94","12776.94","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","13461.10","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12915.3078","","Fee schedule rate ($12,915.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12915.3078","15916.96","15916.96","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MINOR","245","DRG","","","","","","","","inpatient","","","13461.10","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6022.55","","Case rate ($6,658.97). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,088.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6657.33","230.57","6657.33","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","32667.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18336.36","","Standard inlier is a Case rate ($18,336.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,159, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,602.77) for the length of stay and the standard reimbursement.","17502.89","17502.89","18336.36","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","32667.96","","MASSHEALTH [3001]","HB BWF MEDICAID","8197.62","","Case rate ($9,063.88). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,493.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9061.65","2407.93","9061.65","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","32667.96","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19562.14","","Fee schedule rate ($19,562.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19562.14","19562.14","19562.14","1 through 10","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","32667.96","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8197.62","","Case rate ($9,063.88). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,493.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9061.65","3513.98","9061.65","12","2251","42523.39","case rate",""
"Inflammatory Bowel Disease,MODERATE","245","DRG","","","","","","","","inpatient","","","32667.96","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8197.62","","Case rate ($9,063.88). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,493.88, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9061.65","6403.26","9061.65","1 through 10","2251","42523.39","case rate",""
"Inguinal And Femoral Hernia Procedures With Cc","351","MS-DRG","","","","","","","","inpatient","","","34583.36","25937.52","MEDICARE [2001]","HB BWF MEDICARE","14376.02","","Case rate ($14,376.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,398.90, add-ons for qualifying new technology services are included. If operating cost exceeds $59,922.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,638.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,959.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,059.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,077.76. The transfer capital threshold is the transfer adjustment factor * $1,077.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15110.23","15110.23","15110.23","1 through 10","14088.5","14878.0005","other","Inpatient Replacement Plans DRG"
"Inguinal And Femoral Hernia Procedures With McC","350","MS-DRG","","","","","","","","inpatient","","","64005.99","48004.49","MEDICARE [2001]","HB BWF MEDICARE","25476.97","","Case rate ($25,476.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,320.71, add-ons for qualifying new technology services are included. If operating cost exceeds $68,844.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,322.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $23,376.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,981.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,761.67. The transfer capital threshold is the transfer adjustment factor * $1,761.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","22817.65","25476.97","other","Inpatient DRG"
"Inguinal, Femoral And Umbilical Hernia Procedures,MINOR","228","DRG","","","","","","","","inpatient","","","35735.43","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6697.69","","Case rate ($7,405.45). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,835.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7720.95","7720.95","7720.95","1 through 10","6697.69","28650.78","case rate",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","both","","","825.00","618.75","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","784.58","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","825.00","618.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","404.83","49.07","","2115.00","2115.00","2115.00","1 through 10","366.71","647.21","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","825.00","618.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","413.33","50.1","","331.25","331.25","331.25","1 through 10","366.71","647.21","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Cont Inf via Cath","PX-76002904","CDM","64999","CPT","0761","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","282.15","282.15","282.15","1 through 10","366.71","647.21","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","both","","","1182.00","886.50","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1124.08","other","OPPS APC"
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1182.00","886.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","580.01","49.07","","2115.00","2115.00","2115.00","1 through 10","525.4","927.28","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1182.00","886.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","592.18","50.1","","331.25","331.25","331.25","1 through 10","525.4","927.28","percent of total billed charges",""
"Inj Anes/Ther Agent, Pecs (I & II); Single Shot(S)","PX-76002903","CDM","64999","CPT","0761","RC","","","","outpatient","","","1182.00","886.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","927.28","78.45","","282.15","282.15","282.15","1 through 10","525.4","927.28","percent of total billed charges",""
"Inj Paravert F Jnt C/T 1 Lev","PX-76001532","CDM","64490","CPT","0761","RC","","","","both","","","2252.00","1689.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1036.13","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1043.63","981.92","1044.03","1 through 10","764.84","1643.96","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2251.00","1688.25","AETNA [1001]","HB CH AETNA HMO / PPO","1312.33","58.3","","2482.33","2482.33","2482.33","1 through 10","764.84","1643.23","percent of total billed charges",""
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2251.00","1688.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","2971.41","2971.41","2971.41","1 through 10","764.84","1643.23","other","Multiple Surgery"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2251.00","1688.25","MEDICARE [2001]","HB BWF MEDICARE","1057.27","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","528.64","528.64","528.64","1 through 10","764.84","1643.23","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","both","","","2251.00","1688.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1036.13","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1469.78","1038.24","1562.10","15","764.84","1643.23","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev","PX-76001541","CDM","64493","CPT","0761","RC","","","","outpatient","","","2251.00","1688.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","2730.48","2730.48","2730.48","1 through 10","764.84","2915.92","other","Multiple Surgery"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","HUMANA [1012]","HB BWF MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1563.71","1563.71","1563.71","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","MEDICARE [2001]","HB BWF MEDICARE","1057.17","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1585.91","1492.21","1585.91","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,040.50). Procedure 2, Per diem ($1,520.25). Procedures 3 - 9999, Per diem ($760.13).","3040.50","2509.20","5904.00","1 through 10","1004.41","4462.84","per diem",""
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,324). Procedure 2, Per diem ($1,662). Procedures 3 - 9999, Per diem ($831).","3324.00","3324.00","3324.00","1 through 10","1004.41","4462.84","per diem",""
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","both","","","2251.00","1688.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1036.02","","APC Price ($1,057.17). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1560.54","1470.18","1561.59","1 through 10","1004.41","4462.84","other","OPPS APC"
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","outpatient","","","2251.00","1688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1894.47","1855.11","1894.47","12","1311.96","4373.87","other","ASC "
"Inj Paravert F Jnt L/S 1 Lev|BILATERAL PROCEDURE","PX-76001541","CDM","64493","CPT","0761","RC","","","50","outpatient","","","2251.00","1688.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1311.96","","Case rate ($1,311.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1897.09","1857.74","1897.09","25","1311.96","4373.87","other","ASC "
"Inj Paravert F Jnt L/S 2 Lev","PX-76001544","CDM","64494","CPT","0761","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","298.24","298.24","298.24","1 through 10","120.02","1627.62","percent of total billed charges",""
"Inj Paravert F Jnt L/S 2 Lev|BILATERAL PROCEDURE","PX-76001544","CDM","64494","CPT","0761","RC","","","50","both","","","270.00","202.50","","","","","","1520.25","1254.60","4428.00","1 through 10","","","",""
"Inj Paravert F Jnt L/S 2 Lev|BILATERAL PROCEDURE","PX-76001544","CDM","64494","CPT","0761","RC","","","50","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,324). Procedure 2, Per diem ($1,662). Procedures 3 - 9999, Per diem ($831).","1662.00","1655.36","1662.00","1 through 10","","","per diem",""
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","outpatient","","","2218.00","1663.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1238.49","1238.49","1238.49","1 through 10","764.84","1873.9","other","ASC "
"Inject Anes Celiac Plexus","PX-76001552","CDM","64530","CPT","0761","RC","","","","outpatient","","","2218.00","1663.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1797.37","1797.37","1797.37","1 through 10","764.84","1873.9","other","Multiple Surgery"
"Inject Anes Ganglion Stellate","PX-76001549","CDM","64510","CPT","0761","RC","","","","both","","","2252.00","1689.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1980.94","1980.94","1980.94","1 through 10","764.84","1643.96","other","Multiple Surgery"
"Inject Anes Hypogastric Plexus","PX-76001550","CDM","64517","CPT","0761","RC","","","","outpatient","","","2244.00","1683.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","874.64","","Case rate ($874.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1264.73","1238.49","1264.73","1 through 10","764.84","4472.66","other","ASC "
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","both","","","356.00","267.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","188.68","731.58","other","OPPS APC"
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","356.00","267.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","174.69","49.07","","2115.00","2115.00","2115.00","1 through 10","158.24","567.68","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","356.00","267.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","178.36","50.1","","331.25","331.25","331.25","1 through 10","158.24","567.68","percent of total billed charges",""
"Inject Anes Nerve Facial","PX-76001498","CDM","64999","CPT","0761","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","279.28","78.45","","282.15","282.15","282.15","1 through 10","158.24","567.68","percent of total billed charges",""
"Inject Anes Nerve Greater Occipital","PX-76001499","CDM","64405","CPT","0761","RC","","","","both","","","1190.00","892.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","347.55","316.80","347.55","1 through 10","247.48","868.7","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","1190.00","892.50","MEDICARE [2001]","HB BWF MEDICARE","350.52","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","701.12","15","333.03","1444.05","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","both","","","1190.00","892.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.51","","APC Price ($350.52). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","333.03","1444.05","other","OPPS APC"
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","outpatient","","","1190.00","892.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","300.14","300.14","300.14","1 through 10","424.52","1804.32","other","ASC "
"Inject Anes Nerve Greater Occipital|BILATERAL PROCEDURE","PX-76001499","CDM","64405","CPT","0761","RC","","","50","outpatient","","","1190.00","892.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","424.52","","Case rate ($424.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","306.93","306.93","306.93","1 through 10","424.52","1804.32","other","ASC "
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1189.00","891.75","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","598.81","1606.27","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","both","","","1189.00","891.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","813.87","813.47","1208.95","1 through 10","598.81","1606.27","other","OPPS APC"
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1189.00","891.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","969.63","969.63","969.63","1 through 10","528.51","970.06","other","ASC "
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1189.00","891.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","705.08","59.3","","677.42","677.42","677.42","1 through 10","528.51","970.06","percent of total billed charges",""
"Inject Anes Nerve Peripheral Other","PX-76001516","CDM","64450","CPT","0761","RC","","","","outpatient","","","1189.00","891.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1694.63","597.29","1784.70","1 through 10","528.51","970.06","other","Multiple Surgery"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","both","","","718.00","538.50","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","731.58","other","OPPS APC"
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","352.32","49.07","","2115.00","2115.00","2115.00","1 through 10","319.15","567.68","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","718.00","538.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.72","50.1","","331.25","331.25","331.25","1 through 10","319.15","567.68","percent of total billed charges",""
"Inject Anes Nerve Phrenic","PX-76001501","CDM","64999","CPT","0761","RC","","","","outpatient","","","718.00","538.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","563.27","78.45","","282.15","282.15","282.15","1 through 10","319.15","567.68","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1796.00","1347.00","AETNA [1001]","HB CH AETNA HMO / PPO","1047.07","58.3","","989.98","989.98","989.98","1 through 10","598.81","1399.26","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1796.00","1347.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","606.94","606.94","606.94","1 through 10","598.81","1399.26","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1796.00","1347.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","606.94","606.94","606.94","1 through 10","598.81","1399.26","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","both","","","1796.00","1347.00","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","616.81","566.08","616.81","1 through 10","598.81","1399.26","other","OPPS APC"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","968.26","968.26","968.26","1 through 10","598.81","1873.9","other","ASC "
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.18","969.63","990.18","1 through 10","598.81","1873.9","other","ASC "
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1065.03","59.3","","1023.16","1023.16","1023.16","1 through 10","598.81","1873.9","percent of total billed charges",""
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","1407.20","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Inject Epidural Blood/Clot Patch","PX-76001464","CDM","62273","CPT","0761","RC","","","","outpatient","","","1796.00","1347.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1425.17","1479.06","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Inject Lymphangiogram","PX-76001211","CDM","38790","CPT","0761","RC","","","","outpatient","","","417.00","312.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","247.28","59.3","","4442.47","4442.47","4442.47","1 through 10","141.83","327.14","percent of total billed charges",""
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","both","","","1124.00","843.00","AETNA [1001]","HB CH AETNA HMO / PPO","655.29","58.3","","4168.58","4168.58","4168.58","1 through 10","453.34","1375.08","percent of total billed charges",""
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","both","","","1124.00","843.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","666.53","59.3","","2457.88","2457.88","2457.88","1 through 10","453.34","1375.08","percent of total billed charges",""
"Inject Sentinel Node ID","PX-76001212","CDM","38792","CPT","0761","RC","","","","outpatient","","","1124.00","843.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","881.78","78.45","","915.54","915.54","915.54","1 through 10","404.24","1015.22","percent of total billed charges",""
"Inject Sentinel Node ID|BILATERAL PROCEDURE","PX-76001212","CDM","38792","CPT","0761","RC","","","50","outpatient","","","1124.00","843.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","606.36","","Case rate ($606.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","437.79","428.70","437.79","1 through 10","606.36","1522.84","other","ASC "
"Inject Sentinel Node ID|BILATERAL PROCEDURE","PX-76001212","CDM","38792","CPT","0761","RC","","","50","outpatient","","","1124.00","843.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","606.36","","Case rate ($606.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","438.40","438.40","438.40","1 through 10","606.36","1522.84","other","ASC "
"Inject Shoulder Arthrogram","PX-76000386","CDM","23350","CPT","0761","RC","","","","outpatient","","","258.00","193.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.99","59.3","","147.09","147.09","147.09","1 through 10","85.85","202.4","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","361.07","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","360.73","360.73","361.53","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","374.79","1 through 10","247.48","731.58","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","640.97","640.97","640.97","1 through 10","247.48","731.58","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","661.00","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","316.79","316.79","316.79","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","520.60","520.60","1 through 10","247.48","731.58","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","204.34","408.67","1 through 10","247.48","567.68","other","ASC "
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","200.37","409.23","1 through 10","247.48","567.68","other","ASC "
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.24","59.3","","10495.26","1547.92","10495.26","1 through 10","247.48","567.68","percent of total billed charges",""
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","581.58","581.58","1 through 10","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Point 1-2 Muscle(S)","PX-76000289","CDM","20552","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","616.23","611.28","616.23","1 through 10","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","361.07","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","361.53","360.73","361.63","18","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","AETNA [1001]","HB CH AETNA HMO / PPO","396.44","58.3","","374.79","374.79","4602.91","1 through 10","247.48","731.58","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","344.95","344.95","344.95","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","344.95","344.95","344.95","15","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","FALLON HEALTH [1008]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1051.68","1051.68","1051.68","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","640.97","616.23","727.59","1 through 10","247.48","731.58","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","HUMANA [1012]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","345.65","345.65","345.65","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","350.56","661.00","140","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","343.55","343.55","343.55","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","343.55","343.55","1 through 10","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","343.54","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","343.55","318.09","350.56","39","247.48","731.58","other","OPPS APC"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","both","","","680.00","510.00","WELLPOINT [1015]","HB CH WELLPOINT","529.79","77.91","","520.60","520.60","4483.59","12","247.48","731.58","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","408.67","400.18","408.67","35","247.48","567.68","other","ASC "
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","283.01","","Case rate ($283.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","409.23","400.74","409.23","71","247.48","567.68","other","ASC "
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","403.24","59.3","","387.35","387.35","7919.21","11","247.48","567.68","percent of total billed charges",""
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","581.58","559.30","581.58","18","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","247.48","","Case rate ($247.48). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","611.28","589.00","613.42","1 through 10","247.48","567.68","other","Multiple Surgery"
"Inject Trigger Pt 3+ Muscle Groups","PX-76000290","CDM","20553","CPT","0761","RC","","","","outpatient","","","680.00","510.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","533.46","78.45","","508.18","301.15","640.97","1 through 10","247.48","567.68","percent of total billed charges",""
"Inject Venogram Extremity","PX-76001030","CDM","36005","CPT","0361","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","629.64","53","","612.15","612.15","612.15","1 through 10","528.07","925.57","percent of total billed charges",""
"Injection Air/Contrast Peritoneal Cavity Spx","PX-75000286","CDM","49400","CPT","0750","RC","","","","outpatient","","","482.00","361.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","285.83","59.3","","274.83","274.83","274.83","1 through 10","155.76","378.13","percent of total billed charges",""
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","both","","","1222.00","916.50","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1162.12","other","OPPS APC"
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","599.64","49.07","","2115.00","2115.00","2115.00","1 through 10","543.18","958.66","percent of total billed charges",""
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","612.22","50.1","","331.25","331.25","331.25","1 through 10","543.18","958.66","percent of total billed charges",""
"Injection Anes/Ther Agent, Accessory Spinal Nerve (Cn XI)","PX-76002952","CDM","64999","CPT","0761","RC","","","","outpatient","","","1222.00","916.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","958.66","78.45","","282.15","282.15","282.15","1 through 10","543.18","958.66","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","both","","","1226.00","919.50","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1165.93","other","OPPS APC"
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1226.00","919.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","601.60","49.07","","2115.00","2115.00","2115.00","1 through 10","544.96","961.8","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1226.00","919.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","614.23","50.1","","331.25","331.25","331.25","1 through 10","544.96","961.8","percent of total billed charges",""
"Injection Anesthetic/Therapeutic Agent, Cervical Plexus","PX-76002827","CDM","64999","CPT","0760","RC","","","","outpatient","","","1226.00","919.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","961.80","78.45","","282.15","282.15","282.15","1 through 10","544.96","961.8","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","440.00","330.00","AETNA [1001]","HB CH AETNA HMO / PPO","256.52","58.3","","242.68","242.68","242.68","1 through 10","233.2","342.8","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","148.14","148.14","148.14","1 through 10","233.2","342.8","per diem",""
"Injection Procedure Myelography/CT Lumbar","PX-36000346","CDM","62284","CPT","0361","RC","","","","both","","","440.00","330.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","196.13","196.13","196.13","1 through 10","233.2","342.8","per diem",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","AETNA [1001]","HB CH AETNA HMO / PPO","486.22","58.3","","242.68","242.68","242.68","1 through 10","442.02","649.77","percent of total billed charges",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","148.14","148.14","148.14","1 through 10","442.02","649.77","per diem",""
"Injection Procedure Myelography/CT Lumbar","PX-98301694","CDM","62284","CPT","0983","RC","","","","both","","","834.00","625.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","196.13","196.13","196.13","1 through 10","442.02","649.77","per diem",""
"Injection Remdesivir, 1 Mg","PX-63601353","CDM","J0248","HCPCS","0636","RC","","","","both","","","21.84","16.38","MOLINA [1014]","HB BWF MEDICARE","6.73","","APC Price ($6.73).","12.59","12.58","12.59","400","6.39","20.77","other","OPPS APC"
"Injection Remdesivir, 1 Mg","PX-63601353","CDM","J0248","HCPCS","0636","RC","","","","both","","","21.84","16.38","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6.59","","APC Price ($6.73). Final payment is multiplied by 98%.","6.25","6.23","6.25","700","6.39","20.77","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","87.33","79.12","87.33","1 through 10","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","125.31","125.31","250.62","1 through 10","46.83","232.43","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","1 through 10","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.00","25.00","25.00","1 through 10","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","75.35","83.17","22","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","ELDER SERVICES [1037]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10.79","10.79","10.79","1 through 10","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MEDICARE [2001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","76.89","253.56","525","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","82.83","82.83","1 through 10","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","TRICARE [160005]","HB BWF TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","80.29","80.29","1 through 10","46.83","232.43","other","Tricare OPPS"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","21.58","82.83","1 through 10","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","both","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","75.66","84.52","67","46.83","232.43","other","OPPS APC"
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","129.51","129.51","129.51","1 through 10","54","204.65","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","64.04","59.3","","129.48","129.48","129.48","1 through 10","54","204.65","percent of total billed charges",""
"Injection Subq or Im","PX-98301241","CDM","96372","CPT","0983","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","169.90","100.69","169.90","12","54","204.65","percent of total billed charges",""
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6.69","","APC Price ($6.50). Final payment is multiplied by 103%.","6.69","6.62","6.69","465","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","AETNA [1001]","HB CH AETNA HMO / PPO","14.90","58.3","","15.38","15.38","15.50","9235","6.18","19.73","percent of total billed charges",""
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","6.37","6.30","6.37","1240","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","6.37","6.30","6.38","1550","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","18.65","73","","19.81","19.81","19.81","155","6.18","19.73","percent of total billed charges",""
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MEDICARE [2001]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","6.47","6.41","6.47","16515","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","6.37","6.34","6.37","310","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","MOLINA [1014]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","12.84","12.84","12.84","400","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","18.65","73","","3076.77","3076.77","3076.77","1 through 10","6.18","19.73","percent of total billed charges",""
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","TRICARE [160005]","HB BWF TRICARE","6.18","","APC Price ($6.50). Final payment is multiplied by 95%.","6.48","6.47","6.48","606","6.18","19.73","other","Tricare OPPS"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","6.34","6.30","6.37","620","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.55","19.16","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","12.68","6.28","12.74","8660","6.18","19.73","other","OPPS APC"
"Injection,Onabotulinumtoxina","PX-63601218","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.55","19.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.34","52.2","","13.97","13.97","14.08","7127","0.01","13.34","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5034.00","3775.50","AETNA [1001]","HB CH AETNA HMO / PPO","2934.82","58.3","","2731.24","2731.24","2731.24","1 through 10","789.41","4787.33","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5034.00","3775.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","814.34","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","817.66","817.66","817.66","1 through 10","789.41","4787.33","other","OPPS APC"
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5034.00","3775.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2668.02","53","","2553.01","2553.01","2553.01","1 through 10","789.41","4787.33","percent of total billed charges",""
"Inpatient Hemodialysis","PX-80000003","CDM","90935","CPT","0801","RC","","","","both","","","5034.00","3775.50","WELLPOINT [1015]","HB CH WELLPOINT","3921.99","77.91","","3793.87","3793.87","3793.87","1 through 10","789.41","4787.33","percent of total billed charges",""
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","5715.00","4286.25","AETNA [1001]","HB CH AETNA HMO / PPO","3331.85","58.3","","3150.82","3150.82","3150.82","1 through 10","2377.37","4452.56","percent of total billed charges",""
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","5715.00","4286.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","3663.09","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3678.68","3663.09","3678.68","1 through 10","2377.37","4452.56","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","5715.00","4286.25","MEDICARE [2001]","HB BWF MEDICARE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11213.55","3737.85","11213.55","18","2377.37","4452.56","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","both","","","5715.00","4286.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","3663.09","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3663.09","3409.32","3670.60","1 through 10","2377.37","4452.56","other","OPPS APC"
"Insert Cath Cv Tunlw/O Port >5yrs","PX-76001085","CDM","36558","CPT","0361","RC","","","","outpatient","","","5715.00","4286.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3389.00","59.3","","3256.40","3256.40","3256.40","1 through 10","1873.9","4483.42","percent of total billed charges",""
"Insert Cath Periph Cv W/O Port >5","PX-76001092","CDM","36569","CPT","0761","RC","","","","outpatient","","","2730.00","2047.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1805.91","1768.39","1805.91","1 through 10","1093.63","4472.66","other","ASC "
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","AETNA [1001]","HB CH AETNA HMO / PPO","149.25","58.3","","4168.58","1692.50","4168.58","1 through 10","89.6","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","149.25","58.3","","1492.50","1492.50","1492.50","1 through 10","89.6","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.68","53","","2799.99","2799.99","2799.99","1 through 10","89.6","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","256.00","100","","720.76","720.76","720.76","1 through 10","89.6","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","256.00","100","","787.66","787.66","787.66","1 through 10","89.6","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","both","","","256.00","192.00","WELLPOINT [1015]","HB CH WELLPOINT","199.45","77.91","","3255.93","3255.93","3255.93","1 through 10","89.6","319.64","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","89.94","","Case rate ($89.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","129.87","127.18","129.87","18","89.94","567.68","other","ASC "
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","89.94","","Case rate ($89.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","130.05","127.36","130.05","24","89.94","567.68","other","ASC "
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.81","59.3","","2622.50","1547.92","13619.85","1 through 10","89.94","567.68","percent of total billed charges",""
"Insert Intrauterine Device- 58300","PX-76001382","CDM","58300","CPT","0761","RC","","","","outpatient","","","256.00","192.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.83","78.45","","3885.52","1359.97","4589.73","1 through 10","89.94","567.68","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"INSERT KNEE 10MM SZ 4 TIBIAL TRIATHLON","SUP-ITM-10273847","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","AETNA [1001]","HB CH AETNA HMO / PPO","2399.05","58.3","","1634.24","1004.95","1718.99","42","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","2123.89","1900.92","2123.89","1 through 10","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2399.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2180.95","53","","939.37","939.37","5593.65","1 through 10","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3497.75","85","","2323.25","1864.50","2882.25","16","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4115.00","100","","2909.44","1772.40","10952.08","45","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4115.00","100","","2323.25","2323.25","2323.25","1 through 10","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4115.00","100","","2882.25","1772.40","10169.17","187","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","1659.41","1659.41","1659.41","1 through 10","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","WELLPOINT [1015]","HB CH WELLPOINT","3206.00","77.91","","2050.91","1468.48","2902.83","52","1829.12","4115","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2440.20","59.3","","1548.60","1092.60","3613.79","82","2057.5","3228.22","percent of total billed charges",""
"INSERT POLY SZ 3+ 7MM INFINITY EVERLAST","SUP-ITM-10321919","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3228.22","78.45","","2085.51","998.68","6202.11","56","2057.5","3228.22","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","AETNA [1001]","HB CH AETNA HMO / PPO","1590.37","58.3","","1634.24","1004.95","1718.99","42","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1991.37","73","","2123.89","1900.92","2123.89","1 through 10","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1590.37","58.3","","3729.00","1254.19","3729.00","1 through 10","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1445.79","53","","939.37","939.37","5593.65","1 through 10","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2318.72","85","","2323.25","1864.50","2882.25","16","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2727.90","100","","2909.44","1772.40","10952.08","45","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2727.90","100","","2323.25","2323.25","2323.25","1 through 10","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2727.90","100","","2882.25","1772.40","10169.17","187","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1991.37","73","","1659.41","1659.41","1659.41","1 through 10","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","both","","","2727.90","2045.92","WELLPOINT [1015]","HB CH WELLPOINT","2125.31","77.91","","2050.91","1468.48","2902.83","52","1212.55","2727.9","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2727.90","2045.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","1617.64","59.3","","1548.60","1092.60","3613.79","82","1363.95","2140.04","percent of total billed charges",""
"INSERT TIBIAL SIZE 3 PROLONG TRABECULAR METAL BLUE","SUP-ITM-10235656","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2727.90","2045.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2140.04","78.45","","2085.51","998.68","6202.11","56","1363.95","2140.04","percent of total billed charges",""
"Insertion Picc W/Rs&I 5 Yr/>","PX-76002573","CDM","36573","CPT","0761","RC","","","","outpatient","","","2202.00","1651.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1768.39","1768.39","1768.39","1 through 10","944.66","4472.66","other","ASC "
"Insj/Rplcmt Spi Npgr Dir/Induxive Coupling","PX-98301699","CDM","63685","CPT","0983","RC","","","","both","","","3325.00","2493.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1762.25","53","","6817.92","6817.92","6817.92","1 through 10","1426.43","2590.51","percent of total billed charges",""
"Insj/Rplcmt Spi Npgr Dir/Induxive Coupling","PX-98301699","CDM","63685","CPT","0983","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1631.58","49.07","","45737.36","44787.13","45737.36","1 through 10","1330","2608.46","percent of total billed charges",""
"Insj/Rplcmt Spi Npgr Dir/Induxive Coupling","PX-98301699","CDM","63685","CPT","0983","RC","","","","outpatient","","","3325.00","2493.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1665.83","50.1","","44850.48","44850.48","45800.71","1 through 10","1330","2608.46","percent of total billed charges",""
"Insj/Rplcmt Spi Npgr Dir/Induxive Coupling","PX-98301699","CDM","63685","CPT","0983","RC","","","","outpatient","","","3325.00","2493.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1971.73","59.3","","25447.05","25447.05","25447.05","1 through 10","1330","2608.46","percent of total billed charges",""
"Insrt/Place Neurostim Gen per/Gas","PX-76001565","CDM","64590","CPT","0761","RC","","","","both","","","5896.00","4422.00","WELLPOINT [1015]","HB CH WELLPOINT","4593.57","77.91","","6511.88","6511.88","6511.88","1 through 10","2529.38","4593.57","percent of total billed charges",""
"Insrt/Place Neurostim Gener Spinal","PX-76001495","CDM","63685","CPT","0761","RC","","","","both","","","9705.00","7278.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5143.65","53","","6817.92","6817.92","6817.92","1 through 10","4163.45","7561.17","percent of total billed charges",""
"Insrt/Place Neurostim Gener Spinal","PX-76001495","CDM","63685","CPT","0761","RC","","","","outpatient","","","9705.00","7278.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4762.24","49.07","","45737.36","44787.13","45737.36","1 through 10","3882","7613.57","percent of total billed charges",""
"Insrt/Place Neurostim Gener Spinal","PX-76001495","CDM","63685","CPT","0761","RC","","","","outpatient","","","9705.00","7278.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4862.21","50.1","","44850.48","44850.48","45800.71","1 through 10","3882","7613.57","percent of total billed charges",""
"Insrt/Place Neurostim Gener Spinal","PX-76001495","CDM","63685","CPT","0761","RC","","","","outpatient","","","9705.00","7278.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","5755.07","59.3","","25447.05","25447.05","25447.05","1 through 10","3882","7613.57","percent of total billed charges",""
"Instill Anticarcinogen Agnt Bladder","PX-76001263","CDM","51720","CPT","0761","RC","","","","outpatient","","","711.00","533.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","231.42","","Case rate ($231.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","550.78","550.78","550.78","1 through 10","231.42","1176.36","other","Multiple Surgery"
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","1634.24","1004.95","1718.99","42","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","2123.89","1900.92","2123.89","1 through 10","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","3729.00","1254.19","3729.00","1 through 10","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","939.37","939.37","5593.65","1 through 10","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","510.00","85","","2323.25","1864.50","2882.25","16","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","600.00","100","","2909.44","1772.40","10952.08","45","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","600.00","100","","2323.25","2323.25","2323.25","1 through 10","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","600.00","100","","2882.25","1772.40","10169.17","187","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","1659.41","1659.41","1659.41","1 through 10","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","2050.91","1468.48","2902.83","52","266.7","600","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","1548.60","1092.60","3613.79","82","300","470.7","percent of total billed charges",""
"INSTRUMENT KNEE EMPOWER THREADED SQUARE HEADED BONE PINS","SUP-ITM-10328860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","2085.51","998.68","6202.11","56","300","470.7","percent of total billed charges",""
"Insulin Antibody","PX-30000841","CDM","86337","CPT","0302","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","103.19","103.19","1 through 10","20.98","136.51","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","11.2","70.08","percent of total billed charges",""
"Insulin Total","PX-30000528","CDM","83525","CPT","0301","RC","","","","both","","","96.00","72.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","70.08","73","","67.89","67.89","67.89","1 through 10","11.2","70.08","percent of total billed charges",""
"Intentional Self-Harm And Attempted Suicide,EXTREME","817","DRG","","","","","","","","inpatient","","","51254.41","","FALLON HEALTH [1008]","HB BWF MEDICAID","20604.86","","Case rate ($22,782.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,212.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,543.11 and the sum of the standard inlier and any outlier amount.","17711.21","17711.21","17711.21","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,EXTREME","817","DRG","","","","","","","","inpatient","","","51254.41","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","20604.86","","Case rate ($22,782.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,212.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,543.11 and the sum of the standard inlier and any outlier amount.","22776.62","22776.62","22776.62","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","42644.13","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18856.94","","Standard inlier is a Case rate ($18,856.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,993, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,676.82) for the length of stay and the standard reimbursement.","19356.93","19356.93","19356.93","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","42644.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","18709.14","","Fee schedule rate ($18,709.14). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18164.39","18164.39","18164.39","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","42644.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12371.82","","Case rate ($13,679.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,109.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,127.40 and the sum of the standard inlier and any outlier amount.","13675.82","13675.82","13675.82","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MAJOR","817","DRG","","","","","","","","inpatient","","","42644.13","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","12371.82","","Case rate ($13,679.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,109.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,127.40 and the sum of the standard inlier and any outlier amount.","2656.21","2656.21","2656.21","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","24218.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11605.40","","Standard inlier is a Case rate ($11,605.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $21,092, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,647.43) for the length of stay and the standard reimbursement.","11078.03","11078.03","11078.03","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","24218.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12466.52","","Standard inlier is a Case rate ($12,466.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,553, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,769.57) for the length of stay and the standard reimbursement.","12466.51","12466.51","12466.51","1 through 10","3957.98","39796.65","case rate",""
"Intentional Self-Harm And Attempted Suicide,MODERATE","817","DRG","","","","","","","","inpatient","","","24218.60","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8949.30","","Case rate ($9,894.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,324.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,538.88 and the sum of the standard inlier and any outlier amount.","1515.89","1515.89","1515.89","1 through 10","3957.98","39796.65","case rate",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Interleukin 6, Plasma (Il6)","PX-30003714","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Interstitial And Alveolar Lung Diseases,EXTREME","142","DRG","","","","","","","","inpatient","","","65861.83","","MASSHEALTH [3001]","HB BWF MEDICAID","16580.30","","Case rate ($18,332.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $60,762.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18327.88","18327.88","18327.88","1 through 10","7390.36","81206.51","case rate",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","13339.86","","MASSHEALTH [3001]","HB BWF MEDICAID","7962.29","","Case rate ($8,803.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,233.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11804.40","11804.40","11804.40","1 through 10","7390.36","81206.51","case rate",""
"Interstitial And Alveolar Lung Diseases,MAJOR","142","DRG","","","","","","","","inpatient","","","13339.86","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7962.29","","Case rate ($8,803.68). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,233.68, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11804.39","11804.39","11804.39","1 through 10","7390.36","81206.51","case rate",""
"Interstitial And Alveolar Lung Diseases,MODERATE","142","DRG","","","","","","","","inpatient","","","21264.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18791.94","","Standard inlier is a Case rate ($18,791.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,594, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,667.44) for the length of stay and the standard reimbursement.","17937.76","17937.76","17937.76","1 through 10","7390.36","81206.51","case rate",""
"Interstitial And Alveolar Lung Diseases,MODERATE","142","DRG","","","","","","","","inpatient","","","21264.88","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8694.48","","Fee schedule rate ($8,694.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8441.30","8441.30","8441.30","1 through 10","7390.36","81206.51","case rate",""
"Interstitial And Alveolar Lung Diseases,MODERATE","142","DRG","","","","","","","","inpatient","","","21264.88","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","18531.85","","Fee schedule rate ($18,531.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18531.85","18531.85","18531.85","1 through 10","7390.36","81206.51","case rate",""
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","21264.88","15948.66","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8896.50","","Case rate ($9,078.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,092.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,616.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,231.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,067.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,753.05 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.98. The transfer capital threshold is the transfer adjustment factor * $670.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9107.61","9107.61","9107.61","1 through 10","8896.5","9742.51","other","Inpatient DRG"
"Interstitial Lung Disease With Cc","197","MS-DRG","","","","","","","","inpatient","","","21264.88","15948.66","MEDICARE [2001]","HB BWF MEDICARE","9078.06","","Case rate ($9,078.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,092.30, add-ons for qualifying new technology services are included. If operating cost exceeds $54,616.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,231.76, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,067.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,753.05 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $670.98. The transfer capital threshold is the transfer adjustment factor * $670.98. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10028.82","10028.82","10028.82","1 through 10","8896.5","9742.51","other","Inpatient Replacement Plans DRG"
"Interstitial Lung Disease With McC","196","MS-DRG","","","","","","","","inpatient","","","27640.62","20730.46","MEDICARE [2001]","HB BWF MEDICARE","17715.57","","Case rate ($17,715.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,743.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,267.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,894.95, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,042.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,404.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,334.17. The transfer capital threshold is the transfer adjustment factor * $1,334.17. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15544.12","0.03","18985.65","15","17361.26","18631.8649","other","Inpatient Replacement Plans DRG"
"Interstitial Lung Disease Without Cc/McC","198","MS-DRG","","","","","","","","inpatient","","","21983.50","16487.62","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6794.95","","Case rate ($6,933.62). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,944.37, add-ons for qualifying new technology services are included. If operating cost exceeds $52,468.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,067.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,088.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,605.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $506.32. The transfer capital threshold is the transfer adjustment factor * $506.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6501.71","6501.71","6501.71","1 through 10","6794.95","7351.79","other","Inpatient DRG"
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","51211.57","","MASSHEALTH [3001]","HB BWF MEDICAID","9919.16","","Case rate ($10,967.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,397.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,863.54 and the sum of the standard inlier and any outlier amount.","10964.64","10964.64","10964.64","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","51211.57","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","9919.16","","Case rate ($10,967.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,397.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,863.54 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MAJOR","247","DRG","","","","","","","","inpatient","","","51211.57","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9919.16","","Case rate ($10,967.34). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,397.34, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,863.54 and the sum of the standard inlier and any outlier amount.","10964.65","695.29","10964.65","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","14665.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11352.90","","Standard inlier is a Case rate ($11,352.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,611.59) for the length of stay and the standard reimbursement.","10837.00","10837.00","10837.00","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","14665.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12195.28","","Standard inlier is a Case rate ($12,195.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,731.07) for the length of stay and the standard reimbursement.","12195.27","12195.27","12195.27","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","14665.14","","MASSHEALTH [3001]","HB BWF MEDICAID","4082.82","","Case rate ($4,514.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,944.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.86","1390.86","1390.86","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","14665.14","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11701.16","","Fee schedule rate ($11,701.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11701.16","11701.16","11701.16","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MINOR","247","DRG","","","","","","","","inpatient","","","14665.14","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4082.82","","Case rate ($4,514.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,944.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4768.45","4768.45","4768.45","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","24618.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14709.00","","Standard inlier is a Case rate ($14,709). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,295, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,088) for the length of stay and the standard reimbursement.","14709.00","14709.00","14709.00","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","24618.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15800.40","","Standard inlier is a Case rate ($15,800.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,739, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,242.80) for the length of stay and the standard reimbursement.","15800.40","15800.40","15800.40","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","24618.33","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15103.13","","Fee schedule rate ($15,103.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15103.13","15103.13","15103.13","1 through 10","4082.82","38015.68","case rate",""
"Intestinal Obstruction,MODERATE","247","DRG","","","","","","","","inpatient","","","24618.33","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5542.76","","Case rate ($6,128.47). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,558.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1599.73","1599.73","6150.52","1 through 10","4082.82","38015.68","case rate",""
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","36947.65","27710.74","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","9930.80","","Case rate ($9,641.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,656.71, add-ons for qualifying new technology services are included. If operating cost exceeds $55,180.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,275.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,588.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,317.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.24. The transfer capital threshold is the transfer adjustment factor * $714.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","9811.23","9811.23","9811.23","1 through 10","9448.72","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","36947.65","27710.74","MEDICARE [2001]","HB BWF MEDICARE","9641.55","","Case rate ($9,641.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,656.71, add-ons for qualifying new technology services are included. If operating cost exceeds $55,180.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,275.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,588.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,317.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.24. The transfer capital threshold is the transfer adjustment factor * $714.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10294.49","0.03","10362.69","16","9448.72","10370.73","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","36947.65","27710.74","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9448.72","","Case rate ($9,641.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,656.71, add-ons for qualifying new technology services are included. If operating cost exceeds $55,180.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,275.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,588.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,317.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.24. The transfer capital threshold is the transfer adjustment factor * $714.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9334.96","9334.96","9334.96","1 through 10","9448.72","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","065","MS-DRG","","","","","","","","inpatient","","","36947.65","27710.74","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9448.72","","Case rate ($9,641.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,656.71, add-ons for qualifying new technology services are included. If operating cost exceeds $55,180.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,275.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,588.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,317.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.24. The transfer capital threshold is the transfer adjustment factor * $714.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9313.96","9313.96","10519.13","1 through 10","9448.72","10370.73","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","49073.99","36805.49","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","18478.35","","Case rate ($18,855.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,885.63, add-ons for qualifying new technology services are included. If operating cost exceeds $64,409.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,982.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,094.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,546.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.70. The transfer capital threshold is the transfer adjustment factor * $1,421.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16022.04","16022.04","16022.04","1 through 10","18478.35","19671.1988","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","49073.99","36805.49","HUMANA [1012]","HB BWF MEDICARE","18855.46","","Case rate ($18,855.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,885.63, add-ons for qualifying new technology services are included. If operating cost exceeds $64,409.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,982.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,094.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,546.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.70. The transfer capital threshold is the transfer adjustment factor * $1,421.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18017.09","18017.09","18017.09","1 through 10","18478.35","19671.1988","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","49073.99","36805.49","MEDICARE [2001]","HB BWF MEDICARE","18855.46","","Case rate ($18,855.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,885.63, add-ons for qualifying new technology services are included. If operating cost exceeds $64,409.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,982.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,094.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,546.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.70. The transfer capital threshold is the transfer adjustment factor * $1,421.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17833.20","0.03","20030.71","18","18478.35","19671.1988","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction With McC","064","MS-DRG","","","","","","","","inpatient","","","49073.99","36805.49","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","18478.35","","Case rate ($18,855.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,885.63, add-ons for qualifying new technology services are included. If operating cost exceeds $64,409.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,982.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,094.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,546.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,421.70. The transfer capital threshold is the transfer adjustment factor * $1,421.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18022.08","18022.08","18022.08","1 through 10","18478.35","19671.1988","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","33586.77","25190.08","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6840.05","","Case rate ($6,640.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,651.11, add-ons for qualifying new technology services are included. If operating cost exceeds $52,174.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,044.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,817.75 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,311.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.84. The transfer capital threshold is the transfer adjustment factor * $483.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","6704.62","6704.62","6704.62","1 through 10","6508.01","6840.05","other","Inpatient DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","33586.77","25190.08","MEDICARE [2001]","HB BWF MEDICARE","6640.83","","Case rate ($6,640.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,651.11, add-ons for qualifying new technology services are included. If operating cost exceeds $52,174.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,044.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,817.75 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,311.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.84. The transfer capital threshold is the transfer adjustment factor * $483.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7095.26","7095.26","7095.26","1 through 10","6508.01","6840.05","other","Inpatient Replacement Plans DRG"
"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC","066","MS-DRG","","","","","","","","inpatient","","","33586.77","25190.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6508.01","","Case rate ($6,640.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,651.11, add-ons for qualifying new technology services are included. If operating cost exceeds $52,174.84 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,044.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $5,817.75 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,311.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $483.84. The transfer capital threshold is the transfer adjustment factor * $483.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6417.33","6417.33","6417.33","1 through 10","6508.01","6840.05","other","Inpatient DRG"
"Intracranial Hemorrhage,MAJOR","044","DRG","","","","","","","","inpatient","","","55139.38","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","20139.9852","","Per diem ($5,584). If length of stay < 7, first 1 days paid at a per diem of $11,168 instead.","20139.9852","27921.88","27921.88","1 through 10","2747","34521.24","per diem","Estimated amount calculated based on 4 day length of stay."
"Intragastric Balloon (Igb)","PX-75000443","CDM","43999","CPT","0750","RC","","","","both","","","1301.00","975.75","WELLPOINT [1015]","HB CH WELLPOINT","1013.61","77.91","","2383.28","2383.28","2383.28","1 through 10","558.13","1237.25","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","2865.62","2301.45","3387.26","1 through 10","328.19","596.01","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","183.06","183.06","183.06","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","71.76","71.76","71.76","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","658.78","226.20","658.78","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","313.69","313.69","313.69","1 through 10","328.19","596.01","per diem",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","328.19","42.9","","3983.66","3983.66","3983.66","1 through 10","328.19","596.01","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","8839.07","6775.90","15881.04","13","328.19","596.01","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","6386.22","2961.64","7549.44","18","306","600.14","percent of total billed charges",""
"Intraop Sentinel Lymph Node ID W/Dye Injection","PX-76001214","CDM","38900","CPT","0761","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","5073.44","3245.24","8596.72","1 through 10","306","600.14","percent of total billed charges",""
"Intrinsic Factor Antibody","PX-30000842","CDM","86340","CPT","0302","RC","","","","both","","","124.00","93.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","65.72","53","","64.13","64.13","64.13","1 through 10","14.78","90.52","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1900.15","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1898.64","1898.30","1902.17","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3678.04","3678.04","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.28","1807.90","1815.28","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3678.04","3678.04","3678.04","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1491.78","1491.78","1491.78","1 through 10","1093.63","2108.24","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","1394.43","1394.43","1394.43","1 through 10","1093.63","2108.24","percent of total billed charges",""
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","MEDICARE [2001]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","11213.55","64","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","MOLINA [1014]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6888.20","6888.20","6888.20","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.28","1809.40","1815.28","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","both","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3409.32","1713.00","3670.10","1 through 10","1093.63","2108.24","other","OPPS APC"
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","outpatient","","","2706.00","2029.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1768.39","1768.39","1768.39","1 through 10","1093.63","2959.67","other","ASC "
"Intro Cath Dialysis Circuit Dx Angrph Fluor S&I","PX-36000407","CDM","36901","CPT","0361","RC","","","","outpatient","","","2706.00","2029.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1250.63","","Case rate ($1,250.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1808.41","1770.89","1808.41","1 through 10","1093.63","2959.67","other","ASC "
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13871.64","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","13858.17","13858.17","13858.17","1 through 10","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11814.80","11814.80","11814.80","1 through 10","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13198.26","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13252.13","11766.77","13252.13","1 through 10","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","MEDICARE [2001]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","24013.82","13467.61","40402.83","54","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","MOLINA [1014]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","26719.74","26719.74","26719.74","1 through 10","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13198.26","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","39756.39","39756.39","39756.39","1 through 10","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","both","","","17072.00","12804.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13198.26","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13198.26","11814.80","13225.20","1 through 10","7588.5","30885.95","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","outpatient","","","17072.00","12804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","15966.45","15634.74","15966.45","1 through 10","7939.38","13392.98","other","ASC "
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","outpatient","","","17072.00","12804.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","20450.03","20450.03","20450.03","1 through 10","7939.38","13392.98","other","Multiple Surgery"
"Intro Cath Dialysis Circuit W/Tcat Plmt IV Stent","PX-36000409","CDM","36903","CPT","0361","RC","","","","outpatient","","","17072.00","12804.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","13392.98","78.45","","12762.85","12762.85","12762.85","1 through 10","7939.38","13392.98","percent of total billed charges",""
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6974.02","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6967.26","6419.12","6976.16","16","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","AETNA [1001]","HB CH AETNA HMO / PPO","6372.19","58.3","","6026.08","6026.08","6026.08","1 through 10","4210.68","15281.41","percent of total billed charges",""
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6662.57","6662.57","6662.57","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6635.49","395.00","6770.90","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6635.48","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6662.57","6113.45","6662.57","26","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","FALLON HEALTH [1008]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20312.70","6770.90","20312.70","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6139.78","6113.45","6139.78","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5792.90","53","","5632.84","5632.84","5632.84","1 through 10","4210.68","15281.41","percent of total billed charges",""
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","MEDICARE [2001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20312.70","6770.90","20312.70","401","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6637.98","6637.98","6637.98","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","MOLINA [1014]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13433.47","12351.66","13433.47","18","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6635.48","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6635.48","6113.45","19928.64","19","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6635.48","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6770.90","6238.21","6770.90","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6635.48","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6635.48","6113.45","6643.39","42","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","WELLPOINT [1015]","HB CH WELLPOINT","8515.56","77.91","","8370.61","8370.61","8370.61","1 through 10","4210.68","15281.41","percent of total billed charges",""
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","both","","","10930.00","8197.50","WELLSENSE [1003]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6662.57","6113.45","12270.27","1 through 10","4210.68","15281.41","other","OPPS APC"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","10930.00","8197.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5350.17","","Case rate ($5,350.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","7725.65","7565.14","7725.65","1 through 10","4210.68","8574.59","other","ASC "
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","10930.00","8197.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5350.17","","Case rate ($5,350.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7736.35","7575.84","7736.35","1 through 10","4210.68","8574.59","other","ASC "
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","10930.00","8197.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","4210.68","","Case rate ($4,210.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9895.10","9516.14","19032.28","1 through 10","4210.68","8574.59","other","Multiple Surgery"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","10930.00","8197.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","4210.68","","Case rate ($4,210.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","10400.38","9550.78","10905.66","1 through 10","4210.68","8574.59","other","Multiple Surgery"
"Intro Cath Dialysis Circuit W/Trluml Balo Angiop","PX-36000408","CDM","36902","CPT","0361","RC","","","","outpatient","","","10930.00","8197.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8574.59","78.45","","8170.81","8170.81","8170.81","1 through 10","4210.68","8574.59","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","161.55","62.25","161.55","1 through 10","124.68","280.5","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","52.44","22.90","505.57","1 through 10","124.68","280.5","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","238.43","85","","68.52","68.52","68.52","1 through 10","124.68","280.5","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","280.50","100","","62.20","62.19","81.17","14","124.68","280.5","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","280.50","100","","43.22","31.95","953.91","1 through 10","124.68","280.5","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","63.92","25.16","245.73","18","124.68","280.5","percent of total billed charges",""
"INTRODUCER GUIDEWIRE 8.5FR 60CM 55DEG BILIARY JAGWIRE NITINOL ENDOGLIDE COATED STRAIGHT TIP TRIM BX/2EA","SUP-ITM-10005361","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","97.25","24.56","207.80","18","140.25","220.05","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 7CM 40CM 21G 2.9FR .018IN ACCESS TRANSITIONLESS PEDAL NEEDLE ECHOGENIC PLATINUM TIP NITINOL GUIDEWIRE SET MICROPUNCTURE","SUP-ITM-10133997","CDM","C1894","HCPCS","0272","RC","","","","both","","","135.96","101.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","72.06","53","","69.13","15.86","85.00","1 through 10","60.43","135.96","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 7CM 40CM 21G 2.9FR .018IN ACCESS TRANSITIONLESS PEDAL NEEDLE ECHOGENIC PLATINUM TIP NITINOL GUIDEWIRE SET MICROPUNCTURE","SUP-ITM-10133997","CDM","C1894","HCPCS","0272","RC","","","","both","","","135.96","101.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","115.57","85","","29.94","29.94","29.94","1 through 10","60.43","135.96","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 7CM 40CM 21G 2.9FR .018IN ACCESS TRANSITIONLESS PEDAL NEEDLE ECHOGENIC PLATINUM TIP NITINOL GUIDEWIRE SET MICROPUNCTURE","SUP-ITM-10133997","CDM","C1894","HCPCS","0272","RC","","","","both","","","135.96","101.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.96","100","","60.23","29.94","60.23","12","60.43","135.96","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 7CM 40CM 21G 2.9FR .018IN ACCESS TRANSITIONLESS PEDAL NEEDLE ECHOGENIC PLATINUM TIP NITINOL GUIDEWIRE SET MICROPUNCTURE","SUP-ITM-10133997","CDM","C1894","HCPCS","0272","RC","","","","both","","","135.96","101.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.96","100","","65.22","29.94","360.69","1 through 10","60.43","135.96","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 7CM 40CM 21G 2.9FR .018IN ACCESS TRANSITIONLESS PEDAL NEEDLE ECHOGENIC PLATINUM TIP NITINOL GUIDEWIRE SET MICROPUNCTURE","SUP-ITM-10133997","CDM","C1894","HCPCS","0272","RC","","","","both","","","135.96","101.97","WELLPOINT [1015]","HB CH WELLPOINT","105.93","77.91","","51.37","51.37","284.08","1 through 10","60.43","135.96","percent of total billed charges",""
"INTRODUCER SHEATH 4FR 7CM 40CM 21G 2.9FR .018IN ACCESS TRANSITIONLESS PEDAL NEEDLE ECHOGENIC PLATINUM TIP NITINOL GUIDEWIRE SET MICROPUNCTURE","SUP-ITM-10133997","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","135.96","101.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.66","78.45","","123.30","23.02","333.57","1 through 10","67.98","106.66","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","29.94","22.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","15.87","53","","69.13","15.86","85.00","1 through 10","13.31","29.94","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","29.94","22.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","25.45","85","","29.94","29.94","29.94","1 through 10","13.31","29.94","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","29.94","22.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","29.94","100","","60.23","29.94","60.23","12","13.31","29.94","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","29.94","22.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","29.94","100","","65.22","29.94","360.69","1 through 10","13.31","29.94","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","both","","","29.94","22.45","WELLPOINT [1015]","HB CH WELLPOINT","23.33","77.91","","51.37","51.37","284.08","1 through 10","13.31","29.94","percent of total billed charges",""
"INTRODUCER SHEATH 6FR 35MM 5.5CM .035IN BRITE TIP RADIOPAQUE WITH MINI-WIRE GREEN BX/5EA","SUP-ITM-10079803","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","29.94","22.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","23.49","78.45","","123.30","23.02","333.57","1 through 10","14.97","23.49","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","69.13","15.86","85.00","1 through 10","33.34","75","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","29.94","29.94","29.94","1 through 10","33.34","75","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","60.23","29.94","60.23","12","33.34","75","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","65.22","29.94","360.69","1 through 10","33.34","75","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","51.37","51.37","284.08","1 through 10","33.34","75","percent of total billed charges",""
"INTRODUCER VASCULAR 10FR .038IN 23CM FAST-CATH HEMOSTATIS SHEATH BX/5EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10236785","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","123.30","23.02","333.57","1 through 10","37.5","58.84","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","both","","","460.00","345.00","AETNA [1001]","HB CH AETNA HMO / PPO","268.18","58.3","","2.21","2.21","2.21","7865","0.32","335.8","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","both","","","460.00","345.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","268.18","58.3","","2.21","0.35","2.21","227","0.32","335.8","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0255","RC","","","","both","","","460.00","345.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","243.80","53","","9.68","4.59","206.35","1 through 10","0.32","335.8","percent of total billed charges",""
"Iodixanol Inj 320mg","PX-25500007","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","460.00","345.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.12","52.2","","597.26","0.48","597.26","454","230","240.12","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","both","","","167.00","125.25","AETNA [1001]","HB CH AETNA HMO / PPO","97.36","58.3","","2.21","2.21","2.21","7865","0.32","121.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","both","","","167.00","125.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.36","58.3","","2.21","0.35","2.21","227","0.32","121.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0255","RC","","","","both","","","167.00","125.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","88.51","53","","9.68","4.59","206.35","1 through 10","0.32","121.91","percent of total billed charges",""
"Iodixanol Vl 320mg/Ml 1ml","PX-25500006","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","167.00","125.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.17","52.2","","597.26","0.48","597.26","454","83.5","87.17","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","both","","","53.00","39.75","AETNA [1001]","HB CH AETNA HMO / PPO","30.90","58.3","","2.21","2.21","2.21","7865","0.32","38.69","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","both","","","53.00","39.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","30.90","58.3","","2.21","0.35","2.21","227","0.32","38.69","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0255","RC","","","","both","","","53.00","39.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.09","53","","9.68","4.59","206.35","1 through 10","0.32","38.69","percent of total billed charges",""
"Iohexol Vl 300mg/Ml Iodine 1ml","PX-25500013","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","53.00","39.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.67","52.2","","597.26","0.48","597.26","454","26.5","27.67","percent of total billed charges",""
"Ionm 1 on 1 in or W/Attendan 15min","PX-92000126","CDM","95940","CPT","0920","RC","","","","both","","","170.00","127.50","WELLPOINT [1015]","HB CH WELLPOINT","132.45","77.91","","127.49","127.49","127.49","13","90.1","170","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","both","","","87.00","65.25","AETNA [1001]","HB CH AETNA HMO / PPO","50.72","58.3","","2.21","2.21","2.21","7865","0.32","63.51","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","50.72","58.3","","2.21","0.35","2.21","227","0.32","63.51","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0255","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.11","53","","9.68","4.59","206.35","1 through 10","0.32","63.51","percent of total billed charges",""
"Iopamidol Inj","PX-25500009","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","87.00","65.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","45.41","52.2","","597.26","0.48","597.26","454","43.5","45.41","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","both","","","43.00","32.25","AETNA [1001]","HB CH AETNA HMO / PPO","25.07","58.3","","2.21","2.21","2.21","7865","0.32","31.39","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","both","","","43.00","32.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","25.07","58.3","","2.21","0.35","2.21","227","0.32","31.39","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0255","RC","","","","both","","","43.00","32.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","22.79","53","","9.68","4.59","206.35","1 through 10","0.32","31.39","percent of total billed charges",""
"Iopamidol Inj","PX-25500010","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","43.00","32.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","22.45","52.2","","597.26","0.48","597.26","454","21.5","22.45","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","both","","","79.00","59.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.06","58.3","","2.21","2.21","2.21","7865","0.32","57.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","both","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.06","58.3","","2.21","0.35","2.21","227","0.32","57.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0255","RC","","","","both","","","79.00","59.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.87","53","","9.68","4.59","206.35","1 through 10","0.32","57.67","percent of total billed charges",""
"Iopamidol Inj","PX-25500012","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","79.00","59.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","41.24","52.2","","597.26","0.48","597.26","454","39.5","41.24","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","both","","","40.00","30.00","AETNA [1001]","HB CH AETNA HMO / PPO","23.32","58.3","","2.21","2.21","2.21","7865","0.32","29.2","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","both","","","40.00","30.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","23.32","58.3","","2.21","0.35","2.21","227","0.32","29.2","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0255","RC","","","","both","","","40.00","30.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","21.20","53","","9.68","4.59","206.35","1 through 10","0.32","29.2","percent of total billed charges",""
"Iopamidol Vl 61% 300mg/Ml 50ml","PX-25500008","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","40.00","30.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.88","52.2","","597.26","0.48","597.26","454","20","20.88","percent of total billed charges",""
"IPG ETERNA 16 CHANNEL","SUP-ITM-10311862","CDM","C1822","HCPCS","0278","RC","","","","both","","","35900.00","26925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","19027.00","53","","16922.90","16922.90","16922.90","1 through 10","19027","35900","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","AETNA [1001]","HB CH AETNA HMO / PPO","34.40","58.3","","32.32","32.32","32.32","63","6.34","43.07","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","both","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.23","44.45","","43.82","25.97","43.82","1 through 10","6.34","43.07","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","59.00","44.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.99","59.3","","33.40","33.40","33.40","64","6.67","46.29","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","59.00","44.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","34.99","59.3","","33.40","33.40","33.40","1 through 10","6.67","46.29","percent of total billed charges",""
"IRON","PX-30000531","CDM","83540","CPT","0301","RC","","","","outpatient","","","59.00","44.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","46.29","78.45","","43.82","25.97","43.82","61","6.67","46.29","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","AETNA [1001]","HB CH AETNA HMO / PPO","41.39","58.3","","39.12","39.12","39.12","64","8.57","51.83","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","both","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.56","44.45","","53.05","31.44","53.05","1 through 10","8.57","51.83","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","71.00","53.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.10","59.3","","40.43","40.43","40.43","62","9.02","55.7","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","71.00","53.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","42.10","59.3","","40.43","40.43","40.43","1 through 10","9.02","55.7","percent of total billed charges",""
"Iron Binding Capacity","PX-30000532","CDM","83550","CPT","0301","RC","","","","outpatient","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.70","78.45","","53.05","31.44","53.05","60","9.02","55.7","percent of total billed charges",""
"Irreversible Electroporation Ablation of Lymph Node","PX-76002337","CDM","38999","CPT","0761","RC","","","","outpatient","","","4109.00","3081.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2016.29","49.07","","12132.25","11259.00","12132.25","1 through 10","970.06","3223.51","percent of total billed charges",""
"Irreversible Electroporation Ablation of Lymph Node","PX-76002337","CDM","38999","CPT","0761","RC","","","","outpatient","","","4109.00","3081.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2058.61","50.1","","10684.50","310.07","10684.50","1 through 10","970.06","3223.51","percent of total billed charges",""
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","both","","","711.00","533.25","MEDICARE [2001]","HB BWF MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","1 through 10","231.42","684.2","other","OPPS APC"
"Irrig/Lavage/Instill Bladder","PX-76001256","CDM","51700","CPT","0761","RC","","","","outpatient","","","711.00","533.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","264.64","","Case rate ($264.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","382.67","382.67","382.67","1 through 10","231.42","774.58","other","ASC "
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","124.00","93.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.53","59.3","","70.91","70.91","70.91","1 through 10","20.4","124.73","percent of total billed charges",""
"Islet Cell Antibody","PX-30000843","CDM","86341","CPT","0302","RC","","","","outpatient","","","124.00","93.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","97.28","78.45","","119.81","119.81","119.81","1 through 10","20.4","124.73","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.78","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB CH AETNA HMO / PPO","124.18","58.3","","117.37","0.02","234.74","31","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","53.91","53.91","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","51.02","53.92","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","103.70","92","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","MOLINA [1014]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.53","54.79","108.53","1 through 10","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","19.80","19.80","53.91","55","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.79","54.79","54.79","22","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.70","53.69","54.79","22","52.05","165.95","other","OPPS APC"
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","both","","","213.00","159.75","WELLPOINT [1015]","HB CH WELLPOINT","165.95","77.91","","163.03","163.03","163.03","83","52.05","165.95","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","inpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.38","70.6","","477.42","477.42","477.42","1 through 10","119.28","150.38","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","213.00","159.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","126.31","59.3","","121.30","121.30","121.30","42","62.55","167.1","percent of total billed charges",""
"IV Infus Hydration Ea Additional Hour - 96361","PX-26000002","CDM","96361","CPT","0260","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","657.00","94.31","657.00","32","62.55","167.1","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","257.71","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","257.47","257.47","257.47","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","AETNA [1001]","HB CH AETNA HMO / PPO","338.72","58.3","","640.72","320.36","640.72","1 through 10","223.15","728.13","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","246.21","246.21","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","MEDICARE [2001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","27","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","245.21","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.21","250.21","250.21","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","both","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.71","247.71","247.71","1 through 10","223.15","728.13","other","OPPS APC"
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","inpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","410.19","70.6","","434.37","434.37","434.37","1 through 10","325.36","410.19","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","581.00","435.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","344.53","59.3","","331.09","331.09","331.09","1 through 10","290.5","462.33","percent of total billed charges",""
"IV Infus Hydration Initial 31 Min-1 Hour - 96360","PX-26000001","CDM","96360","CPT","0260","RC","","","","outpatient","","","581.00","435.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","455.79","78.45","","257.41","257.41","257.41","1 through 10","290.5","462.33","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","AETNA [1001]","HB CH AETNA HMO / PPO","214.54","58.3","","202.99","202.99","358.00","1 through 10","80.29","286.71","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","HUMANA [1012]","HB BWF MEDICARE","84.52","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.90","82.90","82.90","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","MEDICARE [2001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","76.89","84.52","12","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","82.83","82.83","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","82.83","82.83","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","82.83","","APC Price ($84.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","75.36","84.52","1 through 10","80.29","286.71","other","OPPS APC"
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","both","","","368.00","276.00","WELLPOINT [1015]","HB CH WELLPOINT","286.71","77.91","","281.96","281.96","281.96","1 through 10","80.29","286.71","percent of total billed charges",""
"IV Infus Non-Chemo Ea Add’L Seq Diff Drug Up to 1 Hr - 96367","PX-26000005","CDM","96367","CPT","0260","RC","","","","outpatient","","","368.00","276.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","218.22","59.3","","209.79","92.97","209.79","1 through 10","98.67","288.7","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","257.71","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","257.47","257.47","258.37","102","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","AETNA [1001]","HB CH AETNA HMO / PPO","420.34","58.3","","397.47","397.47","397.47","74","237.7","728.13","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","246.21","246.21","168","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","249.09","232.98","1621.22","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","230.19","246.21","26","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","ELDER SERVICES [1037]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","300.61","300.61","300.61","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","FALLON HEALTH [1008]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","229.25","229.25","229.25","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","HUMANA [1012]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.41","229.44","246.71","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","MARTIN'S POINT [160007]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","230.19","246.21","18","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","MEDICARE [2001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","467.86","3787","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.21","229.25","245.21","62","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","MOLINA [1014]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","495.42","463.18","495.42","1 through 10","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","TRICARE [160005]","HB BWF TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","237.70","237.70","237.70","12","237.7","728.13","other","Tricare OPPS"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","245.21","735.63","130","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","both","","","721.00","540.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","233.93","250.21","261","237.7","728.13","other","OPPS APC"
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","721.00","540.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","427.55","59.3","","410.79","408.78","410.79","49","309.09","764.73","percent of total billed charges",""
"IV Infus Non-Chemo Initial Up to 1 Hr - 96365","PX-26000003","CDM","96365","CPT","0260","RC","","","","outpatient","","","721.00","540.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","565.62","78.45","","538.93","319.38","538.93","102","309.09","764.73","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","16","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","AETNA [1001]","HB CH AETNA HMO / PPO","163.82","58.3","","154.79","154.79","154.79","36","52.05","218.93","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.91","51.02","70.57","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.48","54.35","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","51.02","53.92","14","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","ELDER SERVICES [1037]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","70.65","70.65","70.65","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","50.81","50.81","50.81","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","MARTIN'S POINT [160007]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.02","51.02","51.02","1 through 10","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.80","54.79","164.37","1494","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","50.81","53.70","15","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","TRICARE [160005]","HB BWF TRICARE","52.05","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","52.05","52.05","52.06","12","52.05","218.93","other","Tricare OPPS"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.92","53.69","161.08","163","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","53.81","93","52.05","218.93","other","OPPS APC"
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","both","","","281.00","210.75","WELLPOINT [1015]","HB CH WELLPOINT","218.93","77.91","","215.01","215.01","215.02","70","52.05","218.93","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","281.00","210.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.63","59.3","","159.98","159.98","159.98","52","62.55","220.44","percent of total billed charges",""
"IV Infus Non-Chemo Same Drug Ea Hr - 96366","PX-26000004","CDM","96366","CPT","0260","RC","","","","outpatient","","","281.00","210.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.44","78.45","","209.88","209.88","209.88","92","62.55","220.44","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","257.71","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","257.47","257.47","258.37","15","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","AETNA [1001]","HB CH AETNA HMO / PPO","453.57","58.3","","429.22","429.22","858.44","20","110.41","728.13","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","246.21","246.21","246.21","16","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","246.21","246.21","1 through 10","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","MEDICARE [2001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","467.86","244","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","250.21","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","245.21","245.21","245.21","1 through 10","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","TRICARE [160005]","HB BWF TRICARE","237.70","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","237.70","237.70","237.70","1 through 10","110.41","728.13","other","Tricare OPPS"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","245.21","245.21","246.21","1 through 10","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","250.21","243.43","250.21","1 through 10","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","both","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","245.20","","APC Price ($250.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","246.21","245.21","250.21","26","110.41","728.13","other","OPPS APC"
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","778.00","583.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","461.35","59.3","","443.60","443.51","443.60","14","204.65","610.34","percent of total billed charges",""
"Ivp/ IV < 16 Min Initial Drug - 96374","PX-26000012","CDM","96374","CPT","0260","RC","","","","outpatient","","","778.00","583.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","610.34","78.45","","581.98","344.89","581.98","16","204.65","610.34","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","AETNA [1001]","HB CH AETNA HMO / PPO","144.00","58.3","","136.08","136.08","136.08","1 through 10","109.79","247","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","both","","","247.00","185.25","WELLPOINT [1015]","HB CH WELLPOINT","192.44","77.91","","189.02","189.02","189.02","25","109.79","247","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","247.00","185.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","146.47","59.3","","140.64","140.64","140.64","12","123.5","193.77","percent of total billed charges",""
"Ivp/ IV <16 Min Ea Add’L Seq Same Drug - 96376","PX-26000014","CDM","96376","CPT","0260","RC","","","","outpatient","","","247.00","185.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","193.77","78.45","","109.34","109.34","109.34","1 through 10","123.5","193.77","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.83","38","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","175.20","175.20","618.00","25","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","309.00","53.91","309.00","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","51.02","53.92","24","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","225.57","225.57","225.57","1 through 10","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","54.79","54.79","164.37","628","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","53.69","53.69","53.69","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","MOLINA [1014]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","108.49","108.49","108.49","1 through 10","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","TRICARE [160005]","HB BWF TRICARE","52.05","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","52.05","49.25","52.05","1 through 10","52.05","247.75","other","Tricare OPPS"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.91","53.69","161.08","77","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","54.79","49.93","103.70","17","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.82","51.02","54.79","73","52.05","247.75","other","OPPS APC"
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","243.37","243.37","243.37","17","52.05","247.75","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","181.07","60.27","181.08","27","62.55","249.47","percent of total billed charges",""
"Ivp/ IV <16min Ea Addl Seg Diff Drug - 96375","PX-26000013","CDM","96375","CPT","0260","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","237.56","140.78","237.56","39","62.55","249.47","percent of total billed charges",""
"Jak2 Exons 12 - 15 Sequencing","PX-31000942","CDM","0027U","CPT","0310","RC","","","","outpatient","","","1211.00","908.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","606.71","50.1","","1178.00","1178.00","1178.00","1 through 10","353.72","950.03","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Jc Virus, Pcr Quant","PX-30001626","CDM","87799","CPT","0301","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","AETNA [1001]","HB CH AETNA HMO / PPO","1241.21","58.3","","554.95","91.85","1421.75","94","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1554.18","73","","2490.03","2490.03","2490.03","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1241.21","58.3","","750.00","750.00","750.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1128.38","53","","1192.50","120.84","4149.90","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1809.66","85","","750.00","75.00","750.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2129.01","100","","657.00","121.50","1971.00","14","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2129.01","100","","75.00","75.00","75.00","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2129.01","100","","366.00","144.00","1971.00","45","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1554.18","73","","667.50","667.50","667.50","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","946.34","44.45","","123.77","123.77","123.77","1 through 10","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","both","","","2129.01","1596.76","WELLPOINT [1015]","HB CH WELLPOINT","1658.71","77.91","","483.51","229.32","1316.08","96","946.34","2129.01","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2129.01","1596.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","1262.50","59.3","","439.50","225.34","1872.27","197","1064.51","1670.21","percent of total billed charges",""
"JOINT PLATE 3.5MM METATARSOPHALANGEAL BONE A.L.P.S. TIMAX TITANIUM COMPRESSION FUSION SINGLE","SUP-ITM-10073257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2129.01","1596.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1670.21","78.45","","385.32","55.36","1815.62","58","1064.51","1670.21","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","AETNA [1001]","HB CH AETNA HMO / PPO","128.81","58.3","","554.95","91.85","1421.75","94","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","161.29","73","","2490.03","2490.03","2490.03","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","128.81","58.3","","750.00","750.00","750.00","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","117.10","53","","1192.50","120.84","4149.90","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","187.81","85","","750.00","75.00","750.00","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","220.95","100","","657.00","121.50","1971.00","14","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","220.95","100","","75.00","75.00","75.00","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","220.95","100","","366.00","144.00","1971.00","45","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","161.29","73","","667.50","667.50","667.50","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.21","44.45","","123.77","123.77","123.77","1 through 10","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.95","165.71","WELLPOINT [1015]","HB CH WELLPOINT","172.14","77.91","","483.51","229.32","1316.08","96","98.21","220.95","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.95","165.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.02","59.3","","439.50","225.34","1872.27","197","110.48","173.34","percent of total billed charges",""
"K-WIRE 1.1MM 6IN","SUP-ITM-10335435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.95","165.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.34","78.45","","385.32","55.36","1815.62","58","110.48","173.34","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","112.35","84.26","AETNA [1001]","HB CH AETNA HMO / PPO","65.50","58.3","","161.55","62.25","161.55","1 through 10","49.94","112.35","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","112.35","84.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","59.55","53","","52.44","22.90","505.57","1 through 10","49.94","112.35","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","112.35","84.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","95.50","85","","68.52","68.52","68.52","1 through 10","49.94","112.35","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","112.35","84.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","112.35","100","","62.20","62.19","81.17","14","49.94","112.35","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","112.35","84.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","112.35","100","","43.22","31.95","953.91","1 through 10","49.94","112.35","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","both","","","112.35","84.26","WELLPOINT [1015]","HB CH WELLPOINT","87.53","77.91","","63.92","25.16","245.73","18","49.94","112.35","percent of total billed charges",""
"K-WIRE 1X100MM STAINLESS STEEL BLUNT TIP","SUP-ITM-10048261","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","112.35","84.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.14","78.45","","97.25","24.56","207.80","18","56.18","88.14","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","AETNA [1001]","HB CH AETNA HMO / PPO","372.62","58.3","","554.95","91.85","1421.75","94","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","466.58","73","","2490.03","2490.03","2490.03","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","372.62","58.3","","750.00","750.00","750.00","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","338.75","53","","1192.50","120.84","4149.90","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","543.28","85","","750.00","75.00","750.00","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","639.15","100","","657.00","121.50","1971.00","14","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","639.15","100","","75.00","75.00","75.00","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","639.15","100","","366.00","144.00","1971.00","45","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","466.58","73","","667.50","667.50","667.50","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","284.10","44.45","","123.77","123.77","123.77","1 through 10","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","both","","","639.15","479.36","WELLPOINT [1015]","HB CH WELLPOINT","497.96","77.91","","483.51","229.32","1316.08","96","284.1","639.15","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.15","479.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","379.02","59.3","","439.50","225.34","1872.27","197","319.58","501.41","percent of total billed charges",""
"K-WIRE 3MM DIAMETER 285MM LENGTH BONE","SUP-ITM-10232859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","639.15","479.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","501.41","78.45","","385.32","55.36","1815.62","58","319.58","501.41","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","AETNA [1001]","HB CH AETNA HMO / PPO","109.00","58.3","","554.95","91.85","1421.75","94","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","136.48","73","","2490.03","2490.03","2490.03","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","109.00","58.3","","750.00","750.00","750.00","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","99.09","53","","1192.50","120.84","4149.90","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","158.92","85","","750.00","75.00","750.00","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","186.96","100","","657.00","121.50","1971.00","14","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","186.96","100","","75.00","75.00","75.00","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","186.96","100","","366.00","144.00","1971.00","45","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","136.48","73","","667.50","667.50","667.50","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","83.10","44.45","","123.77","123.77","123.77","1 through 10","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","both","","","186.96","140.22","WELLPOINT [1015]","HB CH WELLPOINT","145.66","77.91","","483.51","229.32","1316.08","96","83.1","186.96","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.96","140.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.87","59.3","","439.50","225.34","1872.27","197","93.48","146.67","percent of total billed charges",""
"K-WIRE 6 0.9MM","SUP-ITM-10334841","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","186.96","140.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","146.67","78.45","","385.32","55.36","1815.62","58","93.48","146.67","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","AETNA [1001]","HB CH AETNA HMO / PPO","148.63","58.3","","554.95","91.85","1421.75","94","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","186.11","73","","2490.03","2490.03","2490.03","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.63","58.3","","750.00","750.00","750.00","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.12","53","","1192.50","120.84","4149.90","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","216.70","85","","750.00","75.00","750.00","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","254.94","100","","657.00","121.50","1971.00","14","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","254.94","100","","75.00","75.00","75.00","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","254.94","100","","366.00","144.00","1971.00","45","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.11","73","","667.50","667.50","667.50","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.32","44.45","","123.77","123.77","123.77","1 through 10","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","both","","","254.94","191.20","WELLPOINT [1015]","HB CH WELLPOINT","198.62","77.91","","483.51","229.32","1316.08","96","113.32","254.94","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","254.94","191.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.18","59.3","","439.50","225.34","1872.27","197","127.47","200","percent of total billed charges",""
"K-WIRE 6 1.6MM","SUP-ITM-10334842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","254.94","191.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.00","78.45","","385.32","55.36","1815.62","58","127.47","200","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","554.95","91.85","1421.75","94","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","2490.03","2490.03","2490.03","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","750.00","750.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","1192.50","120.84","4149.90","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","750.00","75.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","657.00","121.50","1971.00","14","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","75.00","75.00","75.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","366.00","144.00","1971.00","45","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","667.50","667.50","667.50","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","123.77","123.77","123.77","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","483.51","229.32","1316.08","96","53.34","120","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","439.50","225.34","1872.27","197","60","94.14","percent of total billed charges",""
"K-WIRE BLUNT THREADED NITINOL","SUP-ITM-10187066","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","385.32","55.36","1815.62","58","60","94.14","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","554.95","91.85","1421.75","94","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","2490.03","2490.03","2490.03","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","750.00","750.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","1192.50","120.84","4149.90","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.75","85","","750.00","75.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.00","100","","657.00","121.50","1971.00","14","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","135.00","100","","75.00","75.00","75.00","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.00","100","","366.00","144.00","1971.00","45","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","667.50","667.50","667.50","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","123.77","123.77","123.77","1 through 10","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","483.51","229.32","1316.08","96","60.01","135","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","439.50","225.34","1872.27","197","67.5","105.91","percent of total billed charges",""
"K-WIRE BONE .54X14IN TIMBERLINE SS CHAMBERED","SUP-ITM-10104603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","385.32","55.36","1815.62","58","67.5","105.91","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","AETNA [1001]","HB CH AETNA HMO / PPO","99.66","58.3","","554.95","91.85","1421.75","94","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","124.79","73","","2490.03","2490.03","2490.03","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.66","58.3","","750.00","750.00","750.00","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.60","53","","1192.50","120.84","4149.90","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","145.30","85","","750.00","75.00","750.00","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","170.94","100","","657.00","121.50","1971.00","14","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","170.94","100","","75.00","75.00","75.00","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","170.94","100","","366.00","144.00","1971.00","45","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.79","73","","667.50","667.50","667.50","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.98","44.45","","123.77","123.77","123.77","1 through 10","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.94","128.20","WELLPOINT [1015]","HB CH WELLPOINT","133.18","77.91","","483.51","229.32","1316.08","96","75.98","170.94","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.94","128.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.37","59.3","","439.50","225.34","1872.27","197","85.47","134.1","percent of total billed charges",""
"K-WIRE BONE .6X70MM FIXATION SS TROCAR POINT CS/10EA","SUP-ITM-10019883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.94","128.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.10","78.45","","385.32","55.36","1815.62","58","85.47","134.1","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","AETNA [1001]","HB CH AETNA HMO / PPO","99.24","58.3","","554.95","91.85","1421.75","94","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","124.26","73","","2490.03","2490.03","2490.03","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.24","58.3","","750.00","750.00","750.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.22","53","","1192.50","120.84","4149.90","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","144.69","85","","750.00","75.00","750.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","170.22","100","","657.00","121.50","1971.00","14","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","170.22","100","","75.00","75.00","75.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","170.22","100","","366.00","144.00","1971.00","45","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.26","73","","667.50","667.50","667.50","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.66","44.45","","123.77","123.77","123.77","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","WELLPOINT [1015]","HB CH WELLPOINT","132.62","77.91","","483.51","229.32","1316.08","96","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.22","127.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.94","59.3","","439.50","225.34","1872.27","197","85.11","133.54","percent of total billed charges",""
"K-WIRE BONE .9MM SINGLE LASER MARK NONTHREADED","SUP-ITM-10232371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.22","127.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.54","78.45","","385.32","55.36","1815.62","58","85.11","133.54","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","554.95","91.85","1421.75","94","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","45.99","73","","2490.03","2490.03","2490.03","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","36.73","58.3","","750.00","750.00","750.00","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","33.39","53","","1192.50","120.84","4149.90","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","53.55","85","","750.00","75.00","750.00","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","63.00","100","","657.00","121.50","1971.00","14","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","63.00","100","","75.00","75.00","75.00","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","63.00","100","","366.00","144.00","1971.00","45","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","45.99","73","","667.50","667.50","667.50","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","123.77","123.77","123.77","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","both","","","63.00","47.25","WELLPOINT [1015]","HB CH WELLPOINT","49.08","77.91","","483.51","229.32","1316.08","96","28","63","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","439.50","225.34","1872.27","197","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE .9X150MM SMALL EVOLVE TRIAD SS FIXATION BLUNT TROCAR TIP","SUP-ITM-10057343","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","385.32","55.36","1815.62","58","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.62","86.71","AETNA [1001]","HB CH AETNA HMO / PPO","67.41","58.3","","161.55","62.25","161.55","1 through 10","51.39","115.62","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.62","86.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","61.28","53","","52.44","22.90","505.57","1 through 10","51.39","115.62","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.62","86.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","98.28","85","","68.52","68.52","68.52","1 through 10","51.39","115.62","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.62","86.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","115.62","100","","62.20","62.19","81.17","14","51.39","115.62","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.62","86.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","115.62","100","","43.22","31.95","953.91","1 through 10","51.39","115.62","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.62","86.71","WELLPOINT [1015]","HB CH WELLPOINT","90.08","77.91","","63.92","25.16","245.73","18","51.39","115.62","percent of total billed charges",""
"K-WIRE BONE 0.045INX160MM VARIAX SS DISTAL RADIUS ZEBRA MARKING","SUP-ITM-10113244","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","115.62","86.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.70","78.45","","97.25","24.56","207.80","18","57.81","90.7","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","AETNA [1001]","HB CH AETNA HMO / PPO","52.47","58.3","","554.95","91.85","1421.75","94","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","65.70","73","","2490.03","2490.03","2490.03","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","52.47","58.3","","750.00","750.00","750.00","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","47.70","53","","1192.50","120.84","4149.90","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","76.50","85","","750.00","75.00","750.00","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","90.00","100","","657.00","121.50","1971.00","14","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","90.00","100","","75.00","75.00","75.00","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","90.00","100","","366.00","144.00","1971.00","45","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","65.70","73","","667.50","667.50","667.50","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.01","44.45","","123.77","123.77","123.77","1 through 10","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","both","","","90.00","67.50","WELLPOINT [1015]","HB CH WELLPOINT","70.12","77.91","","483.51","229.32","1316.08","96","40.01","90","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.00","67.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","53.37","59.3","","439.50","225.34","1872.27","197","45","70.61","percent of total billed charges",""
"K-WIRE BONE 0.045INX6.0CM SS TROCAR POINT THREADED","SUP-ITM-10019548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","385.32","55.36","1815.62","58","45","70.61","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","AETNA [1001]","HB CH AETNA HMO / PPO","99.24","58.3","","554.95","91.85","1421.75","94","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","124.26","73","","2490.03","2490.03","2490.03","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.24","58.3","","750.00","750.00","750.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.22","53","","1192.50","120.84","4149.90","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","144.69","85","","750.00","75.00","750.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","170.22","100","","657.00","121.50","1971.00","14","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","170.22","100","","75.00","75.00","75.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","170.22","100","","366.00","144.00","1971.00","45","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.26","73","","667.50","667.50","667.50","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.66","44.45","","123.77","123.77","123.77","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","WELLPOINT [1015]","HB CH WELLPOINT","132.62","77.91","","483.51","229.32","1316.08","96","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.22","127.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.94","59.3","","439.50","225.34","1872.27","197","85.11","133.54","percent of total billed charges",""
"K-WIRE BONE 1.15MM DOUBLE LASER MARK NONTHREADED","SUP-ITM-10232370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.22","127.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.54","78.45","","385.32","55.36","1815.62","58","85.11","133.54","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","554.95","91.85","1421.75","94","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","2490.03","2490.03","2490.03","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","34.98","58.3","","750.00","750.00","750.00","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","1192.50","120.84","4149.90","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","51.00","85","","750.00","75.00","750.00","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","60.00","100","","657.00","121.50","1971.00","14","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","60.00","100","","75.00","75.00","75.00","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","60.00","100","","366.00","144.00","1971.00","45","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","667.50","667.50","667.50","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","123.77","123.77","123.77","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","483.51","229.32","1316.08","96","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","439.50","225.34","1872.27","197","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.1X100MM FIXATION SS COLOR","SUP-ITM-10229998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","385.32","55.36","1815.62","58","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","AETNA [1001]","HB CH AETNA HMO / PPO","31.34","58.3","","554.95","91.85","1421.75","94","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","39.24","73","","2490.03","2490.03","2490.03","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.34","58.3","","750.00","750.00","750.00","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.49","53","","1192.50","120.84","4149.90","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","45.70","85","","750.00","75.00","750.00","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","53.76","100","","657.00","121.50","1971.00","14","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","53.76","100","","75.00","75.00","75.00","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","53.76","100","","366.00","144.00","1971.00","45","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","39.24","73","","667.50","667.50","667.50","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.90","44.45","","123.77","123.77","123.77","1 through 10","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.76","40.32","WELLPOINT [1015]","HB CH WELLPOINT","41.88","77.91","","483.51","229.32","1316.08","96","23.9","53.76","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.76","40.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.88","59.3","","439.50","225.34","1872.27","197","26.88","42.17","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10002394","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.76","40.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.17","78.45","","385.32","55.36","1815.62","58","26.88","42.17","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","AETNA [1001]","HB CH AETNA HMO / PPO","33.58","58.3","","554.95","91.85","1421.75","94","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","42.05","73","","2490.03","2490.03","2490.03","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","33.58","58.3","","750.00","750.00","750.00","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.53","53","","1192.50","120.84","4149.90","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","48.96","85","","750.00","75.00","750.00","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","57.60","100","","657.00","121.50","1971.00","14","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","57.60","100","","75.00","75.00","75.00","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","57.60","100","","366.00","144.00","1971.00","45","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","42.05","73","","667.50","667.50","667.50","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","25.60","44.45","","123.77","123.77","123.77","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","both","","","57.60","43.20","WELLPOINT [1015]","HB CH WELLPOINT","44.88","77.91","","483.51","229.32","1316.08","96","25.6","57.6","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.60","43.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","34.16","59.3","","439.50","225.34","1872.27","197","28.8","45.19","percent of total billed charges",""
"K-WIRE BONE 1.1X150MM FIXATION SS SPADE POINT DUAL END THREADED","SUP-ITM-10002118","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.19","78.45","","385.32","55.36","1815.62","58","28.8","45.19","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","AETNA [1001]","HB CH AETNA HMO / PPO","99.24","58.3","","554.95","91.85","1421.75","94","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","124.26","73","","2490.03","2490.03","2490.03","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.24","58.3","","750.00","750.00","750.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.22","53","","1192.50","120.84","4149.90","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","144.69","85","","750.00","75.00","750.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","170.22","100","","657.00","121.50","1971.00","14","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","170.22","100","","75.00","75.00","75.00","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","170.22","100","","366.00","144.00","1971.00","45","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.26","73","","667.50","667.50","667.50","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.66","44.45","","123.77","123.77","123.77","1 through 10","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.22","127.66","WELLPOINT [1015]","HB CH WELLPOINT","132.62","77.91","","483.51","229.32","1316.08","96","75.66","170.22","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.22","127.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.94","59.3","","439.50","225.34","1872.27","197","85.11","133.54","percent of total billed charges",""
"K-WIRE BONE 1.20MM TRIPLE LASER MARK NONTHREADED","SUP-ITM-10232369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.22","127.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.54","78.45","","385.32","55.36","1815.62","58","85.11","133.54","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","AETNA [1001]","HB CH AETNA HMO / PPO","590.83","58.3","","554.95","91.85","1421.75","94","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","739.80","73","","2490.03","2490.03","2490.03","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","590.83","58.3","","750.00","750.00","750.00","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.12","53","","1192.50","120.84","4149.90","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","861.42","85","","750.00","75.00","750.00","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1013.43","100","","657.00","121.50","1971.00","14","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1013.43","100","","75.00","75.00","75.00","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1013.43","100","","366.00","144.00","1971.00","45","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","739.80","73","","667.50","667.50","667.50","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.47","44.45","","123.77","123.77","123.77","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","WELLPOINT [1015]","HB CH WELLPOINT","789.56","77.91","","483.51","229.32","1316.08","96","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","600.96","59.3","","439.50","225.34","1872.27","197","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.25X100MM FIXATION SS THREADED TIP CS/10EA","SUP-ITM-10002228","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","795.04","78.45","","385.32","55.36","1815.62","58","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","AETNA [1001]","HB CH AETNA HMO / PPO","13.27","58.3","","554.95","91.85","1421.75","94","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","16.61","73","","2490.03","2490.03","2490.03","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","13.27","58.3","","750.00","750.00","750.00","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","12.06","53","","1192.50","120.84","4149.90","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","19.35","85","","750.00","75.00","750.00","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","22.76","100","","657.00","121.50","1971.00","14","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","22.76","100","","75.00","75.00","75.00","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","22.76","100","","366.00","144.00","1971.00","45","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16.61","73","","667.50","667.50","667.50","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.12","44.45","","123.77","123.77","123.77","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","WELLPOINT [1015]","HB CH WELLPOINT","17.73","77.91","","483.51","229.32","1316.08","96","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.50","59.3","","439.50","225.34","1872.27","197","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 1.25X150MM FIXATION TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10148159","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17.86","78.45","","385.32","55.36","1815.62","58","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","161.55","62.25","161.55","1 through 10","124.68","280.5","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","52.44","22.90","505.57","1 through 10","124.68","280.5","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","238.43","85","","68.52","68.52","68.52","1 through 10","124.68","280.5","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","280.50","100","","62.20","62.19","81.17","14","124.68","280.5","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","280.50","100","","43.22","31.95","953.91","1 through 10","124.68","280.5","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","63.92","25.16","245.73","18","124.68","280.5","percent of total billed charges",""
"K-WIRE BONE 1.4MM SMOOTH","SUP-ITM-10194747","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","97.25","24.56","207.80","18","140.25","220.05","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"K-WIRE BONE 1.4X228MM IN II SS FIXATION CANNULATED","SUP-ITM-10056821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","AETNA [1001]","HB CH AETNA HMO / PPO","32.43","58.3","","554.95","91.85","1421.75","94","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","40.60","73","","2490.03","2490.03","2490.03","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","32.43","58.3","","750.00","750.00","750.00","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","29.48","53","","1192.50","120.84","4149.90","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","47.28","85","","750.00","75.00","750.00","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","55.62","100","","657.00","121.50","1971.00","14","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","55.62","100","","75.00","75.00","75.00","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","55.62","100","","366.00","144.00","1971.00","45","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","40.60","73","","667.50","667.50","667.50","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.72","44.45","","123.77","123.77","123.77","1 through 10","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","both","","","55.62","41.71","WELLPOINT [1015]","HB CH WELLPOINT","43.33","77.91","","483.51","229.32","1316.08","96","24.72","55.62","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","55.62","41.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","32.98","59.3","","439.50","225.34","1872.27","197","27.81","43.63","percent of total billed charges",""
"K-WIRE BONE 1.6 127MM DVR ANATOMIC SS","SUP-ITM-10019753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","55.62","41.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.63","78.45","","385.32","55.36","1815.62","58","27.81","43.63","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","AETNA [1001]","HB CH AETNA HMO / PPO","45.04","58.3","","161.55","62.25","161.55","1 through 10","34.34","77.25","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","40.94","53","","52.44","22.90","505.57","1 through 10","34.34","77.25","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","65.66","85","","68.52","68.52","68.52","1 through 10","34.34","77.25","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","77.25","100","","62.20","62.19","81.17","14","34.34","77.25","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","77.25","100","","43.22","31.95","953.91","1 through 10","34.34","77.25","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","both","","","77.25","57.94","WELLPOINT [1015]","HB CH WELLPOINT","60.19","77.91","","63.92","25.16","245.73","18","34.34","77.25","percent of total billed charges",""
"K-WIRE BONE 1.6MM 6.0IN FIXATION SS THREADED TIP","SUP-ITM-10017063","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","77.25","57.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","60.60","78.45","","97.25","24.56","207.80","18","38.63","60.6","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","554.95","91.85","1421.75","94","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","2490.03","2490.03","2490.03","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","34.98","58.3","","750.00","750.00","750.00","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","31.80","53","","1192.50","120.84","4149.90","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","51.00","85","","750.00","75.00","750.00","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","60.00","100","","657.00","121.50","1971.00","14","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","60.00","100","","75.00","75.00","75.00","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","60.00","100","","366.00","144.00","1971.00","45","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","43.80","73","","667.50","667.50","667.50","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","26.67","44.45","","123.77","123.77","123.77","1 through 10","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","both","","","60.00","45.00","WELLPOINT [1015]","HB CH WELLPOINT","46.75","77.91","","483.51","229.32","1316.08","96","26.67","60","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","439.50","225.34","1872.27","197","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.6MM 65 SS","SUP-ITM-10028332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","385.32","55.36","1815.62","58","30","47.07","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.09","114.82","AETNA [1001]","HB CH AETNA HMO / PPO","89.25","58.3","","161.55","62.25","161.55","1 through 10","68.05","153.09","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.09","114.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.14","53","","52.44","22.90","505.57","1 through 10","68.05","153.09","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.09","114.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","130.13","85","","68.52","68.52","68.52","1 through 10","68.05","153.09","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.09","114.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","153.09","100","","62.20","62.19","81.17","14","68.05","153.09","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.09","114.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","153.09","100","","43.22","31.95","953.91","1 through 10","68.05","153.09","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","both","","","153.09","114.82","WELLPOINT [1015]","HB CH WELLPOINT","119.27","77.91","","63.92","25.16","245.73","18","68.05","153.09","percent of total billed charges",""
"K-WIRE BONE 1.6MM STAINLESS STEEL SURGICAL TRABECULAR METAL TOTAL ANKLE DISPOSABLE","SUP-ITM-10235658","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","153.09","114.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.10","78.45","","97.25","24.56","207.80","18","76.55","120.1","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","AETNA [1001]","HB CH AETNA HMO / PPO","590.83","58.3","","554.95","91.85","1421.75","94","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","739.80","73","","2490.03","2490.03","2490.03","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","590.83","58.3","","750.00","750.00","750.00","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.12","53","","1192.50","120.84","4149.90","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","861.42","85","","750.00","75.00","750.00","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1013.43","100","","657.00","121.50","1971.00","14","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1013.43","100","","75.00","75.00","75.00","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1013.43","100","","366.00","144.00","1971.00","45","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","739.80","73","","667.50","667.50","667.50","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","450.47","44.45","","123.77","123.77","123.77","1 through 10","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","both","","","1013.43","760.07","WELLPOINT [1015]","HB CH WELLPOINT","789.56","77.91","","483.51","229.32","1316.08","96","450.47","1013.43","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","600.96","59.3","","439.50","225.34","1872.27","197","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.6X100MM THREADED TIP CS/10PK/10EA","SUP-ITM-10002205","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1013.43","760.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","795.04","78.45","","385.32","55.36","1815.62","58","506.72","795.04","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","AETNA [1001]","HB CH AETNA HMO / PPO","48.97","58.3","","554.95","91.85","1421.75","94","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","2490.03","2490.03","2490.03","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","48.97","58.3","","750.00","750.00","750.00","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.52","53","","1192.50","120.84","4149.90","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","71.40","85","","750.00","75.00","750.00","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","84.00","100","","657.00","121.50","1971.00","14","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","84.00","100","","75.00","75.00","75.00","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","84.00","100","","366.00","144.00","1971.00","45","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","667.50","667.50","667.50","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.34","44.45","","123.77","123.77","123.77","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB CH WELLPOINT","65.44","77.91","","483.51","229.32","1316.08","96","37.34","84","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.81","59.3","","439.50","225.34","1872.27","197","42","65.9","percent of total billed charges",""
"K-WIRE BONE 1.6X127MM SINGLE DIAMOND","SUP-ITM-10306390","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.90","78.45","","385.32","55.36","1815.62","58","42","65.9","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","AETNA [1001]","HB CH AETNA HMO / PPO","21.42","58.3","","554.95","91.85","1421.75","94","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","26.82","73","","2490.03","2490.03","2490.03","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","21.42","58.3","","750.00","750.00","750.00","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","19.47","53","","1192.50","120.84","4149.90","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","31.23","85","","750.00","75.00","750.00","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","36.74","100","","657.00","121.50","1971.00","14","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","36.74","100","","75.00","75.00","75.00","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","36.74","100","","366.00","144.00","1971.00","45","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","26.82","73","","667.50","667.50","667.50","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.33","44.45","","123.77","123.77","123.77","1 through 10","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","both","","","36.74","27.55","WELLPOINT [1015]","HB CH WELLPOINT","28.62","77.91","","483.51","229.32","1316.08","96","16.33","36.74","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","36.74","27.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.79","59.3","","439.50","225.34","1872.27","197","18.37","28.82","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM 5 FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10011480","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","36.74","27.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.82","78.45","","385.32","55.36","1815.62","58","18.37","28.82","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","AETNA [1001]","HB CH AETNA HMO / PPO","31.48","58.3","","554.95","91.85","1421.75","94","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","39.42","73","","2490.03","2490.03","2490.03","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.48","58.3","","750.00","750.00","750.00","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.62","53","","1192.50","120.84","4149.90","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","45.90","85","","750.00","75.00","750.00","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","54.00","100","","657.00","121.50","1971.00","14","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","54.00","100","","75.00","75.00","75.00","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","54.00","100","","366.00","144.00","1971.00","45","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","39.42","73","","667.50","667.50","667.50","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.00","44.45","","123.77","123.77","123.77","1 through 10","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.00","40.50","WELLPOINT [1015]","HB CH WELLPOINT","42.07","77.91","","483.51","229.32","1316.08","96","24","54","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.00","40.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","32.02","59.3","","439.50","225.34","1872.27","197","27","42.36","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM CHARLOTTE FIXATION TROCAR TIP SINGLE END","SUP-ITM-10017401","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.00","40.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.36","78.45","","385.32","55.36","1815.62","58","27","42.36","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.32","86.49","AETNA [1001]","HB CH AETNA HMO / PPO","67.23","58.3","","161.55","62.25","161.55","1 through 10","51.26","115.32","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.32","86.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","61.12","53","","52.44","22.90","505.57","1 through 10","51.26","115.32","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.32","86.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","98.02","85","","68.52","68.52","68.52","1 through 10","51.26","115.32","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.32","86.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","115.32","100","","62.20","62.19","81.17","14","51.26","115.32","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.32","86.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","115.32","100","","43.22","31.95","953.91","1 through 10","51.26","115.32","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","both","","","115.32","86.49","WELLPOINT [1015]","HB CH WELLPOINT","89.85","77.91","","63.92","25.16","245.73","18","51.26","115.32","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SMOOTH DOUBLE SHARP TIP 2 TIPHALLU FIX STAINLESS STEEL LOWER EXTREMITY","SUP-ITM-10048260","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","115.32","86.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.47","78.45","","97.25","24.56","207.80","18","57.66","90.47","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","AETNA [1001]","HB CH AETNA HMO / PPO","70.08","58.3","","554.95","91.85","1421.75","94","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.75","73","","2490.03","2490.03","2490.03","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","70.08","58.3","","750.00","750.00","750.00","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.71","53","","1192.50","120.84","4149.90","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.18","85","","750.00","75.00","750.00","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.21","100","","657.00","121.50","1971.00","14","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.21","100","","75.00","75.00","75.00","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.21","100","","366.00","144.00","1971.00","45","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.75","73","","667.50","667.50","667.50","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.43","44.45","","123.77","123.77","123.77","1 through 10","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.21","90.16","WELLPOINT [1015]","HB CH WELLPOINT","93.66","77.91","","483.51","229.32","1316.08","96","53.43","120.21","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.21","90.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.28","59.3","","439.50","225.34","1872.27","197","60.11","94.3","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 115116ND","SUP-ITM-10043007","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.21","90.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.30","78.45","","385.32","55.36","1815.62","58","60.11","94.3","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","AETNA [1001]","HB CH AETNA HMO / PPO","26.22","58.3","","554.95","91.85","1421.75","94","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","32.83","73","","2490.03","2490.03","2490.03","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","26.22","58.3","","750.00","750.00","750.00","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","23.83","53","","1192.50","120.84","4149.90","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","38.22","85","","750.00","75.00","750.00","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","44.97","100","","657.00","121.50","1971.00","14","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","44.97","100","","75.00","75.00","75.00","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","44.97","100","","366.00","144.00","1971.00","45","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","32.83","73","","667.50","667.50","667.50","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","19.99","44.45","","123.77","123.77","123.77","1 through 10","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","both","","","44.97","33.73","WELLPOINT [1015]","HB CH WELLPOINT","35.04","77.91","","483.51","229.32","1316.08","96","19.99","44.97","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","44.97","33.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.67","59.3","","439.50","225.34","1872.27","197","22.49","35.28","percent of total billed charges",""
"K-WIRE BONE 1.6X150MM SS 390164","SUP-ITM-10090993","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","44.97","33.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.28","78.45","","385.32","55.36","1815.62","58","22.49","35.28","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","554.95","91.85","1421.75","94","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","2490.03","2490.03","2490.03","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","750.00","750.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","1192.50","120.84","4149.90","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","224.40","85","","750.00","75.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","264.00","100","","657.00","121.50","1971.00","14","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","264.00","100","","75.00","75.00","75.00","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","264.00","100","","366.00","144.00","1971.00","45","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","667.50","667.50","667.50","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","123.77","123.77","123.77","1 through 10","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","483.51","229.32","1316.08","96","117.35","264","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","439.50","225.34","1872.27","197","132","207.11","percent of total billed charges",""
"K-WIRE BONE 1.6X200MM SINGLE ENDED TROCAR TIP","SUP-ITM-10237995","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","385.32","55.36","1815.62","58","132","207.11","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","AETNA [1001]","HB CH AETNA HMO / PPO","10.23","58.3","","554.95","91.85","1421.75","94","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","12.80","73","","2490.03","2490.03","2490.03","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","10.23","58.3","","750.00","750.00","750.00","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","9.30","53","","1192.50","120.84","4149.90","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","14.91","85","","750.00","75.00","750.00","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","17.54","100","","657.00","121.50","1971.00","14","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","17.54","100","","75.00","75.00","75.00","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","17.54","100","","366.00","144.00","1971.00","45","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","12.80","73","","667.50","667.50","667.50","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.80","44.45","","123.77","123.77","123.77","1 through 10","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.54","13.15","WELLPOINT [1015]","HB CH WELLPOINT","13.67","77.91","","483.51","229.32","1316.08","96","7.8","17.54","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.54","13.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","10.40","59.3","","439.50","225.34","1872.27","197","8.77","13.76","percent of total billed charges",""
"K-WIRE BONE 1.8X150MM SS TROCAR POINT PK/10EA","SUP-ITM-10078926","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.54","13.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","13.76","78.45","","385.32","55.36","1815.62","58","8.77","13.76","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","AETNA [1001]","HB CH AETNA HMO / PPO","80.42","58.3","","554.95","91.85","1421.75","94","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","100.70","73","","2490.03","2490.03","2490.03","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","80.42","58.3","","750.00","750.00","750.00","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","73.11","53","","1192.50","120.84","4149.90","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","117.25","85","","750.00","75.00","750.00","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","137.94","100","","657.00","121.50","1971.00","14","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","137.94","100","","75.00","75.00","75.00","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","137.94","100","","366.00","144.00","1971.00","45","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","100.70","73","","667.50","667.50","667.50","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.31","44.45","","123.77","123.77","123.77","1 through 10","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","both","","","137.94","103.45","WELLPOINT [1015]","HB CH WELLPOINT","107.47","77.91","","483.51","229.32","1316.08","96","61.31","137.94","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.94","103.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.80","59.3","","439.50","225.34","1872.27","197","68.97","108.21","percent of total billed charges",""
"K-WIRE BONE 1.8X200MM SS TROCAR POINT SINGLE PK/5EA","SUP-ITM-10230184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","137.94","103.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.21","78.45","","385.32","55.36","1815.62","58","68.97","108.21","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","AETNA [1001]","HB CH AETNA HMO / PPO","45.47","58.3","","554.95","91.85","1421.75","94","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","2490.03","2490.03","2490.03","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.47","58.3","","750.00","750.00","750.00","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.34","53","","1192.50","120.84","4149.90","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","66.30","85","","750.00","75.00","750.00","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","78.00","100","","657.00","121.50","1971.00","14","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","78.00","100","","75.00","75.00","75.00","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","78.00","100","","366.00","144.00","1971.00","45","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","667.50","667.50","667.50","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","123.77","123.77","123.77","1 through 10","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","WELLPOINT [1015]","HB CH WELLPOINT","60.77","77.91","","483.51","229.32","1316.08","96","34.67","78","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.25","59.3","","439.50","225.34","1872.27","197","39","61.19","percent of total billed charges",""
"K-WIRE BONE 127 1.5MM SS STANDARD TIP","SUP-ITM-10126428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","385.32","55.36","1815.62","58","39","61.19","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","AETNA [1001]","HB CH AETNA HMO / PPO","60.08","58.3","","554.95","91.85","1421.75","94","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","75.23","73","","2490.03","2490.03","2490.03","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","60.08","58.3","","750.00","750.00","750.00","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","54.62","53","","1192.50","120.84","4149.90","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","87.59","85","","750.00","75.00","750.00","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","103.05","100","","657.00","121.50","1971.00","14","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","103.05","100","","75.00","75.00","75.00","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","103.05","100","","366.00","144.00","1971.00","45","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","75.23","73","","667.50","667.50","667.50","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.81","44.45","","123.77","123.77","123.77","1 through 10","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","WELLPOINT [1015]","HB CH WELLPOINT","80.29","77.91","","483.51","229.32","1316.08","96","45.81","103.05","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.11","59.3","","439.50","225.34","1872.27","197","51.53","80.84","percent of total billed charges",""
"K-WIRE BONE 1X100MM SS","SUP-ITM-10028138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.84","78.45","","385.32","55.36","1815.62","58","51.53","80.84","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","AETNA [1001]","HB CH AETNA HMO / PPO","13.27","58.3","","554.95","91.85","1421.75","94","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","16.61","73","","2490.03","2490.03","2490.03","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","13.27","58.3","","750.00","750.00","750.00","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","12.06","53","","1192.50","120.84","4149.90","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","19.35","85","","750.00","75.00","750.00","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","22.76","100","","657.00","121.50","1971.00","14","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","22.76","100","","75.00","75.00","75.00","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","22.76","100","","366.00","144.00","1971.00","45","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16.61","73","","667.50","667.50","667.50","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10.12","44.45","","123.77","123.77","123.77","1 through 10","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","both","","","22.76","17.07","WELLPOINT [1015]","HB CH WELLPOINT","17.73","77.91","","483.51","229.32","1316.08","96","10.12","22.76","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.50","59.3","","439.50","225.34","1872.27","197","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 1X150MM TITANIUM TROCAR POINT PK/10EA","SUP-ITM-10027377","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","22.76","17.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17.86","78.45","","385.32","55.36","1815.62","58","11.38","17.86","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","AETNA [1001]","HB CH AETNA HMO / PPO","67.74","58.3","","554.95","91.85","1421.75","94","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","84.82","73","","2490.03","2490.03","2490.03","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","67.74","58.3","","750.00","750.00","750.00","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","61.58","53","","1192.50","120.84","4149.90","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","98.76","85","","750.00","75.00","750.00","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","116.19","100","","657.00","121.50","1971.00","14","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","116.19","100","","75.00","75.00","75.00","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","116.19","100","","366.00","144.00","1971.00","45","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","84.82","73","","667.50","667.50","667.50","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.65","44.45","","123.77","123.77","123.77","1 through 10","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","both","","","116.19","87.14","WELLPOINT [1015]","HB CH WELLPOINT","90.52","77.91","","483.51","229.32","1316.08","96","51.65","116.19","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.19","87.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.90","59.3","","439.50","225.34","1872.27","197","58.1","91.15","percent of total billed charges",""
"K-WIRE BONE 2.0X152MM SS","SUP-ITM-10023435","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","116.19","87.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","91.15","78.45","","385.32","55.36","1815.62","58","58.1","91.15","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","161.55","62.25","161.55","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","33.39","53","","52.44","22.90","505.57","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","53.55","85","","68.52","68.52","68.52","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","63.00","100","","62.20","62.19","81.17","14","28","63","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","63.00","100","","43.22","31.95","953.91","1 through 10","28","63","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","both","","","63.00","47.25","WELLPOINT [1015]","HB CH WELLPOINT","49.08","77.91","","63.92","25.16","245.73","18","28","63","percent of total billed charges",""
"K-WIRE BONE 2.0X228MM SMOOTH TIP","SUP-ITM-10021624","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","97.25","24.56","207.80","18","31.5","49.42","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","AETNA [1001]","HB CH AETNA HMO / PPO","183.51","58.3","","554.95","91.85","1421.75","94","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","229.77","73","","2490.03","2490.03","2490.03","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.51","58.3","","750.00","750.00","750.00","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.82","53","","1192.50","120.84","4149.90","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","267.55","85","","750.00","75.00","750.00","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","314.76","100","","657.00","121.50","1971.00","14","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","314.76","100","","75.00","75.00","75.00","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","314.76","100","","366.00","144.00","1971.00","45","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.77","73","","667.50","667.50","667.50","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","139.91","44.45","","123.77","123.77","123.77","1 through 10","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","both","","","314.76","236.07","WELLPOINT [1015]","HB CH WELLPOINT","245.23","77.91","","483.51","229.32","1316.08","96","139.91","314.76","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","314.76","236.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.65","59.3","","439.50","225.34","1872.27","197","157.38","246.93","percent of total billed charges",""
"K-WIRE BONE 2.0X450MM SS SMOOTH","SUP-ITM-10001820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","314.76","236.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","246.93","78.45","","385.32","55.36","1815.62","58","157.38","246.93","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","AETNA [1001]","HB CH AETNA HMO / PPO","125.93","58.3","","554.95","91.85","1421.75","94","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","157.68","73","","2490.03","2490.03","2490.03","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","125.93","58.3","","750.00","750.00","750.00","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","114.48","53","","1192.50","120.84","4149.90","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","183.60","85","","750.00","75.00","750.00","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","216.00","100","","657.00","121.50","1971.00","14","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","216.00","100","","75.00","75.00","75.00","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","216.00","100","","366.00","144.00","1971.00","45","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","157.68","73","","667.50","667.50","667.50","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.01","44.45","","123.77","123.77","123.77","1 through 10","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","both","","","216.00","162.00","WELLPOINT [1015]","HB CH WELLPOINT","168.29","77.91","","483.51","229.32","1316.08","96","96.01","216","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.00","162.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","128.09","59.3","","439.50","225.34","1872.27","197","108","169.45","percent of total billed charges",""
"K-WIRE BONE 2.5X200MM LONG BLUNT TIP","SUP-ITM-10090891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","216.00","162.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","169.45","78.45","","385.32","55.36","1815.62","58","108","169.45","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","AETNA [1001]","HB CH AETNA HMO / PPO","143.02","58.3","","554.95","91.85","1421.75","94","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","179.08","73","","2490.03","2490.03","2490.03","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","143.02","58.3","","750.00","750.00","750.00","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","130.01","53","","1192.50","120.84","4149.90","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","208.51","85","","750.00","75.00","750.00","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","245.31","100","","657.00","121.50","1971.00","14","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","245.31","100","","75.00","75.00","75.00","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","245.31","100","","366.00","144.00","1971.00","45","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","179.08","73","","667.50","667.50","667.50","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","109.04","44.45","","123.77","123.77","123.77","1 through 10","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","both","","","245.31","183.98","WELLPOINT [1015]","HB CH WELLPOINT","191.12","77.91","","483.51","229.32","1316.08","96","109.04","245.31","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.31","183.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","145.47","59.3","","439.50","225.34","1872.27","197","122.66","192.45","percent of total billed charges",""
"K-WIRE BONE 2.5X285MM FIXATION SS TROCAR POINT PK/10BX/10EA","SUP-ITM-10004375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","245.31","183.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","192.45","78.45","","385.32","55.36","1815.62","58","122.66","192.45","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","AETNA [1001]","HB CH AETNA HMO / PPO","51.49","58.3","","554.95","91.85","1421.75","94","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","64.47","73","","2490.03","2490.03","2490.03","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","51.49","58.3","","750.00","750.00","750.00","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.81","53","","1192.50","120.84","4149.90","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","75.07","85","","750.00","75.00","750.00","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","88.32","100","","657.00","121.50","1971.00","14","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","88.32","100","","75.00","75.00","75.00","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","88.32","100","","366.00","144.00","1971.00","45","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","64.47","73","","667.50","667.50","667.50","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.26","44.45","","123.77","123.77","123.77","1 through 10","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.32","66.24","WELLPOINT [1015]","HB CH WELLPOINT","68.81","77.91","","483.51","229.32","1316.08","96","39.26","88.32","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.32","66.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.37","59.3","","439.50","225.34","1872.27","197","44.16","69.29","percent of total billed charges",""
"K-WIRE BONE 2.8X300MM FIXATION SS TROCAR POINT THREADED","SUP-ITM-10003861","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.32","66.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.29","78.45","","385.32","55.36","1815.62","58","44.16","69.29","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","AETNA [1001]","HB CH AETNA HMO / PPO","53.71","58.3","","554.95","91.85","1421.75","94","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","67.25","73","","2490.03","2490.03","2490.03","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","53.71","58.3","","750.00","750.00","750.00","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","48.83","53","","1192.50","120.84","4149.90","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","78.31","85","","750.00","75.00","750.00","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","92.13","100","","657.00","121.50","1971.00","14","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","92.13","100","","75.00","75.00","75.00","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","92.13","100","","366.00","144.00","1971.00","45","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","67.25","73","","667.50","667.50","667.50","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.95","44.45","","123.77","123.77","123.77","1 through 10","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","both","","","92.13","69.10","WELLPOINT [1015]","HB CH WELLPOINT","71.78","77.91","","483.51","229.32","1316.08","96","40.95","92.13","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","92.13","69.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.63","59.3","","439.50","225.34","1872.27","197","46.07","72.28","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS DRILL TIP","SUP-ITM-10124858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","92.13","69.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.28","78.45","","385.32","55.36","1815.62","58","46.07","72.28","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","AETNA [1001]","HB CH AETNA HMO / PPO","11.52","58.3","","554.95","91.85","1421.75","94","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","14.42","73","","2490.03","2490.03","2490.03","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","11.52","58.3","","750.00","750.00","750.00","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","10.47","53","","1192.50","120.84","4149.90","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","16.80","85","","750.00","75.00","750.00","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","19.76","100","","657.00","121.50","1971.00","14","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","19.76","100","","75.00","75.00","75.00","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19.76","100","","366.00","144.00","1971.00","45","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","14.42","73","","667.50","667.50","667.50","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.78","44.45","","123.77","123.77","123.77","1 through 10","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.76","14.82","WELLPOINT [1015]","HB CH WELLPOINT","15.40","77.91","","483.51","229.32","1316.08","96","8.78","19.76","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.76","14.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","11.72","59.3","","439.50","225.34","1872.27","197","9.88","15.5","percent of total billed charges",""
"K-WIRE BONE 2X150MM FIXATION SS TROCAR POINT PK/10EA","SUP-ITM-10001632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.76","14.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","15.50","78.45","","385.32","55.36","1815.62","58","9.88","15.5","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","554.95","91.85","1421.75","94","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","2490.03","2490.03","2490.03","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","134.67","58.3","","750.00","750.00","750.00","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","122.43","53","","1192.50","120.84","4149.90","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","196.35","85","","750.00","75.00","750.00","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","231.00","100","","657.00","121.50","1971.00","14","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","231.00","100","","75.00","75.00","75.00","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","231.00","100","","366.00","144.00","1971.00","45","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","667.50","667.50","667.50","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.68","44.45","","123.77","123.77","123.77","1 through 10","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","WELLPOINT [1015]","HB CH WELLPOINT","179.97","77.91","","483.51","229.32","1316.08","96","102.68","231","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","439.50","225.34","1872.27","197","115.5","181.22","percent of total billed charges",""
"K-WIRE BONE 2X152MM STANDARD DIAMOND TIP WITH STOP","SUP-ITM-10318364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","385.32","55.36","1815.62","58","115.5","181.22","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","AETNA [1001]","HB CH AETNA HMO / PPO","43.10","58.3","","554.95","91.85","1421.75","94","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","53.96","73","","2490.03","2490.03","2490.03","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.10","58.3","","750.00","750.00","750.00","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.18","53","","1192.50","120.84","4149.90","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","62.83","85","","750.00","75.00","750.00","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","73.92","100","","657.00","121.50","1971.00","14","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","73.92","100","","75.00","75.00","75.00","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","73.92","100","","366.00","144.00","1971.00","45","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","53.96","73","","667.50","667.50","667.50","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.86","44.45","","123.77","123.77","123.77","1 through 10","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","both","","","73.92","55.44","WELLPOINT [1015]","HB CH WELLPOINT","57.59","77.91","","483.51","229.32","1316.08","96","32.86","73.92","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.92","55.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.83","59.3","","439.50","225.34","1872.27","197","36.96","57.99","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS SPADE POINT DUAL END NONTHREADED","SUP-ITM-10013135","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","73.92","55.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.99","78.45","","385.32","55.36","1815.62","58","36.96","57.99","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","AETNA [1001]","HB CH AETNA HMO / PPO","45.33","58.3","","554.95","91.85","1421.75","94","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","56.76","73","","2490.03","2490.03","2490.03","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.33","58.3","","750.00","750.00","750.00","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.21","53","","1192.50","120.84","4149.90","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","66.10","85","","750.00","75.00","750.00","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","77.76","100","","657.00","121.50","1971.00","14","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","77.76","100","","75.00","75.00","75.00","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","77.76","100","","366.00","144.00","1971.00","45","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.76","73","","667.50","667.50","667.50","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.56","44.45","","123.77","123.77","123.77","1 through 10","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.76","58.32","WELLPOINT [1015]","HB CH WELLPOINT","60.58","77.91","","483.51","229.32","1316.08","96","34.56","77.76","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.76","58.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.11","59.3","","439.50","225.34","1872.27","197","38.88","61","percent of total billed charges",""
"K-WIRE BONE 2X230MM FIXATION SS THREADED","SUP-ITM-10004541","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.76","58.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.00","78.45","","385.32","55.36","1815.62","58","38.88","61","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","AETNA [1001]","HB CH AETNA HMO / PPO","43.36","58.3","","554.95","91.85","1421.75","94","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.29","73","","2490.03","2490.03","2490.03","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.36","58.3","","750.00","750.00","750.00","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.42","53","","1192.50","120.84","4149.90","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.21","85","","750.00","75.00","750.00","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","74.37","100","","657.00","121.50","1971.00","14","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","74.37","100","","75.00","75.00","75.00","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","74.37","100","","366.00","144.00","1971.00","45","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.29","73","","667.50","667.50","667.50","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.06","44.45","","123.77","123.77","123.77","1 through 10","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","both","","","74.37","55.78","WELLPOINT [1015]","HB CH WELLPOINT","57.94","77.91","","483.51","229.32","1316.08","96","33.06","74.37","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","74.37","55.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.10","59.3","","439.50","225.34","1872.27","197","37.19","58.34","percent of total billed charges",""
"K-WIRE BONE 2X240MM FIXATION SS TROCAR POINT PK/3EA","SUP-ITM-10027388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","74.37","55.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.34","78.45","","385.32","55.36","1815.62","58","37.19","58.34","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","AETNA [1001]","HB CH AETNA HMO / PPO","53.06","58.3","","554.95","91.85","1421.75","94","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","66.44","73","","2490.03","2490.03","2490.03","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","53.06","58.3","","750.00","750.00","750.00","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","48.24","53","","1192.50","120.84","4149.90","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","77.37","85","","750.00","75.00","750.00","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","91.02","100","","657.00","121.50","1971.00","14","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","91.02","100","","75.00","75.00","75.00","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","91.02","100","","366.00","144.00","1971.00","45","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","66.44","73","","667.50","667.50","667.50","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.46","44.45","","123.77","123.77","123.77","1 through 10","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","both","","","91.02","68.26","WELLPOINT [1015]","HB CH WELLPOINT","70.91","77.91","","483.51","229.32","1316.08","96","40.46","91.02","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.02","68.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","53.97","59.3","","439.50","225.34","1872.27","197","45.51","71.41","percent of total billed charges",""
"K-WIRE BONE 2X280MM FIXATION SS SPADE POINT THREADED","SUP-ITM-10007375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","91.02","68.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","71.41","78.45","","385.32","55.36","1815.62","58","45.51","71.41","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","AETNA [1001]","HB CH AETNA HMO / PPO","101.60","58.3","","554.95","91.85","1421.75","94","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","127.22","73","","2490.03","2490.03","2490.03","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","101.60","58.3","","750.00","750.00","750.00","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","92.36","53","","1192.50","120.84","4149.90","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","148.13","85","","750.00","75.00","750.00","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","174.27","100","","657.00","121.50","1971.00","14","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","174.27","100","","75.00","75.00","75.00","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","174.27","100","","366.00","144.00","1971.00","45","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","127.22","73","","667.50","667.50","667.50","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.46","44.45","","123.77","123.77","123.77","1 through 10","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","both","","","174.27","130.70","WELLPOINT [1015]","HB CH WELLPOINT","135.77","77.91","","483.51","229.32","1316.08","96","77.46","174.27","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.27","130.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.34","59.3","","439.50","225.34","1872.27","197","87.14","136.71","percent of total billed charges",""
"K-WIRE BONE 2X350MM 13 3/4IN LONG SS SPADE POINT FLAT NON THREADED","SUP-ITM-10004044","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","174.27","130.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.71","78.45","","385.32","55.36","1815.62","58","87.14","136.71","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","AETNA [1001]","HB CH AETNA HMO / PPO","313.21","58.3","","554.95","91.85","1421.75","94","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","392.19","73","","2490.03","2490.03","2490.03","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","313.21","58.3","","750.00","750.00","750.00","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","284.74","53","","1192.50","120.84","4149.90","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","456.65","85","","750.00","75.00","750.00","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","537.24","100","","657.00","121.50","1971.00","14","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","537.24","100","","75.00","75.00","75.00","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","537.24","100","","366.00","144.00","1971.00","45","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","392.19","73","","667.50","667.50","667.50","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.80","44.45","","123.77","123.77","123.77","1 through 10","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.24","402.93","WELLPOINT [1015]","HB CH WELLPOINT","418.56","77.91","","483.51","229.32","1316.08","96","238.8","537.24","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.24","402.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","318.58","59.3","","439.50","225.34","1872.27","197","268.62","421.46","percent of total billed charges",""
"K-WIRE BONE 2X400MM FIXATION SS SPADE POINT","SUP-ITM-10004051","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.24","402.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","421.46","78.45","","385.32","55.36","1815.62","58","268.62","421.46","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","AETNA [1001]","HB CH AETNA HMO / PPO","348.28","58.3","","554.95","91.85","1421.75","94","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","436.09","73","","2490.03","2490.03","2490.03","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","348.28","58.3","","750.00","750.00","750.00","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","316.62","53","","1192.50","120.84","4149.90","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","507.78","85","","750.00","75.00","750.00","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","597.39","100","","657.00","121.50","1971.00","14","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","597.39","100","","75.00","75.00","75.00","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","597.39","100","","366.00","144.00","1971.00","45","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","436.09","73","","667.50","667.50","667.50","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","265.54","44.45","","123.77","123.77","123.77","1 through 10","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","both","","","597.39","448.04","WELLPOINT [1015]","HB CH WELLPOINT","465.43","77.91","","483.51","229.32","1316.08","96","265.54","597.39","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","597.39","448.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","354.25","59.3","","439.50","225.34","1872.27","197","298.7","468.65","percent of total billed charges",""
"K-WIRE BONE 3X285MM T2 SS SMOOTH BALL TIP BX/1EA","SUP-ITM-10016986","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","597.39","448.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","468.65","78.45","","385.32","55.36","1815.62","58","298.7","468.65","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","AETNA [1001]","HB CH AETNA HMO / PPO","5.74","58.3","","554.95","91.85","1421.75","94","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7.19","73","","2490.03","2490.03","2490.03","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.74","58.3","","750.00","750.00","750.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5.22","53","","1192.50","120.84","4149.90","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8.37","85","","750.00","75.00","750.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9.85","100","","657.00","121.50","1971.00","14","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9.85","100","","75.00","75.00","75.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9.85","100","","366.00","144.00","1971.00","45","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7.19","73","","667.50","667.50","667.50","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4.38","44.45","","123.77","123.77","123.77","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","WELLPOINT [1015]","HB CH WELLPOINT","7.67","77.91","","483.51","229.32","1316.08","96","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9.85","7.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","5.84","59.3","","439.50","225.34","1872.27","197","4.93","7.73","percent of total billed charges",""
"K-WIRE BONE 4IN K 0.035 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10041923","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9.85","7.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7.73","78.45","","385.32","55.36","1815.62","58","4.93","7.73","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","554.95","91.85","1421.75","94","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","2490.03","2490.03","2490.03","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","750.00","750.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","1192.50","120.84","4149.90","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","750.00","75.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","657.00","121.50","1971.00","14","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","75.00","75.00","75.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","366.00","144.00","1971.00","45","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","667.50","667.50","667.50","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","123.77","123.77","123.77","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","483.51","229.32","1316.08","96","53.34","120","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","439.50","225.34","1872.27","197","60","94.14","percent of total billed charges",""
"K-WIRE BONE 500MM FIXATION LUXOR SS CANNULATED SHARP TIP","SUP-ITM-10026439","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","385.32","55.36","1815.62","58","60","94.14","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.84","58.3","","554.95","91.85","1421.75","94","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","2490.03","2490.03","2490.03","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.84","58.3","","750.00","750.00","750.00","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.58","53","","1192.50","120.84","4149.90","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","68.29","85","","750.00","75.00","750.00","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","80.34","100","","657.00","121.50","1971.00","14","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","80.34","100","","75.00","75.00","75.00","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","80.34","100","","366.00","144.00","1971.00","45","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","667.50","667.50","667.50","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","123.77","123.77","123.77","1 through 10","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","WELLPOINT [1015]","HB CH WELLPOINT","62.59","77.91","","483.51","229.32","1316.08","96","35.71","80.34","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.64","59.3","","439.50","225.34","1872.27","197","40.17","63.03","percent of total billed charges",""
"K-WIRE BONE 6.0INX1.6MM SM FIXATION TITANIUM FRAGMENT","SUP-ITM-10021696","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","385.32","55.36","1815.62","58","40.17","63.03","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","AETNA [1001]","HB CH AETNA HMO / PPO","5.74","58.3","","554.95","91.85","1421.75","94","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7.19","73","","2490.03","2490.03","2490.03","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.74","58.3","","750.00","750.00","750.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5.22","53","","1192.50","120.84","4149.90","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8.37","85","","750.00","75.00","750.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9.85","100","","657.00","121.50","1971.00","14","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9.85","100","","75.00","75.00","75.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9.85","100","","366.00","144.00","1971.00","45","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7.19","73","","667.50","667.50","667.50","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4.38","44.45","","123.77","123.77","123.77","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","WELLPOINT [1015]","HB CH WELLPOINT","7.67","77.91","","483.51","229.32","1316.08","96","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9.85","7.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","5.84","59.3","","439.50","225.34","1872.27","197","4.93","7.73","percent of total billed charges",""
"K-WIRE BONE 6IN K .028 SS SMOOTH TROCAR POINT DUAL PK/6EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10137797","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9.85","7.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7.73","78.45","","385.32","55.36","1815.62","58","4.93","7.73","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","AETNA [1001]","HB CH AETNA HMO / PPO","5.74","58.3","","554.95","91.85","1421.75","94","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7.19","73","","2490.03","2490.03","2490.03","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.74","58.3","","750.00","750.00","750.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5.22","53","","1192.50","120.84","4149.90","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8.37","85","","750.00","75.00","750.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9.85","100","","657.00","121.50","1971.00","14","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9.85","100","","75.00","75.00","75.00","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9.85","100","","366.00","144.00","1971.00","45","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7.19","73","","667.50","667.50","667.50","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4.38","44.45","","123.77","123.77","123.77","1 through 10","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","both","","","9.85","7.39","WELLPOINT [1015]","HB CH WELLPOINT","7.67","77.91","","483.51","229.32","1316.08","96","4.38","9.85","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9.85","7.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","5.84","59.3","","439.50","225.34","1872.27","197","4.93","7.73","percent of total billed charges",""
"K-WIRE BONE 9 .045 SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10126580","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9.85","7.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7.73","78.45","","385.32","55.36","1815.62","58","4.93","7.73","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","554.95","91.85","1421.75","94","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","2490.03","2490.03","2490.03","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","750.00","750.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","1192.50","120.84","4149.90","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","750.00","75.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","657.00","121.50","1971.00","14","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","75.00","75.00","75.00","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","366.00","144.00","1971.00","45","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","667.50","667.50","667.50","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","123.77","123.77","123.77","1 through 10","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","483.51","229.32","1316.08","96","53.34","120","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","439.50","225.34","1872.27","197","60","94.14","percent of total billed charges",""
"K-WIRE BONE PRECEPT NITINOL BEVEL BLUNT TIP","SUP-ITM-10094561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","385.32","55.36","1815.62","58","60","94.14","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","AETNA [1001]","HB CH AETNA HMO / PPO","36.03","58.3","","554.95","91.85","1421.75","94","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","45.11","73","","2490.03","2490.03","2490.03","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","36.03","58.3","","750.00","750.00","750.00","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.75","53","","1192.50","120.84","4149.90","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","52.53","85","","750.00","75.00","750.00","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","61.80","100","","657.00","121.50","1971.00","14","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","61.80","100","","75.00","75.00","75.00","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","61.80","100","","366.00","144.00","1971.00","45","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","45.11","73","","667.50","667.50","667.50","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.47","44.45","","123.77","123.77","123.77","1 through 10","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","WELLPOINT [1015]","HB CH WELLPOINT","48.15","77.91","","483.51","229.32","1316.08","96","27.47","61.8","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.80","46.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.65","59.3","","439.50","225.34","1872.27","197","30.9","48.48","percent of total billed charges",""
"K-WIRE COBALT 1.1X105MM CHROME","SUP-ITM-10171749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.80","46.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.48","78.45","","385.32","55.36","1815.62","58","30.9","48.48","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","AETNA [1001]","HB CH AETNA HMO / PPO","4.06","58.3","","554.95","91.85","1421.75","94","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5.08","73","","2490.03","2490.03","2490.03","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4.06","58.3","","750.00","750.00","750.00","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3.69","53","","1192.50","120.84","4149.90","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5.92","85","","750.00","75.00","750.00","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6.96","100","","657.00","121.50","1971.00","14","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6.96","100","","75.00","75.00","75.00","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6.96","100","","366.00","144.00","1971.00","45","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5.08","73","","667.50","667.50","667.50","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.09","44.45","","123.77","123.77","123.77","1 through 10","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","both","","","6.96","5.22","WELLPOINT [1015]","HB CH WELLPOINT","5.42","77.91","","483.51","229.32","1316.08","96","3.09","6.96","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6.96","5.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","4.13","59.3","","439.50","225.34","1872.27","197","3.48","5.46","percent of total billed charges",""
"K-WIRE GUIDE 9IN 0.062 BONE SS SMOOTH TROCAR POINT DUAL PK/6EA","SUP-ITM-10148258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6.96","5.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5.46","78.45","","385.32","55.36","1815.62","58","3.48","5.46","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","AETNA [1001]","HB CH AETNA HMO / PPO","40.40","58.3","","554.95","91.85","1421.75","94","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","50.59","73","","2490.03","2490.03","2490.03","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","40.40","58.3","","750.00","750.00","750.00","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","36.73","53","","1192.50","120.84","4149.90","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","58.91","85","","750.00","75.00","750.00","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","69.30","100","","657.00","121.50","1971.00","14","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","69.30","100","","75.00","75.00","75.00","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","69.30","100","","366.00","144.00","1971.00","45","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","50.59","73","","667.50","667.50","667.50","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.80","44.45","","123.77","123.77","123.77","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","WELLPOINT [1015]","HB CH WELLPOINT","53.99","77.91","","483.51","229.32","1316.08","96","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","41.09","59.3","","439.50","225.34","1872.27","197","34.65","54.37","percent of total billed charges",""
"K-WIRE SINGLE ENDED 1.6X150MM TROCAR TIP SMOOTH","SUP-ITM-10241237","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","54.37","78.45","","385.32","55.36","1815.62","58","34.65","54.37","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","AETNA [1001]","HB CH AETNA HMO / PPO","40.40","58.3","","554.95","91.85","1421.75","94","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","50.59","73","","2490.03","2490.03","2490.03","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","40.40","58.3","","750.00","750.00","750.00","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","36.73","53","","1192.50","120.84","4149.90","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","58.91","85","","750.00","75.00","750.00","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","69.30","100","","657.00","121.50","1971.00","14","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","69.30","100","","75.00","75.00","75.00","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","69.30","100","","366.00","144.00","1971.00","45","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","50.59","73","","667.50","667.50","667.50","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","30.80","44.45","","123.77","123.77","123.77","1 through 10","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","both","","","69.30","51.97","WELLPOINT [1015]","HB CH WELLPOINT","53.99","77.91","","483.51","229.32","1316.08","96","30.8","69.3","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","41.09","59.3","","439.50","225.34","1872.27","197","34.65","54.37","percent of total billed charges",""
"K-WIRE SINGLE ENDED 2.5X150MM TROCAR TIP SMOOTH","SUP-ITM-10241231","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","69.30","51.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","54.37","78.45","","385.32","55.36","1815.62","58","34.65","54.37","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","AETNA [1001]","HB CH AETNA HMO / PPO","48.97","58.3","","554.95","91.85","1421.75","94","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","2490.03","2490.03","2490.03","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","48.97","58.3","","750.00","750.00","750.00","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.52","53","","1192.50","120.84","4149.90","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","71.40","85","","750.00","75.00","750.00","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","84.00","100","","657.00","121.50","1971.00","14","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","84.00","100","","75.00","75.00","75.00","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","84.00","100","","366.00","144.00","1971.00","45","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","667.50","667.50","667.50","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.34","44.45","","123.77","123.77","123.77","1 through 10","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB CH WELLPOINT","65.44","77.91","","483.51","229.32","1316.08","96","37.34","84","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.81","59.3","","439.50","225.34","1872.27","197","42","65.9","percent of total billed charges",""
"K-WIRE STANDARD 1.5X127MM TIP TITANIUM","SUP-ITM-10198208","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.90","78.45","","385.32","55.36","1815.62","58","42","65.9","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","AETNA [1001]","HB CH AETNA HMO / PPO","57.72","58.3","","554.95","91.85","1421.75","94","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","72.27","73","","2490.03","2490.03","2490.03","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","57.72","58.3","","750.00","750.00","750.00","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","52.47","53","","1192.50","120.84","4149.90","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","84.15","85","","750.00","75.00","750.00","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","99.00","100","","657.00","121.50","1971.00","14","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","99.00","100","","75.00","75.00","75.00","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","99.00","100","","366.00","144.00","1971.00","45","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","72.27","73","","667.50","667.50","667.50","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.01","44.45","","123.77","123.77","123.77","1 through 10","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.00","74.25","WELLPOINT [1015]","HB CH WELLPOINT","77.13","77.91","","483.51","229.32","1316.08","96","44.01","99","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.00","74.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.71","59.3","","439.50","225.34","1872.27","197","49.5","77.67","percent of total billed charges",""
"K-WIRE STANDARD 2X152MM TIP TITANIUM","SUP-ITM-10198206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.67","78.45","","385.32","55.36","1815.62","58","49.5","77.67","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","AETNA [1001]","HB CH AETNA HMO / PPO","7.78","58.3","","554.95","91.85","1421.75","94","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9.75","73","","2490.03","2490.03","2490.03","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7.78","58.3","","750.00","750.00","750.00","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.08","53","","1192.50","120.84","4149.90","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","11.35","85","","750.00","75.00","750.00","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","13.35","100","","657.00","121.50","1971.00","14","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","13.35","100","","75.00","75.00","75.00","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","13.35","100","","366.00","144.00","1971.00","45","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9.75","73","","667.50","667.50","667.50","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5.93","44.45","","123.77","123.77","123.77","1 through 10","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","both","","","13.35","10.01","WELLPOINT [1015]","HB CH WELLPOINT","10.40","77.91","","483.51","229.32","1316.08","96","5.93","13.35","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.35","10.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","7.92","59.3","","439.50","225.34","1872.27","197","6.68","10.47","percent of total billed charges",""
"K-WIRE STERILE .045 X 4IN SGL TROCAR","SUP-ITM-10332104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13.35","10.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10.47","78.45","","385.32","55.36","1815.62","58","6.68","10.47","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","AETNA [1001]","HB CH AETNA HMO / PPO","33.58","58.3","","161.55","62.25","161.55","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","30.53","53","","52.44","22.90","505.57","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","48.96","85","","68.52","68.52","68.52","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","57.60","100","","62.20","62.19","81.17","14","25.6","57.6","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","57.60","100","","43.22","31.95","953.91","1 through 10","25.6","57.6","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","both","","","57.60","43.20","WELLPOINT [1015]","HB CH WELLPOINT","44.88","77.91","","63.92","25.16","245.73","18","25.6","57.6","percent of total billed charges",""
"K-WIRE THREADED 1.25MM 150MM SPADE POINT SS PK/1EA","SUP-ITM-10028944","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","57.60","43.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.19","78.45","","97.25","24.56","207.80","18","28.8","45.19","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","AETNA [1001]","HB CH AETNA HMO / PPO","1.85","58.3","","1.92","1.90","3.83","69","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","0.30","","APC Price ($0.30).","0.34","0.34","0.34","1 through 10","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2.31","73","","2.51","1.81","2.51","1 through 10","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1.85","58.3","","1.92","1.67","1.93","27","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1.68","53","","3.56","1.78","14.24","24","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2.31","73","","2.98","2.98","2.98","1 through 10","0.3","2.31","percent of total billed charges",""
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","TRICARE [160005]","HB BWF TRICARE","0.33","","APC Price ($0.35). Final payment is multiplied by 95%.","0.75","0.50","1.50","15","0.3","2.31","other","Tricare OPPS"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","0.30","","APC Price ($0.30). Final payment is multiplied by 98%.","0.50","0.35","0.75","1 through 10","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","both","","","3.17","2.38","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","0.30","","APC Price ($0.30). Final payment is multiplied by 98%.","0.98","0.50","1.48","220","0.3","2.31","other","OPPS APC"
"Ketorolac Inj 15mg","PX-63600137","CDM","J1885","HCPCS","0636","RC","","","","outpatient","","","3.17","2.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","1.65","52.2","","3.51","1.97","3.85","373","0.52","1.65","percent of total billed charges",""
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","52575.19","39431.39","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","18799.86","","Case rate ($18,799.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,216.36, add-ons for qualifying new technology services are included. If operating cost exceeds $62,740.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,854.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,166.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,877.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,293.74. The transfer capital threshold is the transfer adjustment factor * $1,293.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16640.80","16640.80","16640.80","1 through 10","16845.11","18799.86","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","52575.19","39431.39","MEDICARE [2001]","HB BWF MEDICARE","18799.86","","Case rate ($18,799.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,216.36, add-ons for qualifying new technology services are included. If operating cost exceeds $62,740.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,854.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $17,166.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,877.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,293.74. The transfer capital threshold is the transfer adjustment factor * $1,293.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18428.82","18306.25","18428.82","11","16845.11","18799.86","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With Cc","657","MS-DRG","","","","","","","","inpatient","","","52575.19","39431.39","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16845.11","","Case rate ($17,188.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,216.36, add-ons for qualifying new technology services are included. If operating cost exceeds $62,740.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,854.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.5. The base transfer operating payment is the transfer adjustment factor * $15,555.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,877.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,293.74. The transfer capital threshold is the transfer adjustment factor * $1,293.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16547.54","16547.54","16547.54","1 through 10","16845.11","18799.86","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm With McC","656","MS-DRG","","","","","","","","inpatient","","","87436.36","65577.27","MEDICARE [2001]","HB BWF MEDICARE","32456.72","","Case rate ($32,456.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $29,701.75, add-ons for qualifying new technology services are included. If operating cost exceeds $75,225.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,811.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $29,866.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,362.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,250.82. The transfer capital threshold is the transfer adjustment factor * $2,250.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","32646.97","32646.97","32646.97","1 through 10","29060.9","32456.72","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","46636.98","34977.73","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","15066.22","","Case rate ($14,627.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,650.68, add-ons for qualifying new technology services are included. If operating cost exceeds $60,174.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,657.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $13,191.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,311.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.06. The transfer capital threshold is the transfer adjustment factor * $1,097.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","14340.37","14340.37","14340.37","1 through 10","14334.85","15345.7502","other","Inpatient DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","MS-DRG","","","","","","","","inpatient","","","46636.98","34977.73","MEDICARE [2001]","HB BWF MEDICARE","14627.40","","Case rate ($14,627.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,650.68, add-ons for qualifying new technology services are included. If operating cost exceeds $60,174.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,657.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.6. The base transfer operating payment is the transfer adjustment factor * $13,191.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,311.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.06. The transfer capital threshold is the transfer adjustment factor * $1,097.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15206.13","15206.13","15206.13","1 through 10","14334.85","15345.7502","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Neoplasm Without Cc/McC","658","TRIS-DRG","","","","","","","","inpatient","","","51743.66","","TRICARE [160005]","HB BWF TRICARE","13969.85","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($19,298.67). Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $63,120.11 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($20,314.38), capped at $17,661.45. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $63,120.11 is considered a cost outlier and adds an additional payment of 80% of the excess amount. Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","21638.64","21638.64","21638.64","1 through 10","13969.85","13969.85","other","Inpatient DRGs"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","36471.62","27353.71","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12258.58","","Case rate ($12,508.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,528.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,052.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,235.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,189.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.39. The transfer capital threshold is the transfer adjustment factor * $934.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12228.60","12228.60","12228.60","1 through 10","12258.58","13567.25","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","36471.62","27353.71","MEDICARE [2001]","HB BWF MEDICARE","12508.75","","Case rate ($12,508.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,528.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,052.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,235.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,189.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.39. The transfer capital threshold is the transfer adjustment factor * $934.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13575.40","19.89","13575.40","1 through 10","12258.58","13567.25","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","36471.62","27353.71","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","12508.75","","Case rate ($12,508.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,528.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,052.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,235.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,189.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.39. The transfer capital threshold is the transfer adjustment factor * $934.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12230.05","12230.05","12230.05","1 through 10","12258.58","13567.25","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","36471.62","27353.71","MOLINA [1014]","HB BWF MEDICARE","12508.75","","Case rate ($12,508.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,528.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,052.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,235.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,189.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.39. The transfer capital threshold is the transfer adjustment factor * $934.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","24604.45","24604.45","24604.45","1 through 10","12258.58","13567.25","other","Inpatient Replacement Plans DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","36471.62","27353.71","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12258.58","","Case rate ($12,508.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,528.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,052.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,235.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,189.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.39. The transfer capital threshold is the transfer adjustment factor * $934.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13744.76","13744.76","13744.76","1 through 10","12258.58","13567.25","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With Cc","660","MS-DRG","","","","","","","","inpatient","","","36471.62","27353.71","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","12258.58","","Case rate ($12,508.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,528.58, add-ons for qualifying new technology services are included. If operating cost exceeds $58,052.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $11,235.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,189.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.39. The transfer capital threshold is the transfer adjustment factor * $934.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12161.37","12161.37","12161.37","1 through 10","12258.58","13567.25","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm With McC","659","MS-DRG","","","","","","","","inpatient","","","55905.00","41928.75","MEDICARE [2001]","HB BWF MEDICARE","25971.28","","Case rate ($25,971.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,772.62, add-ons for qualifying new technology services are included. If operating cost exceeds $69,296.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,357.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.7. The base transfer operating payment is the transfer adjustment factor * $23,835.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,433.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,796.31. The transfer capital threshold is the transfer adjustment factor * $1,796.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16965.13","0.03","16965.13","1 through 10","23259.8","25971.28","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","26653.71","19990.28","MEDICARE [2001]","HB BWF MEDICARE","10784.14","","Case rate ($10,784.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,888.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,411.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,292.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $9,712.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,548.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.99. The transfer capital threshold is the transfer adjustment factor * $731.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","4095.86","1142.68","10390.29","1 through 10","9675.21","10784.14","other","Inpatient DRG"
"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC","661","MS-DRG","","","","","","","","inpatient","","","26653.71","19990.28","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9675.21","","Case rate ($9,872.66). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,888.19, add-ons for qualifying new technology services are included. If operating cost exceeds $55,411.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,292.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $8,801.42 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,548.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $731.99. The transfer capital threshold is the transfer adjustment factor * $731.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9424.16","9424.16","9424.16","1 through 10","9675.21","10784.14","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","11353.35","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","11239.28","11239.28","11239.28","1 through 10","10802.22","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10802.22","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10685.92","10685.92","10685.92","1 through 10","10802.22","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","ELDER SERVICES [1037]","HB BWF MEDICARE","11022.67","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23396.89","23396.89","23396.89","1 through 10","10802.22","11910.48","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","MEDICARE [2001]","HB BWF MEDICARE","11022.67","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11809.55","2433.09","11888.01","44","10802.22","11910.48","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","11022.67","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10681.83","10681.83","10681.83","1 through 10","10802.22","11910.48","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","MOLINA [1014]","HB BWF MEDICARE","11022.67","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21615.24","21615.24","21615.24","1 through 10","10802.22","11910.48","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","10802.22","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10692.40","10692.40","10714.50","1 through 10","10802.22","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections With McC","689","MS-DRG","","","","","","","","inpatient","","","31143.23","23357.42","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","10802.22","","Case rate ($11,022.67). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,040.08, add-ons for qualifying new technology services are included. If operating cost exceeds $56,563.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,381.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $9,863.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,700.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $820.29. The transfer capital threshold is the transfer adjustment factor * $820.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10652.40","10652.40","10652.41","1 through 10","10802.22","11910.48","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8026.46","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7820.59","7820.59","7820.59","1 through 10","7636.83","8026.46","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7792.68","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7444.54","7444.54","7444.54","1 through 10","7636.83","8026.46","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7636.83","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7416.36","7416.36","7416.36","1 through 10","7636.83","8026.46","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","FALLON HEALTH [1008]","HB BWF MEDICARE","7792.68","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7442.04","7442.04","7442.04","1 through 10","7636.83","8026.46","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","HUMANA [1012]","HB BWF MEDICARE","7792.68","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7430.54","7430.54","7430.54","1 through 10","7636.83","8026.46","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","MEDICARE [2001]","HB BWF MEDICARE","7792.68","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8177.98","0.03","8231.80","51","7636.83","8026.46","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","7792.68","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7382.84","7382.84","7382.84","1 through 10","7636.83","8026.46","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7636.83","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7409.03","7409.03","7433.44","1 through 10","7636.83","8026.46","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7636.83","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8696.38","8696.38","8696.38","1 through 10","7636.83","8026.46","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7636.83","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7438.04","7382.84","16514.28","1 through 10","7636.83","8026.46","other","Inpatient DRG"
"Kidney And Urinary Tract Infections Without McC","690","MS-DRG","","","","","","","","inpatient","","","23310.47","17482.85","WELLSENSE [1003]","HB BWF MEDICARE","7792.68","","Case rate ($7,792.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,804.83, add-ons for qualifying new technology services are included. If operating cost exceeds $53,328.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,133.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,881.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,465.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $572.28. The transfer capital threshold is the transfer adjustment factor * $572.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7403.04","7403.04","7403.04","1 through 10","7636.83","8026.46","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","40865.34","","MASSHEALTH [3001]","HB BWF MEDICAID","13863.75","","Case rate ($15,328.76). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $57,758.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,832.19 and the sum of the standard inlier and any outlier amount.","15325.00","15325.00","15325.00","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,EXTREME","463","DRG","","","","","","","","inpatient","","","40865.34","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","13863.75","","Case rate ($15,328.76). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $57,758.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,832.19 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18981.96","","Standard inlier is a Case rate ($18,981.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,120, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,694.56) for the length of stay and the standard reimbursement.","18119.39","18119.39","18119.39","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20390.42","","Standard inlier is a Case rate ($20,390.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,120, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,894.33) for the length of stay and the standard reimbursement.","20390.41","20390.41","20390.41","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","FALLON HEALTH [1008]","HB BWF MEDICAID","7914.31","","Case rate ($8,750.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,180.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","8748.48","8748.48","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","MASSHEALTH [3001]","HB BWF MEDICAID","7914.31","","Case rate ($8,750.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,180.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","8748.48","8748.48","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8873.39","","Fee schedule rate ($8,873.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7542.44","7542.44","7542.44","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","18913.20","","Fee schedule rate ($18,913.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18913.20","18913.20","18913.20","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7914.31","","Case rate ($8,750.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,180.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","8748.48","8748.48","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MAJOR","463","DRG","","","","","","","","inpatient","","","27662.70","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7914.31","","Case rate ($8,750.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,180.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8748.48","8748.48","8748.48","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","22660.13","","MASSHEALTH [3001]","HB BWF MEDICAID","4162.78","","Case rate ($4,602.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,032.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4877.63","4877.63","4877.63","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","22660.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10215.98","","Fee schedule rate ($10,215.98). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12018.94","12018.94","12018.94","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","22660.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4162.78","","Case rate ($4,602.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,032.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4601.54","4601.54","4601.54","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MINOR","463","DRG","","","","","","","","inpatient","","","22660.13","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4162.78","","Case rate ($4,602.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,032.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4601.54","1707.96","4601.54","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","19227.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14135.35","","Standard inlier is a Case rate ($14,135.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,185, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,006.57) for the length of stay and the standard reimbursement.","14135.34","14135.34","14135.34","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","19227.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15184.18","","Standard inlier is a Case rate ($15,184.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,149, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,155.33) for the length of stay and the standard reimbursement.","15184.18","14493.99","15184.18","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","19227.26","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9905.8398","","Fee schedule rate ($19,104.26). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9905.8398","10614.43","10614.43","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","19227.26","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","21014.49","","Fee schedule rate ($21,014.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13735.94","13735.94","13735.94","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","19227.26","","MASSHEALTH [3001]","HB BWF MEDICAID","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6012.58","6012.58","6012.58","1 through 10","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Infections,MODERATE","463","DRG","","","","","","","","inpatient","","","19227.26","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5227.47","","Case rate ($5,779.86). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,209.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5778.44","2055.21","5778.44","11","4074.1","33976.18","case rate",""
"Kidney And Urinary Tract Neoplasms With Cc","687","MS-DRG","","","","","","","","inpatient","","","17793.67","13345.25","MEDICARE [2001]","HB BWF MEDICARE","10909.21","","Case rate ($10,909.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,002.54, add-ons for qualifying new technology services are included. If operating cost exceeds $55,526.27 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,301.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,829.22 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,663.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.75. The transfer capital threshold is the transfer adjustment factor * $740.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10648.07","10648.07","10648.07","1 through 10","9787.08","10909.21","other","Inpatient DRG"
"Kidney And Urinary Tract Neoplasms With McC","686","MS-DRG","","","","","","","","inpatient","","","26945.05","20208.79","MEDICARE [2001]","HB BWF MEDICARE","16946.74","","Case rate ($16,946.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,973.81, add-ons for qualifying new technology services are included. If operating cost exceeds $62,497.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,835.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $15,332.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,634.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,275.14. The transfer capital threshold is the transfer adjustment factor * $1,275.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19001.56","19001.56","19001.56","1 through 10","16607.81","18514.98","other","Inpatient Replacement Plans DRG"
"Kidney And Urinary Tract Procedures For Malignancy,EXTREME","442","DRG","","","","","","","","inpatient","","","125205.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","105562.47","","Standard inlier is a Case rate ($105,562.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $112,463, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,984.15) for the length of stay and the standard reimbursement.","105562.47","105562.47","105562.47","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MAJOR","442","DRG","","","","","","","","inpatient","","","68820.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","25654.7376","","Fee schedule rate ($55,618.49). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25654.7376","55618.48","55618.48","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","44685.03","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","33247.24","","Standard inlier is a Case rate ($33,247.24). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $45,755, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,719.58) for the length of stay and the standard reimbursement.","33247.24","33247.24","33247.24","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","44685.03","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","35714.17","","Standard inlier is a Case rate ($35,714.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $45,755, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,069.48) for the length of stay and the standard reimbursement.","35714.17","35714.17","35714.17","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MINOR","442","DRG","","","","","","","","inpatient","","","44685.03","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","17382.64","","Fee schedule rate ($17,382.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16555.60","16555.60","16555.60","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","37129.38","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","41473.42","","Standard inlier is a Case rate ($41,473.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $51,256, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,886.98) for the length of stay and the standard reimbursement.","41473.41","41473.41","41473.41","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Malignancy,MODERATE","442","DRG","","","","","","","","inpatient","","","37129.38","","MASSHEALTH [3001]","HB BWF MEDICAID","12324.99","","Case rate ($13,627.39). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,057.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","38780.28","38780.28","38780.28","1 through 10","10746.24","229241.94","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","43534.03","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","30062.89","","Standard inlier is a Case rate ($30,062.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $40,359, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,267.30) for the length of stay and the standard reimbursement.","30062.89","30062.89","30062.89","1 through 10","7542.44","77756.41","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","43534.03","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","22720.6887","","Fee schedule rate ($22,720.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22720.6887","22720.68","22720.68","1 through 10","7542.44","77756.41","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","43534.03","","MASSHEALTH [3001]","HB BWF MEDICAID","10216.18","","Case rate ($11,295.74). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,725.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11292.97","11292.97","11292.97","1 through 10","7542.44","77756.41","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MINOR","443","DRG","","","","","","","","inpatient","","","43534.03","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10216.18","","Case rate ($11,295.74). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,725.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","28480.59","28480.59","28480.59","1 through 10","7542.44","77756.41","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","47635.39","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12965.53","","Fee schedule rate ($12,965.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12965.53","12965.53","12965.53","1 through 10","7542.44","77756.41","case rate",""
"Kidney And Urinary Tract Procedures For Non-Malignancy,MODERATE","443","DRG","","","","","","","","inpatient","","","47635.39","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11195.19","","Case rate ($12,378.20). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,808.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12375.17","12375.17","12375.17","1 through 10","7542.44","77756.41","case rate",""
"Kidney And Urinary Tract Signs And Symptoms With McC","695","MS-DRG","","","","","","","","inpatient","","","7706.92","5780.19","MEDICARE [2001]","HB BWF MEDICARE","11877.64","","Case rate ($11,877.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,887.90, add-ons for qualifying new technology services are included. If operating cost exceeds $56,411.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,369.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,729.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,548.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $808.62. The transfer capital threshold is the transfer adjustment factor * $808.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11465.41","11465.41","11465.41","1 through 10","10653.33","11877.64","other","Inpatient DRG"
"Kidney And Urinary Tract Signs And Symptoms Without McC","696","MS-DRG","","","","","","","","inpatient","","","14010.86","10508.14","MEDICARE [2001]","HB BWF MEDICARE","7289.73","","Case rate ($7,289.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,693.53, add-ons for qualifying new technology services are included. If operating cost exceeds $52,217.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,047.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $6,463.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,354.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.10. The transfer capital threshold is the transfer adjustment factor * $487.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7083.68","7083.68","7130.05","1 through 10","6549.53","7289.73","other","Inpatient DRG"
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","AETNA [1001]","HB CH AETNA HMO / PPO","26235.00","58.3","","1830.28","315.58","1830.28","1 through 10","20002.5","45000","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","32850.00","73","","4170.85","4170.85","4170.85","1 through 10","20002.5","45000","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20002.50","44.45","","649.55","649.55","649.55","1 through 10","20002.5","45000","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","both","","","45000.00","33750.00","WELLPOINT [1015]","HB CH WELLPOINT","35059.50","77.91","","8998.38","2542.37","8998.38","20","20002.5","45000","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","45000.00","33750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26685.00","59.3","","1891.61","1609.14","3664.18","25","22500","35302.5","percent of total billed charges",""
"Kit / Tray Tandem Heart T3","PX-27000707","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","45000.00","33750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35302.50","78.45","","1470.68","1310.06","2481.69","19","22500","35302.5","percent of total billed charges",""
"KIT ACCESSORY 1X4 8 NEUROSTIMULATOR ANCHOR BOOT","SUP-ITM-10012055","CDM","C1883","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","1892.10","1892.10","1892.10","1 through 10","79.5","150","percent of total billed charges",""
"KIT ACCESSORY CORD STIMULATOR SPINE A","SUP-ITM-10020900","CDM","C1883","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.75","53","","1892.10","1892.10","1892.10","1 through 10","516.75","975","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","554.95","91.85","1421.75","94","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","2490.03","2490.03","2490.03","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","750.00","750.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","1192.50","120.84","4149.90","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","752.25","85","","750.00","75.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","885.00","100","","657.00","121.50","1971.00","14","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","885.00","100","","75.00","75.00","75.00","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","885.00","100","","366.00","144.00","1971.00","45","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","667.50","667.50","667.50","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","123.77","123.77","123.77","1 through 10","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","483.51","229.32","1316.08","96","393.38","885","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","439.50","225.34","1872.27","197","442.5","694.28","percent of total billed charges",""
"KIT ANCHOR 5.5MM SUTURE HEALICOIL REGENSORB REPAIR 3 SUTURES KT/3 72203707","SUP-ITM-10126698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","385.32","55.36","1815.62","58","442.5","694.28","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","AETNA [1001]","HB CH AETNA HMO / PPO","2981.46","58.3","","1634.24","1004.95","1718.99","42","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3733.22","73","","2123.89","1900.92","2123.89","1 through 10","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2981.46","58.3","","3729.00","1254.19","3729.00","1 through 10","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2710.42","53","","939.37","939.37","5593.65","1 through 10","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4346.90","85","","2323.25","1864.50","2882.25","16","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5114.00","100","","2909.44","1772.40","10952.08","45","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5114.00","100","","2323.25","2323.25","2323.25","1 through 10","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5114.00","100","","2882.25","1772.40","10169.17","187","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3733.22","73","","1659.41","1659.41","1659.41","1 through 10","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","both","","","5114.00","3835.50","WELLPOINT [1015]","HB CH WELLPOINT","3984.32","77.91","","2050.91","1468.48","2902.83","52","2273.17","5114","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5114.00","3835.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3032.60","59.3","","1548.60","1092.60","3613.79","82","2557","4011.93","percent of total billed charges",""
"KIT BEARING DISC ULNA E PLUS","SUP-ITM-10276257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5114.00","3835.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4011.93","78.45","","2085.51","998.68","6202.11","56","2557","4011.93","percent of total billed charges",""
"KIT BONE 3CC GRAFT AUGMENT INJECTABLE","SUP-ITM-10239256","CDM","C1734","HCPCS","0278","RC","","","","both","","","6640.00","4980.00","WELLPOINT [1015]","HB CH WELLPOINT","5173.22","77.91","","5229.66","5229.66","5229.66","1 through 10","2848.56","6640","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","AETNA [1001]","HB CH AETNA HMO / PPO","4065.84","58.3","","1830.28","315.58","1830.28","1 through 10","3099.94","6974","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5091.02","73","","4170.85","4170.85","4170.85","1 through 10","3099.94","6974","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3099.94","44.45","","649.55","649.55","649.55","1 through 10","3099.94","6974","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","both","","","6974.00","5230.50","WELLPOINT [1015]","HB CH WELLPOINT","5433.44","77.91","","8998.38","2542.37","8998.38","20","3099.94","6974","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6974.00","5230.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4135.58","59.3","","1891.61","1609.14","3664.18","25","3487","5471.1","percent of total billed charges",""
"KIT BONE TAMP 10/2 OI KYPHON EXPRESS 2 FIRST FRACTURE","SUP-ITM-10133158","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6974.00","5230.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5471.10","78.45","","1470.68","1310.06","2481.69","19","3487","5471.1","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","4646.00","3484.50","AETNA [1001]","HB CH AETNA HMO / PPO","2708.62","58.3","","1830.28","315.58","1830.28","1 through 10","2065.15","4646","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","4646.00","3484.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3391.58","73","","4170.85","4170.85","4170.85","1 through 10","2065.15","4646","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","4646.00","3484.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2065.15","44.45","","649.55","649.55","649.55","1 through 10","2065.15","4646","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","both","","","4646.00","3484.50","WELLPOINT [1015]","HB CH WELLPOINT","3619.70","77.91","","8998.38","2542.37","8998.38","20","2065.15","4646","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4646.00","3484.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2755.08","59.3","","1891.61","1609.14","3664.18","25","2323","3644.79","percent of total billed charges",""
"KIT BONE TAMP 15/2 OI KYPHON EXPRESS 2 ADDITIONAL FRACTURE","SUP-ITM-10133161","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4646.00","3484.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3644.79","78.45","","1470.68","1310.06","2481.69","19","2323","3644.79","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","554.95","91.85","1421.75","94","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","2490.03","2490.03","2490.03","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2404.88","58.3","","750.00","750.00","750.00","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","1192.50","120.84","4149.90","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3506.25","85","","750.00","75.00","750.00","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4125.00","100","","657.00","121.50","1971.00","14","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4125.00","100","","75.00","75.00","75.00","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4125.00","100","","366.00","144.00","1971.00","45","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3011.25","73","","667.50","667.50","667.50","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","123.77","123.77","123.77","1 through 10","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","483.51","229.32","1316.08","96","1833.56","4125","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","439.50","225.34","1872.27","197","2062.5","3236.06","percent of total billed charges",""
"KIT BUTTON LARGE PIN DRILL BONE PECTORAL DISTAL","SUP-ITM-10124398","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","385.32","55.36","1815.62","58","2062.5","3236.06","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","554.95","91.85","1421.75","94","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","2490.03","2490.03","2490.03","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","750.00","750.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","1192.50","120.84","4149.90","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","892.50","85","","750.00","75.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1050.00","100","","657.00","121.50","1971.00","14","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1050.00","100","","75.00","75.00","75.00","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1050.00","100","","366.00","144.00","1971.00","45","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","667.50","667.50","667.50","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","123.77","123.77","123.77","1 through 10","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","483.51","229.32","1316.08","96","466.73","1050","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","439.50","225.34","1872.27","197","525","823.73","percent of total billed charges",""
"KIT BUTTON TRACTION FIXATION TIGHTROPE ARTHROSCOPY ANTERIOR CRUCIATE LIGAMENT","SUP-ITM-10079609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","385.32","55.36","1815.62","58","525","823.73","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","both","","","1778.28","1333.71","WELLPOINT [1015]","HB CH WELLPOINT","1385.46","77.91","","60.00","47.26","60.00","1 through 10","790.45","1778.28","percent of total billed charges",""
"KIT CATHETER 15.5FR INSERTION PLEURX PLEURAL CS/10EA","SUP-ITM-10006715","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","1778.28","1333.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1395.06","78.45","","28.02","28.02","28.02","1 through 10","889.14","1395.06","percent of total billed charges",""
"KIT CATHETER 80CM DRAINAGE LUMBAR EXTERNAL PRECOILED GUIDEWIRE TUOHY NEEDLE II","SUP-ITM-10046821","CDM","C1729","HCPCS","0272","RC","","","","both","","","691.32","518.49","WELLPOINT [1015]","HB CH WELLPOINT","538.61","77.91","","60.00","47.26","60.00","1 through 10","307.29","691.32","percent of total billed charges",""
"KIT CATHETER 80CM DRAINAGE LUMBAR EXTERNAL PRECOILED GUIDEWIRE TUOHY NEEDLE II","SUP-ITM-10046821","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","691.32","518.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","542.34","78.45","","28.02","28.02","28.02","1 through 10","345.66","542.34","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","554.95","91.85","1421.75","94","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","2490.03","2490.03","2490.03","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","750.00","750.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","1192.50","120.84","4149.90","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1861.50","85","","750.00","75.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2190.00","100","","657.00","121.50","1971.00","14","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2190.00","100","","75.00","75.00","75.00","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2190.00","100","","366.00","144.00","1971.00","45","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","667.50","667.50","667.50","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","123.77","123.77","123.77","1 through 10","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","483.51","229.32","1316.08","96","973.46","2190","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","439.50","225.34","1872.27","197","1095","1718.06","percent of total billed charges",""
"KIT CEMENT 11ML CONFIDENCE HIGH VISCOSITY HYDRAULIC PUMP RESERVOIR MIXER MINIMALLET NEEDLE HOLDER SPINAL NEEDLESS","SUP-ITM-10078872","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","385.32","55.36","1815.62","58","1095","1718.06","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","AETNA [1001]","HB CH AETNA HMO / PPO","1783.98","58.3","","554.95","91.85","1421.75","94","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2233.80","73","","2490.03","2490.03","2490.03","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1783.98","58.3","","750.00","750.00","750.00","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1621.80","53","","1192.50","120.84","4149.90","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2601.00","85","","750.00","75.00","750.00","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3060.00","100","","657.00","121.50","1971.00","14","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3060.00","100","","75.00","75.00","75.00","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3060.00","100","","366.00","144.00","1971.00","45","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2233.80","73","","667.50","667.50","667.50","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1360.17","44.45","","123.77","123.77","123.77","1 through 10","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3060.00","2295.00","WELLPOINT [1015]","HB CH WELLPOINT","2384.05","77.91","","483.51","229.32","1316.08","96","1360.17","3060","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3060.00","2295.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1814.58","59.3","","439.50","225.34","1872.27","197","1530","2400.57","percent of total billed charges",""
"KIT CEMENT 13GA SPINE CONFIDENCE PLUS HIGH VISCOSITY RADIOPAQUE","SUP-ITM-10137056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3060.00","2295.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2400.57","78.45","","385.32","55.36","1815.62","58","1530","2400.57","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","AETNA [1001]","HB CH AETNA HMO / PPO","2326.17","58.3","","554.95","91.85","1421.75","94","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","2490.03","2490.03","2490.03","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2326.17","58.3","","750.00","750.00","750.00","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2114.70","53","","1192.50","120.84","4149.90","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3391.50","85","","750.00","75.00","750.00","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3990.00","100","","657.00","121.50","1971.00","14","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3990.00","100","","75.00","75.00","75.00","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3990.00","100","","366.00","144.00","1971.00","45","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2912.70","73","","667.50","667.50","667.50","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.56","44.45","","123.77","123.77","123.77","1 through 10","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.00","2992.50","WELLPOINT [1015]","HB CH WELLPOINT","3108.61","77.91","","483.51","229.32","1316.08","96","1773.56","3990","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.07","59.3","","439.50","225.34","1872.27","197","1995","3130.16","percent of total billed charges",""
"KIT CEMENT 8ML BONE QUICKSET CALCIUM PHOSPHATE POLYMER MACROPOROUS RADIOPAQUE","SUP-ITM-10149082","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.00","2992.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.16","78.45","","385.32","55.36","1815.62","58","1995","3130.16","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","AETNA [1001]","HB CH AETNA HMO / PPO","568.43","58.3","","554.95","91.85","1421.75","94","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","711.75","73","","2490.03","2490.03","2490.03","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","568.43","58.3","","750.00","750.00","750.00","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.75","53","","1192.50","120.84","4149.90","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","828.75","85","","750.00","75.00","750.00","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","975.00","100","","657.00","121.50","1971.00","14","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","975.00","100","","75.00","75.00","75.00","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","975.00","100","","366.00","144.00","1971.00","45","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","711.75","73","","667.50","667.50","667.50","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","433.39","44.45","","123.77","123.77","123.77","1 through 10","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","both","","","975.00","731.25","WELLPOINT [1015]","HB CH WELLPOINT","759.62","77.91","","483.51","229.32","1316.08","96","433.39","975","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","578.18","59.3","","439.50","225.34","1872.27","197","487.5","764.89","percent of total billed charges",""
"KIT CEMENT BONE KYPHON XPEDE POLYMETHYLMETHACRYLATE MIXER","SUP-ITM-10091560","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","975.00","731.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.89","78.45","","385.32","55.36","1815.62","58","487.5","764.89","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB CH AETNA HMO / PPO","8.75","58.3","","1634.24","1004.95","1718.99","42","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","2123.89","1900.92","2123.89","1 through 10","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8.75","58.3","","3729.00","1254.19","3729.00","1 through 10","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.95","53","","939.37","939.37","5593.65","1 through 10","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","12.75","85","","2323.25","1864.50","2882.25","16","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","15.00","100","","2909.44","1772.40","10952.08","45","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","15.00","100","","2323.25","2323.25","2323.25","1 through 10","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15.00","100","","2882.25","1772.40","10169.17","187","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","1659.41","1659.41","1659.41","1 through 10","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","WELLPOINT [1015]","HB CH WELLPOINT","11.69","77.91","","2050.91","1468.48","2902.83","52","6.67","15","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.90","59.3","","1548.60","1092.60","3613.79","82","7.5","11.77","percent of total billed charges",""
"KIT CEMENT LARGE IMPLANTATION GLENOID UNIVERS POLYETHYLENE PEGGED","SUP-ITM-10135861","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","2085.51","998.68","6202.11","56","7.5","11.77","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","554.95","91.85","1421.75","94","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","459.90","73","","2490.03","2490.03","2490.03","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","367.29","58.3","","750.00","750.00","750.00","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","333.90","53","","1192.50","120.84","4149.90","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","535.50","85","","750.00","75.00","750.00","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","630.00","100","","657.00","121.50","1971.00","14","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","630.00","100","","75.00","75.00","75.00","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","630.00","100","","366.00","144.00","1971.00","45","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","459.90","73","","667.50","667.50","667.50","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","123.77","123.77","123.77","1 through 10","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB CH WELLPOINT","490.83","77.91","","483.51","229.32","1316.08","96","280.04","630","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","373.59","59.3","","439.50","225.34","1872.27","197","315","494.24","percent of total billed charges",""
"KIT DRILL 2.0X100MM SYSTEM DELIVERY IMPLANT TRIM IT PIN BX/5EA","SUP-ITM-10155837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","385.32","55.36","1815.62","58","315","494.24","percent of total billed charges",""
"KIT ELECTRODE ABLATION ENDOMETRIAL NOVASURE BIPOLAR HANDPIECE CORD CONTROLLER BX/3EA","SUP-ITM-10015957","CDM","C1886","HCPCS","0272","RC","","","","both","","","3090.00","2317.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3090.00","100","","3670.50","3670.50","6900.00","1 through 10","1637.7","3090","percent of total billed charges",""
"KIT ELECTRODE ABLATION ENDOMETRIAL NOVASURE BIPOLAR HANDPIECE CORD CONTROLLER BX/3EA","SUP-ITM-10015957","CDM","C1886","HCPCS","0272","RC","","","","both","","","3090.00","2317.50","WELLPOINT [1015]","HB CH WELLPOINT","2407.42","77.91","","3150.40","3150.40","3150.40","1 through 10","1637.7","3090","percent of total billed charges",""
"KIT ELECTRODE ABLATION ENDOMETRIAL NOVASURE BIPOLAR HANDPIECE CORD CONTROLLER BX/3EA","SUP-ITM-10015957","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","3090.00","2317.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2424.11","78.45","","3075.20","1822.40","5304.72","1 through 10","1373.51","2424.11","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","554.95","91.85","1421.75","94","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2490.03","2490.03","2490.03","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","750.00","750.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","1192.50","120.84","4149.90","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","750.00","75.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","657.00","121.50","1971.00","14","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","75.00","75.00","75.00","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","366.00","144.00","1971.00","45","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","667.50","667.50","667.50","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","123.77","123.77","123.77","1 through 10","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","483.51","229.32","1316.08","96","333.38","750","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","439.50","225.34","1872.27","197","375","588.38","percent of total billed charges",""
"KIT ENDOBUTTON 1.2MM RAP-PAC B LATEX FREE STERILE DISPOSABLE","SUP-ITM-10192570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","385.32","55.36","1815.62","58","375","588.38","percent of total billed charges",""
"KIT EXTENSION 4.32MM PERCUTANEOUS FOR INTERSTIM SURESCAN MRI LEAD","SUP-ITM-10277216","CDM","C1883","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1892.10","1892.10","1892.10","1 through 10","381.6","720","percent of total billed charges",""
"KIT FOCALPAK BX/5EA","SUP-ITM-10287958","CDM","C1886","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","3670.50","3670.50","6900.00","1 through 10","2120","4000","percent of total billed charges",""
"KIT FOCALPAK BX/5EA","SUP-ITM-10287958","CDM","C1886","HCPCS","0272","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","3150.40","3150.40","3150.40","1 through 10","2120","4000","percent of total billed charges",""
"KIT FOCALPAK BX/5EA","SUP-ITM-10287958","CDM","C1886","HCPCS","0272","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","3075.20","1822.40","5304.72","1 through 10","1778","3138","percent of total billed charges",""
"KIT GENERATOR UP TO 16 PULSE SENZA SYSTEM PARESTHESIA FREE IMPLANT ELECTRODE LOW PROFILE","SUP-ITM-10158043","CDM","C1822","HCPCS","0278","RC","","","","both","","","30360.00","22770.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","16090.80","53","","16922.90","16922.90","16922.90","1 through 10","16090.8","30360","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","AETNA [1001]","HB CH AETNA HMO / PPO","8408.70","58.3","","554.95","91.85","1421.75","94","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","10528.91","73","","2490.03","2490.03","2490.03","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8408.70","58.3","","750.00","750.00","750.00","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7644.27","53","","1192.50","120.84","4149.90","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","12259.69","85","","750.00","75.00","750.00","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","14423.16","100","","657.00","121.50","1971.00","14","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","14423.16","100","","75.00","75.00","75.00","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","14423.16","100","","366.00","144.00","1971.00","45","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10528.91","73","","667.50","667.50","667.50","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6411.09","44.45","","123.77","123.77","123.77","1 through 10","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","both","","","14423.16","10817.37","WELLPOINT [1015]","HB CH WELLPOINT","11237.08","77.91","","483.51","229.32","1316.08","96","6411.09","14423.16","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14423.16","10817.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","8552.93","59.3","","439.50","225.34","1872.27","197","7211.58","11314.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM LG BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","14423.16","10817.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11314.97","78.45","","385.32","55.36","1815.62","58","7211.58","11314.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","AETNA [1001]","HB CH AETNA HMO / PPO","7551.86","58.3","","554.95","91.85","1421.75","94","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9456.01","73","","2490.03","2490.03","2490.03","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7551.86","58.3","","750.00","750.00","750.00","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6865.32","53","","1192.50","120.84","4149.90","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","11010.42","85","","750.00","75.00","750.00","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12953.44","100","","657.00","121.50","1971.00","14","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12953.44","100","","75.00","75.00","75.00","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12953.44","100","","366.00","144.00","1971.00","45","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9456.01","73","","667.50","667.50","667.50","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5757.80","44.45","","123.77","123.77","123.77","1 through 10","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","both","","","12953.44","9715.08","WELLPOINT [1015]","HB CH WELLPOINT","10092.03","77.91","","483.51","229.32","1316.08","96","5757.8","12953.44","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12953.44","9715.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","7681.39","59.3","","439.50","225.34","1872.27","197","6476.72","10161.97","percent of total billed charges",""
"KIT GRAFT 2.5X5.0CM MD BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10019457","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12953.44","9715.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10161.97","78.45","","385.32","55.36","1815.62","58","6476.72","10161.97","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","AETNA [1001]","HB CH AETNA HMO / PPO","1955.38","58.3","","554.95","91.85","1421.75","94","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2448.42","73","","2490.03","2490.03","2490.03","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1955.38","58.3","","750.00","750.00","750.00","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1777.62","53","","1192.50","120.84","4149.90","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2850.90","85","","750.00","75.00","750.00","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3354.00","100","","657.00","121.50","1971.00","14","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3354.00","100","","75.00","75.00","75.00","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3354.00","100","","366.00","144.00","1971.00","45","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2448.42","73","","667.50","667.50","667.50","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1490.85","44.45","","123.77","123.77","123.77","1 through 10","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","both","","","3354.00","2515.50","WELLPOINT [1015]","HB CH WELLPOINT","2613.10","77.91","","483.51","229.32","1316.08","96","1490.85","3354","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3354.00","2515.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1988.92","59.3","","439.50","225.34","1872.27","197","1677","2631.21","percent of total billed charges",""
"KIT GRAFT 25ML BONE SUBSTITUTE RESORBABLE BEAD OSTEOSET FAST CURE","SUP-ITM-10056983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3354.00","2515.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2631.21","78.45","","385.32","55.36","1815.62","58","1677","2631.21","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","AETNA [1001]","HB CH AETNA HMO / PPO","5516.25","58.3","","554.95","91.85","1421.75","94","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6907.14","73","","2490.03","2490.03","2490.03","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5516.25","58.3","","750.00","750.00","750.00","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5014.78","53","","1192.50","120.84","4149.90","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8042.56","85","","750.00","75.00","750.00","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9461.84","100","","657.00","121.50","1971.00","14","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9461.84","100","","75.00","75.00","75.00","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9461.84","100","","366.00","144.00","1971.00","45","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6907.14","73","","667.50","667.50","667.50","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4205.79","44.45","","123.77","123.77","123.77","1 through 10","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","both","","","9461.84","7096.38","WELLPOINT [1015]","HB CH WELLPOINT","7371.72","77.91","","483.51","229.32","1316.08","96","4205.79","9461.84","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9461.84","7096.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","5610.87","59.3","","439.50","225.34","1872.27","197","4730.92","7422.81","percent of total billed charges",""
"KIT GRAFT 5X2.5CM SM BONE INFUSE ALLOGRAFT PROTEIN COLLAGEN ABSORBABLE WATER SYRINGE SPONGE","SUP-ITM-10014358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","9461.84","7096.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7422.81","78.45","","385.32","55.36","1815.62","58","4730.92","7422.81","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","554.95","91.85","1421.75","94","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","2490.03","2490.03","2490.03","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","750.00","750.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","1192.50","120.84","4149.90","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","701.25","85","","750.00","75.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","825.00","100","","657.00","121.50","1971.00","14","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","825.00","100","","75.00","75.00","75.00","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","825.00","100","","366.00","144.00","1971.00","45","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","667.50","667.50","667.50","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","123.77","123.77","123.77","1 through 10","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","483.51","229.32","1316.08","96","366.71","825","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","439.50","225.34","1872.27","197","412.5","647.21","percent of total billed charges",""
"KIT HEAD 2.8MM RESECTION PIN BONE STEINMANN UNIVERS II ECLIPSE","SUP-ITM-10210666","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","385.32","55.36","1815.62","58","412.5","647.21","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","AETNA [1001]","HB CH AETNA HMO / PPO","1030.16","58.3","","1634.24","1004.95","1718.99","42","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1289.91","73","","2123.89","1900.92","2123.89","1 through 10","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1030.16","58.3","","3729.00","1254.19","3729.00","1 through 10","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","936.51","53","","939.37","939.37","5593.65","1 through 10","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1501.95","85","","2323.25","1864.50","2882.25","16","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1767.00","100","","2909.44","1772.40","10952.08","45","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1767.00","100","","2323.25","2323.25","2323.25","1 through 10","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1767.00","100","","2882.25","1772.40","10169.17","187","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1289.91","73","","1659.41","1659.41","1659.41","1 through 10","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","WELLPOINT [1015]","HB CH WELLPOINT","1376.67","77.91","","2050.91","1468.48","2902.83","52","785.43","1767","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1767.00","1325.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1047.83","59.3","","1548.60","1092.60","3613.79","82","883.5","1386.21","percent of total billed charges",""
"KIT HUMERAL CONDYLE DISCOVERY HEXALOBULAR ELBOW SYSTEM","SUP-ITM-10197741","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1767.00","1325.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1386.21","78.45","","2085.51","998.68","6202.11","56","883.5","1386.21","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","AETNA [1001]","HB CH AETNA HMO / PPO","1106.59","58.3","","1634.24","1004.95","1718.99","42","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1385.61","73","","2123.89","1900.92","2123.89","1 through 10","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1106.59","58.3","","3729.00","1254.19","3729.00","1 through 10","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1005.99","53","","939.37","939.37","5593.65","1 through 10","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1613.39","85","","2323.25","1864.50","2882.25","16","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1898.10","100","","2909.44","1772.40","10952.08","45","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1898.10","100","","2323.25","2323.25","2323.25","1 through 10","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1898.10","100","","2882.25","1772.40","10169.17","187","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1385.61","73","","1659.41","1659.41","1659.41","1 through 10","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","WELLPOINT [1015]","HB CH WELLPOINT","1478.81","77.91","","2050.91","1468.48","2902.83","52","843.71","1898.1","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1898.10","1423.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","1125.57","59.3","","1548.60","1092.60","3613.79","82","949.05","1489.06","percent of total billed charges",""
"KIT IMPLANT 11X12X10MM SPEEDARC COMPRESSION","SUP-ITM-10211725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1898.10","1423.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1489.06","78.45","","2085.51","998.68","6202.11","56","949.05","1489.06","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","AETNA [1001]","HB CH AETNA HMO / PPO","964.22","58.3","","1634.24","1004.95","1718.99","42","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1207.35","73","","2123.89","1900.92","2123.89","1 through 10","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","964.22","58.3","","3729.00","1254.19","3729.00","1 through 10","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","876.57","53","","939.37","939.37","5593.65","1 through 10","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1405.82","85","","2323.25","1864.50","2882.25","16","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1653.90","100","","2909.44","1772.40","10952.08","45","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1653.90","100","","2323.25","2323.25","2323.25","1 through 10","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1653.90","100","","2882.25","1772.40","10169.17","187","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1207.35","73","","1659.41","1659.41","1659.41","1 through 10","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","both","","","1653.90","1240.42","WELLPOINT [1015]","HB CH WELLPOINT","1288.55","77.91","","2050.91","1468.48","2902.83","52","735.16","1653.9","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","980.76","59.3","","1548.60","1092.60","3613.79","82","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 13X15X13MM SPEED COMPRESSION","SUP-ITM-10211721","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1653.90","1240.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1297.48","78.45","","2085.51","998.68","6202.11","56","826.95","1297.48","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","AETNA [1001]","HB CH AETNA HMO / PPO","1500.05","58.3","","554.95","91.85","1421.75","94","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1878.28","73","","2490.03","2490.03","2490.03","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1500.05","58.3","","750.00","750.00","750.00","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1363.68","53","","1192.50","120.84","4149.90","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2187.03","85","","750.00","75.00","750.00","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2572.98","100","","657.00","121.50","1971.00","14","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2572.98","100","","75.00","75.00","75.00","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2572.98","100","","366.00","144.00","1971.00","45","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1878.28","73","","667.50","667.50","667.50","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1143.69","44.45","","123.77","123.77","123.77","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","WELLPOINT [1015]","HB CH WELLPOINT","2004.61","77.91","","483.51","229.32","1316.08","96","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2572.98","1929.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","1525.78","59.3","","439.50","225.34","1872.27","197","1286.49","2018.5","percent of total billed charges",""
"KIT IMPLANT 15X20X20MM SPEEDSHIFT COMPRESSION OFFSET 10MM","SUP-ITM-10211715","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2572.98","1929.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2018.50","78.45","","385.32","55.36","1815.62","58","1286.49","2018.5","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","AETNA [1001]","HB CH AETNA HMO / PPO","1335.03","58.3","","1634.24","1004.95","1718.99","42","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1671.65","73","","2123.89","1900.92","2123.89","1 through 10","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1335.03","58.3","","3729.00","1254.19","3729.00","1 through 10","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1213.66","53","","939.37","939.37","5593.65","1 through 10","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1946.44","85","","2323.25","1864.50","2882.25","16","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2289.93","100","","2909.44","1772.40","10952.08","45","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2289.93","100","","2323.25","2323.25","2323.25","1 through 10","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2289.93","100","","2882.25","1772.40","10169.17","187","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1671.65","73","","1659.41","1659.41","1659.41","1 through 10","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","both","","","2289.93","1717.45","WELLPOINT [1015]","HB CH WELLPOINT","1784.08","77.91","","2050.91","1468.48","2902.83","52","1017.87","2289.93","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.93","1717.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1357.93","59.3","","1548.60","1092.60","3613.79","82","1144.97","1796.45","percent of total billed charges",""
"KIT IMPLANT 18X18X15MM SPEED COMPRESSION","SUP-ITM-10211708","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2289.93","1717.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1796.45","78.45","","2085.51","998.68","6202.11","56","1144.97","1796.45","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","AETNA [1001]","HB CH AETNA HMO / PPO","1719.42","58.3","","554.95","91.85","1421.75","94","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2152.97","73","","2490.03","2490.03","2490.03","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1719.42","58.3","","750.00","750.00","750.00","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1563.11","53","","1192.50","120.84","4149.90","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2506.88","85","","750.00","75.00","750.00","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2949.27","100","","657.00","121.50","1971.00","14","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2949.27","100","","75.00","75.00","75.00","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2949.27","100","","366.00","144.00","1971.00","45","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2152.97","73","","667.50","667.50","667.50","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1310.95","44.45","","123.77","123.77","123.77","1 through 10","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","both","","","2949.27","2211.95","WELLPOINT [1015]","HB CH WELLPOINT","2297.78","77.91","","483.51","229.32","1316.08","96","1310.95","2949.27","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2949.27","2211.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","1748.92","59.3","","439.50","225.34","1872.27","197","1474.64","2313.7","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM 2 LEGS ELITE COMPRESSION","SUP-ITM-10211741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2949.27","2211.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2313.70","78.45","","385.32","55.36","1815.62","58","1474.64","2313.7","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","AETNA [1001]","HB CH AETNA HMO / PPO","1347.32","58.3","","1634.24","1004.95","1718.99","42","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1687.04","73","","2123.89","1900.92","2123.89","1 through 10","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1347.32","58.3","","3729.00","1254.19","3729.00","1 through 10","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1224.84","53","","939.37","939.37","5593.65","1 through 10","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1964.37","85","","2323.25","1864.50","2882.25","16","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2311.02","100","","2909.44","1772.40","10952.08","45","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2311.02","100","","2323.25","2323.25","2323.25","1 through 10","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2311.02","100","","2882.25","1772.40","10169.17","187","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1687.04","73","","1659.41","1659.41","1659.41","1 through 10","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","both","","","2311.02","1733.26","WELLPOINT [1015]","HB CH WELLPOINT","1800.52","77.91","","2050.91","1468.48","2902.83","52","1027.25","2311.02","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2311.02","1733.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","1370.43","59.3","","1548.60","1092.60","3613.79","82","1155.51","1813","percent of total billed charges",""
"KIT IMPLANT 18X18X18MM SPEEDTITAN COMPRESSION","SUP-ITM-10211706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2311.02","1733.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1813.00","78.45","","2085.51","998.68","6202.11","56","1155.51","1813","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","AETNA [1001]","HB CH AETNA HMO / PPO","1290.38","58.3","","1634.24","1004.95","1718.99","42","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1615.74","73","","2123.89","1900.92","2123.89","1 through 10","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1290.38","58.3","","3729.00","1254.19","3729.00","1 through 10","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1173.07","53","","939.37","939.37","5593.65","1 through 10","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1881.34","85","","2323.25","1864.50","2882.25","16","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2213.34","100","","2909.44","1772.40","10952.08","45","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2213.34","100","","2323.25","2323.25","2323.25","1 through 10","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2213.34","100","","2882.25","1772.40","10169.17","187","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1615.74","73","","1659.41","1659.41","1659.41","1 through 10","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","both","","","2213.34","1660.00","WELLPOINT [1015]","HB CH WELLPOINT","1724.41","77.91","","2050.91","1468.48","2902.83","52","983.83","2213.34","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2213.34","1660.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1312.51","59.3","","1548.60","1092.60","3613.79","82","1106.67","1736.37","percent of total billed charges",""
"KIT IMPLANT 20X15X8MM SPEEDTRIAD COMPRESSION RIGHT OFFSET","SUP-ITM-10211702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2213.34","1660.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1736.37","78.45","","2085.51","998.68","6202.11","56","1106.67","1736.37","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","AETNA [1001]","HB CH AETNA HMO / PPO","1500.05","58.3","","1634.24","1004.95","1718.99","42","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1878.28","73","","2123.89","1900.92","2123.89","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1500.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1363.68","53","","939.37","939.37","5593.65","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2187.03","85","","2323.25","1864.50","2882.25","16","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2572.98","100","","2909.44","1772.40","10952.08","45","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2572.98","100","","2323.25","2323.25","2323.25","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2572.98","100","","2882.25","1772.40","10169.17","187","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1878.28","73","","1659.41","1659.41","1659.41","1 through 10","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","both","","","2572.98","1929.73","WELLPOINT [1015]","HB CH WELLPOINT","2004.61","77.91","","2050.91","1468.48","2902.83","52","1143.69","2572.98","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2572.98","1929.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","1525.78","59.3","","1548.60","1092.60","3613.79","82","1286.49","2018.5","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM SPEEDSHIFT 12MM OFFSET COMPRESSION","SUP-ITM-10211695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2572.98","1929.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2018.50","78.45","","2085.51","998.68","6202.11","56","1286.49","2018.5","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","AETNA [1001]","HB CH AETNA HMO / PPO","1881.21","58.3","","1634.24","1004.95","1718.99","42","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2355.54","73","","2123.89","1900.92","2123.89","1 through 10","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1881.21","58.3","","3729.00","1254.19","3729.00","1 through 10","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1710.19","53","","939.37","939.37","5593.65","1 through 10","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2742.75","85","","2323.25","1864.50","2882.25","16","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3226.77","100","","2909.44","1772.40","10952.08","45","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3226.77","100","","2323.25","2323.25","2323.25","1 through 10","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3226.77","100","","2882.25","1772.40","10169.17","187","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2355.54","73","","1659.41","1659.41","1659.41","1 through 10","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","both","","","3226.77","2420.08","WELLPOINT [1015]","HB CH WELLPOINT","2513.98","77.91","","2050.91","1468.48","2902.83","52","1434.3","3226.77","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.77","2420.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","1913.47","59.3","","1548.60","1092.60","3613.79","82","1613.39","2531.4","percent of total billed charges",""
"KIT IMPLANT 20X20X20MM STAPLE COMPRESSION 2 LEG ELITE","SUP-ITM-10211740","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3226.77","2420.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2531.40","78.45","","2085.51","998.68","6202.11","56","1613.39","2531.4","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","AETNA [1001]","HB CH AETNA HMO / PPO","1668.95","58.3","","554.95","91.85","1421.75","94","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2089.76","73","","2490.03","2490.03","2490.03","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1668.95","58.3","","750.00","750.00","750.00","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1517.23","53","","1192.50","120.84","4149.90","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2433.29","85","","750.00","75.00","750.00","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2862.69","100","","657.00","121.50","1971.00","14","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2862.69","100","","75.00","75.00","75.00","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2862.69","100","","366.00","144.00","1971.00","45","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2089.76","73","","667.50","667.50","667.50","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1272.47","44.45","","123.77","123.77","123.77","1 through 10","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","both","","","2862.69","2147.02","WELLPOINT [1015]","HB CH WELLPOINT","2230.32","77.91","","483.51","229.32","1316.08","96","1272.47","2862.69","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.69","2147.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","1697.58","59.3","","439.50","225.34","1872.27","197","1431.35","2245.78","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEED COMPRESSION","SUP-ITM-10211693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2862.69","2147.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2245.78","78.45","","385.32","55.36","1815.62","58","1431.35","2245.78","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","AETNA [1001]","HB CH AETNA HMO / PPO","1666.36","58.3","","554.95","91.85","1421.75","94","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2086.52","73","","2490.03","2490.03","2490.03","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1666.36","58.3","","750.00","750.00","750.00","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1514.87","53","","1192.50","120.84","4149.90","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2429.51","85","","750.00","75.00","750.00","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2858.25","100","","657.00","121.50","1971.00","14","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2858.25","100","","75.00","75.00","75.00","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2858.25","100","","366.00","144.00","1971.00","45","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2086.52","73","","667.50","667.50","667.50","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1270.49","44.45","","123.77","123.77","123.77","1 through 10","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","both","","","2858.25","2143.69","WELLPOINT [1015]","HB CH WELLPOINT","2226.86","77.91","","483.51","229.32","1316.08","96","1270.49","2858.25","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","1694.94","59.3","","439.50","225.34","1872.27","197","1429.13","2242.3","percent of total billed charges",""
"KIT IMPLANT 25X20X20MM SPEEDTITAN COMPRESSION","SUP-ITM-10211692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2858.25","2143.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2242.30","78.45","","385.32","55.36","1815.62","58","1429.13","2242.3","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","AETNA [1001]","HB CH AETNA HMO / PPO","1916.80","58.3","","1634.24","1004.95","1718.99","42","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2400.11","73","","2123.89","1900.92","2123.89","1 through 10","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1916.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1742.54","53","","939.37","939.37","5593.65","1 through 10","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2794.65","85","","2323.25","1864.50","2882.25","16","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3287.82","100","","2909.44","1772.40","10952.08","45","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3287.82","100","","2323.25","2323.25","2323.25","1 through 10","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3287.82","100","","2882.25","1772.40","10169.17","187","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2400.11","73","","1659.41","1659.41","1659.41","1 through 10","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","both","","","3287.82","2465.86","WELLPOINT [1015]","HB CH WELLPOINT","2561.54","77.91","","2050.91","1468.48","2902.83","52","1461.44","3287.82","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3287.82","2465.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","1949.68","59.3","","1548.60","1092.60","3613.79","82","1643.91","2579.29","percent of total billed charges",""
"KIT IMPLANT 30X20X20X20X20MM ELITE COMPRESSION 4 LEG","SUP-ITM-10211738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3287.82","2465.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2579.29","78.45","","2085.51","998.68","6202.11","56","1643.91","2579.29","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","AETNA [1001]","HB CH AETNA HMO / PPO","4192.94","58.3","","1634.24","1004.95","1718.99","42","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5250.16","73","","2123.89","1900.92","2123.89","1 through 10","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4192.94","58.3","","3729.00","1254.19","3729.00","1 through 10","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3811.76","53","","939.37","939.37","5593.65","1 through 10","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6113.20","85","","2323.25","1864.50","2882.25","16","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7192.00","100","","2909.44","1772.40","10952.08","45","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7192.00","100","","2323.25","2323.25","2323.25","1 through 10","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7192.00","100","","2882.25","1772.40","10169.17","187","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5250.16","73","","1659.41","1659.41","1659.41","1 through 10","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","both","","","7192.00","5394.00","WELLPOINT [1015]","HB CH WELLPOINT","5603.29","77.91","","2050.91","1468.48","2902.83","52","3196.84","7192","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7192.00","5394.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4264.86","59.3","","1548.60","1092.60","3613.79","82","3596","5642.12","percent of total billed charges",""
"KIT IMPLANT IUNI IPOLY LT LATERAL","SUP-ITM-10155866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7192.00","5394.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5642.12","78.45","","2085.51","998.68","6202.11","56","3596","5642.12","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","AETNA [1001]","HB CH AETNA HMO / PPO","1379.96","58.3","","554.95","91.85","1421.75","94","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1727.91","73","","2490.03","2490.03","2490.03","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1379.96","58.3","","750.00","750.00","750.00","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1254.51","53","","1192.50","120.84","4149.90","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2011.95","85","","750.00","75.00","750.00","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2367.00","100","","657.00","121.50","1971.00","14","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2367.00","100","","75.00","75.00","75.00","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2367.00","100","","366.00","144.00","1971.00","45","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1727.91","73","","667.50","667.50","667.50","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1052.13","44.45","","123.77","123.77","123.77","1 through 10","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","both","","","2367.00","1775.25","WELLPOINT [1015]","HB CH WELLPOINT","1844.13","77.91","","483.51","229.32","1316.08","96","1052.13","2367","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.00","1775.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1403.63","59.3","","439.50","225.34","1872.27","197","1183.5","1856.91","percent of total billed charges",""
"KIT IMPLANT SYSTEM BUTTON PROXIMAL TENODESIS FIBERTAK","SUP-ITM-10280230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2367.00","1775.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1856.91","78.45","","385.32","55.36","1815.62","58","1183.5","1856.91","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","69.13","15.86","85.00","1 through 10","80.01","180","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","153.00","85","","29.94","29.94","29.94","1 through 10","80.01","180","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","180.00","100","","60.23","29.94","60.23","12","80.01","180","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","180.00","100","","65.22","29.94","360.69","1 through 10","80.01","180","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","51.37","51.37","284.08","1 through 10","80.01","180","percent of total billed charges",""
"KIT INTRODUCER 12.7X22.8CM PRECISION SPINAL CORD","SUP-ITM-10077225","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","123.30","23.02","333.57","1 through 10","90","141.21","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","69.13","15.86","85.00","1 through 10","373.38","840","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","714.00","85","","29.94","29.94","29.94","1 through 10","373.38","840","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","840.00","100","","60.23","29.94","60.23","12","373.38","840","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","840.00","100","","65.22","29.94","360.69","1 through 10","373.38","840","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","51.37","51.37","284.08","1 through 10","373.38","840","percent of total billed charges",""
"KIT INTRODUCER 18MM LEAD NEUROMODULATION INTERSTIM DILATOR SHEATH FORAMEN NEEDLE GROUND PAD STIMULATION CABLE PERIPHERAL","SUP-ITM-10012184","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","123.30","23.02","333.57","1 through 10","420","658.98","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","116.94","87.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","61.98","53","","69.13","15.86","85.00","1 through 10","51.98","116.94","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","116.94","87.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","99.40","85","","29.94","29.94","29.94","1 through 10","51.98","116.94","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","116.94","87.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","116.94","100","","60.23","29.94","60.23","12","51.98","116.94","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","116.94","87.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","116.94","100","","65.22","29.94","360.69","1 through 10","51.98","116.94","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","both","","","116.94","87.70","WELLPOINT [1015]","HB CH WELLPOINT","91.11","77.91","","51.37","51.37","284.08","1 through 10","51.98","116.94","percent of total billed charges",""
"KIT INTRODUCER 9FRX10CM PERCUTANEOUS SHEATH MULTI LUMEN CS/5EA","SUP-ITM-10114452","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","116.94","87.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","91.74","78.45","","123.30","23.02","333.57","1 through 10","58.47","91.74","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","AETNA [1001]","HB CH AETNA HMO / PPO","3971.40","58.3","","1634.24","1004.95","1718.99","42","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4972.76","73","","2123.89","1900.92","2123.89","1 through 10","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3971.40","58.3","","3729.00","1254.19","3729.00","1 through 10","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3610.36","53","","939.37","939.37","5593.65","1 through 10","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5790.20","85","","2323.25","1864.50","2882.25","16","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6812.00","100","","2909.44","1772.40","10952.08","45","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6812.00","100","","2323.25","2323.25","2323.25","1 through 10","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6812.00","100","","2882.25","1772.40","10169.17","187","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4972.76","73","","1659.41","1659.41","1659.41","1 through 10","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","both","","","6812.00","5109.00","WELLPOINT [1015]","HB CH WELLPOINT","5307.23","77.91","","2050.91","1468.48","2902.83","52","3027.93","6812","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6812.00","5109.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4039.52","59.3","","1548.60","1092.60","3613.79","82","3406","5344.01","percent of total billed charges",""
"KIT KNEE IMPLANT I TOTAL PS POSTERIOR STABILIZING W/O PATELLA 26","SUP-ITM-10140499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6812.00","5109.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5344.01","78.45","","2085.51","998.68","6202.11","56","3406","5344.01","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","AETNA [1001]","HB CH AETNA HMO / PPO","3381.40","58.3","","1634.24","1004.95","1718.99","42","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4234.00","73","","2123.89","1900.92","2123.89","1 through 10","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3381.40","58.3","","3729.00","1254.19","3729.00","1 through 10","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3074.00","53","","939.37","939.37","5593.65","1 through 10","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4930.00","85","","2323.25","1864.50","2882.25","16","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5800.00","100","","2909.44","1772.40","10952.08","45","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5800.00","100","","2323.25","2323.25","2323.25","1 through 10","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5800.00","100","","2882.25","1772.40","10169.17","187","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4234.00","73","","1659.41","1659.41","1659.41","1 through 10","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","WELLPOINT [1015]","HB CH WELLPOINT","4518.78","77.91","","2050.91","1468.48","2902.83","52","2578.1","5800","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5800.00","4350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3439.40","59.3","","1548.60","1092.60","3613.79","82","2900","4550.1","percent of total billed charges",""
"KIT LABORATORY COMPONENT ELBOW HUMERAL DISTAL MRS 45MM","SUP-ITM-10130395","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5800.00","4350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4550.10","78.45","","2085.51","998.68","6202.11","56","2900","4550.1","percent of total billed charges",""
"KIT LABORATORY LEAD EXT SENSA 60CM","SUP-ITM-10158045","CDM","C1883","HCPCS","0278","RC","","","","both","","","2376.00","1782.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1259.28","53","","1892.10","1892.10","1892.10","1 through 10","1259.28","2376","percent of total billed charges",""
"KIT LABORATORY S8 LEAD ADAPTER 25CM","SUP-ITM-10158041","CDM","C1883","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","839.52","53","","1892.10","1892.10","1892.10","1 through 10","839.52","1584","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","2914.41","2185.81","AETNA [1001]","HB CH AETNA HMO / PPO","1699.10","58.3","","1952.48","1952.48","1952.48","1 through 10","1295.46","2914.41","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","2914.41","2185.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1544.64","53","","1825.07","1825.07","1825.07","1 through 10","1295.46","2914.41","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","both","","","2914.41","2185.81","WELLPOINT [1015]","HB CH WELLPOINT","2270.62","77.91","","2712.12","2712.12","2712.12","1 through 10","1295.46","2914.41","percent of total billed charges",""
"KIT LASER 0.5X18IN MESH SLING TVT SUPPORT INCONTINENCE RETROPUBIC SYSTEM TENSION FREE CUT CS/1EA","SUP-ITM-10026682","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2914.41","2185.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.25","59.3","","2017.91","2017.91","2017.91","1 through 10","1457.21","2286.35","percent of total billed charges",""
"KIT LEAD 1.0X8.0 60CM NEUROSTIMULATOR VECTRIS COMPACT OCTAPOLAR CONNECTOR TRIAL SCREEN","SUP-ITM-10133371","CDM","C1897","HCPCS","0278","RC","","","","both","","","2634.00","1975.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2634.00","100","","2502.46","2502.46","2502.46","1 through 10","1396.02","2634","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","both","","","4182.00","3136.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2216.46","53","","3922.00","3922.00","3922.00","1 through 10","2216.46","4182","percent of total billed charges",""
"KIT LEAD 1X8 60CM NEUROSTIMULATOR VECTRIS SURESCAN MRI SAFE COMPACT OCTAPOLAR CONNECTOR","SUP-ITM-10124361","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4182.00","3136.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2479.93","59.3","","3013.82","3013.82","3013.82","1 through 10","1858.9","3280.78","percent of total billed charges",""
"KIT LEAD 25CM ADAPTER M8 TORQUE WRENCH INTRAOPERATIVE PHYSICIAN AID","SUP-ITM-10158044","CDM","C1883","HCPCS","0278","RC","","","","both","","","1584.00","1188.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","839.52","53","","1892.10","1892.10","1892.10","1 through 10","839.52","1584","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","both","","","7100.00","5325.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3763.00","53","","3922.00","3922.00","3922.00","1 through 10","3763","7100","percent of total billed charges",""
"KIT LEAD 4.32MM 28CM MRI INTERSTIM SURESCAN SACRAL NEUROMODULATION","SUP-ITM-10277206","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","7100.00","5325.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4210.30","59.3","","3013.82","3013.82","3013.82","1 through 10","3155.95","5569.95","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2186.25","53","","3922.00","3922.00","3922.00","1 through 10","2186.25","4125","percent of total billed charges",""
"KIT LEAD 5.0MM 70CM PERCUTANEOUS SENZA SPINAL CORD STIMULATION ELECTRODE SPACING LEAD1058-70B","SUP-ITM-10158049","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","3013.82","3013.82","3013.82","1 through 10","1833.56","3236.06","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3074.00","53","","3922.00","3922.00","3922.00","1 through 10","3074","5800","percent of total billed charges",""
"KIT LEAD 50CM AXIUM IMPLANT SLIMTIP PERI OP DEVICES NEUROMODULATION","SUP-ITM-10174960","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5800.00","4350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3439.40","59.3","","3013.82","3013.82","3013.82","1 through 10","2578.1","4550.1","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2438.00","53","","3922.00","3922.00","3922.00","1 through 10","2438","4600","percent of total billed charges",""
"KIT LEAD 56CM AVISTA MRI PERCUTANEOUS 8 CONTACT","SUP-ITM-10174950","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2727.80","59.3","","3013.82","3013.82","3013.82","1 through 10","2044.7","3608.7","percent of total billed charges",""
"KIT LEAD 90CM IMPLANT SLIM TIP AXIUM","SUP-ITM-10174959","CDM","C1778","HCPCS","0278","RC","","","","both","","","5800.00","4350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3074.00","53","","3922.00","3922.00","3922.00","1 through 10","3074","5800","percent of total billed charges",""
"KIT LEAD 90CM IMPLANT SLIM TIP AXIUM","SUP-ITM-10174959","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5800.00","4350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3439.40","59.3","","3013.82","3013.82","3013.82","1 through 10","2578.1","4550.1","percent of total billed charges",""
"KIT LEAD EXTENSION 60CM CERVICAL 60CM","SUP-ITM-10019637","CDM","C1883","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","1892.10","1892.10","1892.10","1 through 10","1423.05","2685","percent of total billed charges",""
"KIT LEAD TRIAL 1 INTELLIS","SUP-ITM-10278900","CDM","C1897","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2637.00","100","","2502.46","2502.46","2502.46","1 through 10","1397.61","2637","percent of total billed charges",""
"KIT LEAD TRIAL 60CM CAP12 EVOKE 12 ELECTRODES 4MM SPACING","SUP-ITM-10317729","CDM","C1897","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2502.46","2502.46","2502.46","1 through 10","1908","3600","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","AETNA [1001]","HB CH AETNA HMO / PPO","297.33","58.3","","554.95","91.85","1421.75","94","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","372.30","73","","2490.03","2490.03","2490.03","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","297.33","58.3","","750.00","750.00","750.00","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","270.30","53","","1192.50","120.84","4149.90","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","433.50","85","","750.00","75.00","750.00","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","510.00","100","","657.00","121.50","1971.00","14","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","510.00","100","","75.00","75.00","75.00","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","510.00","100","","366.00","144.00","1971.00","45","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","372.30","73","","667.50","667.50","667.50","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","226.70","44.45","","123.77","123.77","123.77","1 through 10","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","both","","","510.00","382.50","WELLPOINT [1015]","HB CH WELLPOINT","397.34","77.91","","483.51","229.32","1316.08","96","226.7","510","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","302.43","59.3","","439.50","225.34","1872.27","197","255","400.1","percent of total billed charges",""
"KIT MIXER CEMENT BONE KYPHON HV R HIGH VISCOSITY RADIOPAQUE KYPHOPLASTY PK/1EA","SUP-ITM-10012348","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","510.00","382.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","400.10","78.45","","385.32","55.36","1815.62","58","255","400.1","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","AETNA [1001]","HB CH AETNA HMO / PPO","4195.61","58.3","","554.95","91.85","1421.75","94","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","2490.03","2490.03","2490.03","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4195.61","58.3","","750.00","750.00","750.00","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3814.19","53","","1192.50","120.84","4149.90","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6117.09","85","","750.00","75.00","750.00","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7196.58","100","","657.00","121.50","1971.00","14","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7196.58","100","","75.00","75.00","75.00","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7196.58","100","","366.00","144.00","1971.00","45","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","667.50","667.50","667.50","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","123.77","123.77","123.77","1 through 10","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","WELLPOINT [1015]","HB CH WELLPOINT","5606.86","77.91","","483.51","229.32","1316.08","96","3198.88","7196.58","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","4267.57","59.3","","439.50","225.34","1872.27","197","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 10X380MM LONG 125DEG BONE GAMMA3 TITANIUM RIGHT","SUP-ITM-10091784","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","385.32","55.36","1815.62","58","3598.29","5645.72","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","AETNA [1001]","HB CH AETNA HMO / PPO","2536.59","58.3","","554.95","91.85","1421.75","94","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3176.17","73","","2490.03","2490.03","2490.03","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2536.59","58.3","","750.00","750.00","750.00","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2305.99","53","","1192.50","120.84","4149.90","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3698.28","85","","750.00","75.00","750.00","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4350.92","100","","657.00","121.50","1971.00","14","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4350.92","100","","75.00","75.00","75.00","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4350.92","100","","366.00","144.00","1971.00","45","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3176.17","73","","667.50","667.50","667.50","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.98","44.45","","123.77","123.77","123.77","1 through 10","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","both","","","4350.92","3263.19","WELLPOINT [1015]","HB CH WELLPOINT","3389.80","77.91","","483.51","229.32","1316.08","96","1933.98","4350.92","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.92","3263.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2580.10","59.3","","439.50","225.34","1872.27","197","2175.46","3413.3","percent of total billed charges",""
"KIT NAIL 15.5 11X180MM 125DEG SCREW FEMORAL GAMMA3 TITANIUM TROCHANTERIC","SUP-ITM-10020574","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4350.92","3263.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3413.30","78.45","","385.32","55.36","1815.62","58","2175.46","3413.3","percent of total billed charges",""
"KIT NEUROMODULATION SPINAL CORD REMOTE CONTROL FREELINK","SUP-ITM-10230011","CDM","C1787","HCPCS","0270","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","2948.77","2948.77","2948.77","1 through 10","1272","2400","percent of total billed charges",""
"KIT NEUROMODULATION SPINAL CORD REMOTE CONTROL FREELINK","SUP-ITM-10230011","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","4673.98","4673.98","4673.98","1 through 10","1066.8","1882.8","percent of total billed charges",""
"KIT PADDLE 90CM LEAD","SUP-ITM-10203893","CDM","C1778","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1033.50","53","","3922.00","3922.00","3922.00","1 through 10","1033.5","1950","percent of total billed charges",""
"KIT PADDLE 90CM LEAD","SUP-ITM-10203893","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","3013.82","3013.82","3013.82","1 through 10","866.78","1529.78","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","554.95","91.85","1421.75","94","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","2490.03","2490.03","2490.03","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","750.00","750.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","1192.50","120.84","4149.90","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","510.00","85","","750.00","75.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","600.00","100","","657.00","121.50","1971.00","14","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","600.00","100","","75.00","75.00","75.00","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","600.00","100","","366.00","144.00","1971.00","45","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","667.50","667.50","667.50","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","123.77","123.77","123.77","1 through 10","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","483.51","229.32","1316.08","96","266.7","600","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","439.50","225.34","1872.27","197","300","470.7","percent of total billed charges",""
"KIT PIN 2.7MM BONE ABSORBABLE 2 SLEEVE INTERLOCKING TROCAR ACL FEMORAL FIXATION BX/1EA","SUP-ITM-10014637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","385.32","55.36","1815.62","58","300","470.7","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","AETNA [1001]","HB CH AETNA HMO / PPO","1081.67","58.3","","1634.24","1004.95","1718.99","42","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1354.41","73","","2123.89","1900.92","2123.89","1 through 10","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1081.67","58.3","","3729.00","1254.19","3729.00","1 through 10","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","983.34","53","","939.37","939.37","5593.65","1 through 10","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1577.05","85","","2323.25","1864.50","2882.25","16","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1855.35","100","","2909.44","1772.40","10952.08","45","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1855.35","100","","2323.25","2323.25","2323.25","1 through 10","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1855.35","100","","2882.25","1772.40","10169.17","187","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1354.41","73","","1659.41","1659.41","1659.41","1 through 10","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","both","","","1855.35","1391.51","WELLPOINT [1015]","HB CH WELLPOINT","1445.50","77.91","","2050.91","1468.48","2902.83","52","824.7","1855.35","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1855.35","1391.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","1100.22","59.3","","1548.60","1092.60","3613.79","82","927.68","1455.52","percent of total billed charges",""
"KIT PIN XSM ELBOW 32 8105 27 01 COONRAD/MORREY TOTAL 04 05","SUP-ITM-10020521","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1855.35","1391.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1455.52","78.45","","2085.51","998.68","6202.11","56","927.68","1455.52","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","3922.00","3922.00","3922.00","1 through 10","238.5","450","percent of total billed charges",""
"KIT PLUG 29CM ACCESSORY NEUROSTIMULATION OCTOPOLAR INLINE LOW PROFILE CLOSED BOOT KT/1EA","SUP-ITM-10018141","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","3013.82","3013.82","3013.82","1 through 10","200.03","353.03","percent of total billed charges",""
"KIT PNEUMOTHORAX X RX 8FR 6.44IN 16CM 18GA SHARPS SAFETY FEATURE CS/5EA","SUP-ITM-10009699","CDM","C1729","HCPCS","0272","RC","","","","both","","","295.37","221.53","WELLPOINT [1015]","HB CH WELLPOINT","230.12","77.91","","60.00","47.26","60.00","1 through 10","131.29","295.37","percent of total billed charges",""
"KIT PNEUMOTHORAX X RX 8FR 6.44IN 16CM 18GA SHARPS SAFETY FEATURE CS/5EA","SUP-ITM-10009699","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","295.37","221.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","231.72","78.45","","28.02","28.02","28.02","1 through 10","147.69","231.72","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","AETNA [1001]","HB CH AETNA HMO / PPO","100.74","58.3","","1634.24","1004.95","1718.99","42","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","126.14","73","","2123.89","1900.92","2123.89","1 through 10","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.74","58.3","","3729.00","1254.19","3729.00","1 through 10","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.58","53","","939.37","939.37","5593.65","1 through 10","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","146.88","85","","2323.25","1864.50","2882.25","16","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","172.80","100","","2909.44","1772.40","10952.08","45","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","172.80","100","","2323.25","2323.25","2323.25","1 through 10","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","172.80","100","","2882.25","1772.40","10169.17","187","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.14","73","","1659.41","1659.41","1659.41","1 through 10","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","both","","","172.80","129.60","WELLPOINT [1015]","HB CH WELLPOINT","134.63","77.91","","2050.91","1468.48","2902.83","52","76.81","172.8","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.80","129.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.47","59.3","","1548.60","1092.60","3613.79","82","86.4","135.56","percent of total billed charges",""
"KIT PREP SIZE 1 8 TRIATHLON PRECISION TIBIAL SIZ NON ED 12","SUP-ITM-10119914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","172.80","129.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.56","78.45","","2085.51","998.68","6202.11","56","86.4","135.56","percent of total billed charges",""
"KIT PROCEDURE SYSTEM STIMULATION SPINAL CORD SENZA II IPG 2500 PAIN MANAGEMENT STERILE","SUP-ITM-10266909","CDM","C1822","HCPCS","0278","RC","","","","both","","","53000.00","39750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28090.00","53","","16922.90","16922.90","16922.90","1 through 10","28090","53000","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","both","","","3564.00","2673.00","WELLPOINT [1015]","HB CH WELLPOINT","2776.71","77.91","","2948.77","2948.77","2948.77","1 through 10","1888.92","3564","percent of total billed charges",""
"KIT REMOTE CONTROL NEVRO SENZA PATIENT PROGRAMMER EXTERNAL","SUP-ITM-10158042","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3564.00","2673.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2113.45","59.3","","4673.98","4673.98","4673.98","1 through 10","1584.2","2795.96","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","1634.24","1004.95","1718.99","42","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","2123.89","1900.92","2123.89","1 through 10","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1565.36","58.3","","3729.00","1254.19","3729.00","1 through 10","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","939.37","939.37","5593.65","1 through 10","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2282.25","85","","2323.25","1864.50","2882.25","16","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2685.00","100","","2909.44","1772.40","10952.08","45","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2685.00","100","","2323.25","2323.25","2323.25","1 through 10","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2685.00","100","","2882.25","1772.40","10169.17","187","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","1659.41","1659.41","1659.41","1 through 10","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","2050.91","1468.48","2902.83","52","1193.48","2685","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","1548.60","1092.60","3613.79","82","1342.5","2106.38","percent of total billed charges",""
"KIT REPAIR 1.1MM RECONSTRUCTION TIGHTROPE CMC MINI","SUP-ITM-10154166","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","2085.51","998.68","6202.11","56","1342.5","2106.38","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","AETNA [1001]","HB CH AETNA HMO / PPO","2055.08","58.3","","554.95","91.85","1421.75","94","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2573.25","73","","2490.03","2490.03","2490.03","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2055.08","58.3","","750.00","750.00","750.00","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1868.25","53","","1192.50","120.84","4149.90","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2996.25","85","","750.00","75.00","750.00","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3525.00","100","","657.00","121.50","1971.00","14","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3525.00","100","","75.00","75.00","75.00","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3525.00","100","","366.00","144.00","1971.00","45","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2573.25","73","","667.50","667.50","667.50","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1566.86","44.45","","123.77","123.77","123.77","1 through 10","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","both","","","3525.00","2643.75","WELLPOINT [1015]","HB CH WELLPOINT","2746.33","77.91","","483.51","229.32","1316.08","96","1566.86","3525","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2090.33","59.3","","439.50","225.34","1872.27","197","1762.5","2765.36","percent of total billed charges",""
"KIT REPAIR ENDOSCOPIC FIXATION ANKLE KNOTLESS SYNDESMOSIS TIGHTROPE","SUP-ITM-10124185","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3525.00","2643.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2765.36","78.45","","385.32","55.36","1815.62","58","1762.5","2765.36","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","AETNA [1001]","HB CH AETNA HMO / PPO","1705.28","58.3","","554.95","91.85","1421.75","94","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","2490.03","2490.03","2490.03","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1705.28","58.3","","750.00","750.00","750.00","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1550.25","53","","1192.50","120.84","4149.90","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2486.25","85","","750.00","75.00","750.00","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2925.00","100","","657.00","121.50","1971.00","14","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2925.00","100","","75.00","75.00","75.00","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2925.00","100","","366.00","144.00","1971.00","45","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","667.50","667.50","667.50","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.16","44.45","","123.77","123.77","123.77","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","WELLPOINT [1015]","HB CH WELLPOINT","2278.87","77.91","","483.51","229.32","1316.08","96","1300.16","2925","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1734.53","59.3","","439.50","225.34","1872.27","197","1462.5","2294.66","percent of total billed charges",""
"KIT REPAIR INSTRUMENT TROCAR TIP GUIDEWIRE DRILL BIT PUNCH INTERNALBRACE LIGAMENT AUGMENTATION","SUP-ITM-10132453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2294.66","78.45","","385.32","55.36","1815.62","58","1462.5","2294.66","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.35","23.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","16.62","53","","69.13","15.86","85.00","1 through 10","13.94","31.35","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.35","23.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","26.65","85","","29.94","29.94","29.94","1 through 10","13.94","31.35","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.35","23.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","31.35","100","","60.23","29.94","60.23","12","13.94","31.35","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.35","23.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","31.35","100","","65.22","29.94","360.69","1 through 10","13.94","31.35","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","both","","","31.35","23.51","WELLPOINT [1015]","HB CH WELLPOINT","24.42","77.91","","51.37","51.37","284.08","1 through 10","13.94","31.35","percent of total billed charges",""
"KIT SET 1.0 3/4IN 20GA CATHETERIZATION ARTERIAL CS/2BX/25EA","SUP-ITM-10016272","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","31.35","23.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","24.59","78.45","","123.30","23.02","333.57","1 through 10","15.68","24.59","percent of total billed charges",""
"KIT STENT 7.0FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10003697","CDM","C2617","HCPCS","0278","RC","","","","both","","","557.04","417.78","AETNA [1001]","HB CH AETNA HMO / PPO","324.75","58.3","","188.13","188.13","188.13","1 through 10","247.6","557.04","percent of total billed charges",""
"KIT STENT 7.0FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10003697","CDM","C2617","HCPCS","0278","RC","","","","both","","","557.04","417.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","557.04","100","","331.80","331.80","331.80","1 through 10","247.6","557.04","percent of total billed charges",""
"KIT STENT 7.0FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10003697","CDM","C2617","HCPCS","0278","RC","","","","both","","","557.04","417.78","WELLPOINT [1015]","HB CH WELLPOINT","433.99","77.91","","593.13","261.33","593.13","1 through 10","247.6","557.04","percent of total billed charges",""
"KIT STENT 7.0FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10003697","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","557.04","417.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","330.32","59.3","","194.44","194.43","583.31","13","278.52","437","percent of total billed charges",""
"KIT STENT 7.0FRX28CM URETERAL DOUBLE J CLOSED TIP SILICONE PTFE COATED GUIDEWIRE PUSH CATHETER","SUP-ITM-10003697","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","557.04","417.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","437.00","78.45","","255.09","255.09","255.09","1 through 10","278.52","437","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","989.22","741.91","AETNA [1001]","HB CH AETNA HMO / PPO","576.72","58.3","","188.13","188.13","188.13","1 through 10","439.71","989.22","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","989.22","741.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","989.22","100","","331.80","331.80","331.80","1 through 10","439.71","989.22","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","both","","","989.22","741.91","WELLPOINT [1015]","HB CH WELLPOINT","770.70","77.91","","593.13","261.33","593.13","1 through 10","439.71","989.22","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","989.22","741.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","586.61","59.3","","194.44","194.43","583.31","13","494.61","776.04","percent of total billed charges",""
"KIT STENT 90CMX8.5FR 2 .028 URETERAL SILICONE GUIDEWIRE PTFE COAT SINGLE J DIVERSION","SUP-ITM-10020620","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","989.22","741.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","776.04","78.45","","255.09","255.09","255.09","1 through 10","494.61","776.04","percent of total billed charges",""
"KIT STIMULATOR SPINAL CORD SENZA II IPG PT CHARGER AND REMOTE","SUP-ITM-10235076","CDM","C1822","HCPCS","0278","RC","","","","both","","","43400.00","32550.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","23002.00","53","","16922.90","16922.90","16922.90","1 through 10","23002","43400","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","AETNA [1001]","HB CH AETNA HMO / PPO","1705.28","58.3","","1634.24","1004.95","1718.99","42","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","2123.89","1900.92","2123.89","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1705.28","58.3","","3729.00","1254.19","3729.00","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1550.25","53","","939.37","939.37","5593.65","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2486.25","85","","2323.25","1864.50","2882.25","16","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2925.00","100","","2909.44","1772.40","10952.08","45","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2925.00","100","","2323.25","2323.25","2323.25","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2925.00","100","","2882.25","1772.40","10169.17","187","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","1659.41","1659.41","1659.41","1 through 10","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","WELLPOINT [1015]","HB CH WELLPOINT","2278.87","77.91","","2050.91","1468.48","2902.83","52","1300.16","2925","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1734.53","59.3","","1548.60","1092.60","3613.79","82","1462.5","2294.66","percent of total billed charges",""
"KIT SUBSTANCE 4.75MM ARCHILLES BIOCOMPOSITE SPEEDBRIDGE MID","SUP-ITM-10154170","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2294.66","78.45","","2085.51","998.68","6202.11","56","1462.5","2294.66","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","554.95","91.85","1421.75","94","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","2490.03","2490.03","2490.03","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","750.00","750.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","1192.50","120.84","4149.90","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","701.25","85","","750.00","75.00","750.00","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","825.00","100","","657.00","121.50","1971.00","14","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","825.00","100","","75.00","75.00","75.00","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","825.00","100","","366.00","144.00","1971.00","45","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","667.50","667.50","667.50","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.71","44.45","","123.77","123.77","123.77","1 through 10","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","483.51","229.32","1316.08","96","366.71","825","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","439.50","225.34","1872.27","197","412.5","647.21","percent of total billed charges",""
"KIT SWIVELOCK 3.5X8.5MM DX SL LIGAMENT REPAIR","SUP-ITM-10156090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","385.32","55.36","1815.62","58","412.5","647.21","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","AETNA [1001]","HB CH AETNA HMO / PPO","2666.64","58.3","","1830.28","315.58","1830.28","1 through 10","2033.14","4574","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3339.02","73","","4170.85","4170.85","4170.85","1 through 10","2033.14","4574","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2033.14","44.45","","649.55","649.55","649.55","1 through 10","2033.14","4574","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","both","","","4574.00","3430.50","WELLPOINT [1015]","HB CH WELLPOINT","3563.60","77.91","","8998.38","2542.37","8998.38","20","2033.14","4574","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4574.00","3430.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2712.38","59.3","","1891.61","1609.14","3664.18","25","2287","3588.3","percent of total billed charges",""
"KIT TRAY 10/2 BONE KYPHOPAK EXPRESS ADDITIONAL FRACTURE OSTEO INTRODUCER","SUP-ITM-10026846","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","4574.00","3430.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3588.30","78.45","","1470.68","1310.06","2481.69","19","2287","3588.3","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","AETNA [1001]","HB CH AETNA HMO / PPO","4065.84","58.3","","1830.28","315.58","1830.28","1 through 10","3099.94","6974","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5091.02","73","","4170.85","4170.85","4170.85","1 through 10","3099.94","6974","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3099.94","44.45","","649.55","649.55","649.55","1 through 10","3099.94","6974","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","both","","","6974.00","5230.50","WELLPOINT [1015]","HB CH WELLPOINT","5433.44","77.91","","8998.38","2542.37","8998.38","20","3099.94","6974","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6974.00","5230.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4135.58","59.3","","1891.61","1609.14","3664.18","25","3487","5471.1","percent of total billed charges",""
"KIT TRAY 15/2 BONE KYPHOPAK EXPRESS FIRST FRACTURE OSTEO INTRODUCER","SUP-ITM-10017987","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","6974.00","5230.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5471.10","78.45","","1470.68","1310.06","2481.69","19","3487","5471.1","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","3922.00","3922.00","3922.00","1 through 10","2120","4000","percent of total billed charges",""
"KIT TRIAL 50CM AXIUM LEAD SLIMTIP PERI OP IMPLANT DEVICES NEUROMODULATION","SUP-ITM-10174962","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","3013.82","3013.82","3013.82","1 through 10","1778","3138","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","AETNA [1001]","HB CH AETNA HMO / PPO","1836.45","58.3","","1786.05","1786.05","1786.05","1 through 10","712.5","2454.17","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1836.45","58.3","","3150.00","3150.00","3150.00","1 through 10","712.5","2454.17","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","both","","","3150.00","2362.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1669.50","53","","1669.50","1669.50","1669.50","1 through 10","712.5","2454.17","percent of total billed charges",""
"KIT URETHRAL BULKAMID","SUP-ITM-10287459","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","3150.00","2362.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1867.95","59.3","","1845.90","1845.90","1845.90","1 through 10","1400.18","2471.18","percent of total billed charges",""
"Knee And Lower Leg Procedures Except Foot,EXTREME","313","DRG","","","","","","","","inpatient","","","226339.40","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","45470.74","","Case rate ($50,275.72). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $92,705.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $10,025.58 and the sum of the standard inlier and any outlier amount.","1997.85","1997.85","50263.38","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","144712.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","60267.68","","Standard inlier is a Case rate ($60,267.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $73,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,555.23) for the length of stay and the standard reimbursement.","60267.67","60267.67","60267.67","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","144712.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","64739.51","","Standard inlier is a Case rate ($64,739.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $73,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($9,189.50) for the length of stay and the standard reimbursement.","61796.80","61796.80","61796.80","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MAJOR","313","DRG","","","","","","","","inpatient","","","144712.60","","MASSHEALTH [3001]","HB BWF MEDICAID","24380.38","","Case rate ($26,956.70). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $69,386.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","26950.08","26950.08","26950.08","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","39929.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","31376.75","","Standard inlier is a Case rate ($31,376.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $43,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,454.05) for the length of stay and the standard reimbursement.","29950.93","29950.93","29950.93","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","39929.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","33704.89","","Standard inlier is a Case rate ($33,704.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $43,837, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,784.27) for the length of stay and the standard reimbursement.","33704.88","32172.84","33704.89","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","39929.93","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","22300.0492","","Fee schedule rate ($22,300.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22300.0492","23800.04","23800.04","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","39929.93","","MASSHEALTH [3001]","HB BWF MEDICAID","12046.25","","Case rate ($13,319.20). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,749.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,647.95 and the sum of the standard inlier and any outlier amount.","13315.93","13315.93","13315.93","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MINOR","313","DRG","","","","","","","","inpatient","","","39929.93","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12046.25","","Case rate ($13,319.20). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,749.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,647.95 and the sum of the standard inlier and any outlier amount.","13315.93","13315.93","13315.93","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","56384.02","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","44372.79","","Standard inlier is a Case rate ($44,372.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,025, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,298.53) for the length of stay and the standard reimbursement.","42355.84","42355.84","42355.84","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","56384.02","","MASSHEALTH [3001]","HB BWF MEDICAID","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,883.66 and the sum of the standard inlier and any outlier amount.","19530.03","19530.03","19530.03","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","56384.02","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,883.66 and the sum of the standard inlier and any outlier amount.","19530.03","19530.03","19530.03","1 through 10","11861.93","234259.11","case rate",""
"Knee And Lower Leg Procedures Except Foot,MODERATE","313","DRG","","","","","","","","inpatient","","","56384.02","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","17667.83","","Case rate ($19,534.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,964.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,883.66 and the sum of the standard inlier and any outlier amount.","6312.60","6312.60","6312.60","1 through 10","11861.93","234259.11","case rate",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1634.24","1004.95","1718.99","42","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","2123.89","1900.92","2123.89","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1089.63","58.3","","3729.00","1254.19","3729.00","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","939.37","939.37","5593.65","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1588.65","85","","2323.25","1864.50","2882.25","16","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1869.00","100","","2909.44","1772.40","10952.08","45","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1869.00","100","","2323.25","2323.25","2323.25","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1869.00","100","","2882.25","1772.40","10169.17","187","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","1659.41","1659.41","1659.41","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","2050.91","1468.48","2902.83","52","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1548.60","1092.60","3613.79","82","934.5","1466.23","percent of total billed charges",""
"KNEE AUGMENT 10MM XL BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","2085.51","998.68","6202.11","56","934.5","1466.23","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","AETNA [1001]","HB CH AETNA HMO / PPO","1089.63","58.3","","1634.24","1004.95","1718.99","42","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","2123.89","1900.92","2123.89","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1089.63","58.3","","3729.00","1254.19","3729.00","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","990.57","53","","939.37","939.37","5593.65","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1588.65","85","","2323.25","1864.50","2882.25","16","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1869.00","100","","2909.44","1772.40","10952.08","45","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1869.00","100","","2323.25","2323.25","2323.25","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1869.00","100","","2882.25","1772.40","10169.17","187","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1364.37","73","","1659.41","1659.41","1659.41","1 through 10","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","both","","","1869.00","1401.75","WELLPOINT [1015]","HB CH WELLPOINT","1456.14","77.91","","2050.91","1468.48","2902.83","52","830.77","1869","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1108.32","59.3","","1548.60","1092.60","3613.79","82","934.5","1466.23","percent of total billed charges",""
"KNEE AUGMENT 10MM XS BLOCK MODULAR ROTATING HINGE","SUP-ITM-10035439","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1869.00","1401.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1466.23","78.45","","2085.51","998.68","6202.11","56","934.5","1466.23","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","1634.24","1004.95","1718.99","42","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","2123.89","1900.92","2123.89","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","816.78","58.3","","3729.00","1254.19","3729.00","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","939.37","939.37","5593.65","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1190.85","85","","2323.25","1864.50","2882.25","16","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1401.00","100","","2909.44","1772.40","10952.08","45","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1401.00","100","","2323.25","2323.25","2323.25","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1401.00","100","","2882.25","1772.40","10169.17","187","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","1659.41","1659.41","1659.41","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","2050.91","1468.48","2902.83","52","622.74","1401","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","1548.60","1092.60","3613.79","82","700.5","1099.08","percent of total billed charges",""
"KNEE AUGMENT 5.0MM SIZE 5 TRIATHLON COBALT 09","SUP-ITM-10061780","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","2085.51","998.68","6202.11","56","700.5","1099.08","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","AETNA [1001]","HB CH AETNA HMO / PPO","797.54","58.3","","1634.24","1004.95","1718.99","42","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","998.64","73","","2123.89","1900.92","2123.89","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","797.54","58.3","","3729.00","1254.19","3729.00","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","725.04","53","","939.37","939.37","5593.65","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1162.80","85","","2323.25","1864.50","2882.25","16","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1368.00","100","","2909.44","1772.40","10952.08","45","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1368.00","100","","2323.25","2323.25","2323.25","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1368.00","100","","2882.25","1772.40","10169.17","187","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","998.64","73","","1659.41","1659.41","1659.41","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","WELLPOINT [1015]","HB CH WELLPOINT","1065.81","77.91","","2050.91","1468.48","2902.83","52","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","811.22","59.3","","1548.60","1092.60","3613.79","82","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE 11MM SZ 4 TIBIAL GENESIS II LAT6EX FREE POLYETHYLENE CRUCIATE RETAINING LT","SUP-ITM-10121188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1073.20","78.45","","2085.51","998.68","6202.11","56","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","554.95","91.85","1421.75","94","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","2490.03","2490.03","2490.03","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","750.00","750.00","750.00","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","1192.50","120.84","4149.90","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1606.50","85","","750.00","75.00","750.00","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1890.00","100","","657.00","121.50","1971.00","14","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1890.00","100","","75.00","75.00","75.00","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1890.00","100","","366.00","144.00","1971.00","45","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","667.50","667.50","667.50","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","840.11","44.45","","123.77","123.77","123.77","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","483.51","229.32","1316.08","96","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","439.50","225.34","1872.27","197","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE 27X47MM SZ 3 FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL","SUP-ITM-10014787","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","385.32","55.36","1815.62","58","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"KNEE BASEPLATE 60X85MM SIZE 8 TIBIAL TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED","SUP-ITM-10159262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","554.95","91.85","1421.75","94","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","2490.03","2490.03","2490.03","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.96","58.3","","750.00","750.00","750.00","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","1192.50","120.84","4149.90","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1686.83","85","","750.00","75.00","750.00","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1984.50","100","","657.00","121.50","1971.00","14","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1984.50","100","","75.00","75.00","75.00","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1984.50","100","","366.00","144.00","1971.00","45","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","667.50","667.50","667.50","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","882.11","44.45","","123.77","123.77","123.77","1 through 10","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","483.51","229.32","1316.08","96","882.11","1984.5","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","439.50","225.34","1872.27","197","992.25","1556.84","percent of total billed charges",""
"KNEE BASEPLATE 66X42MM SIZE 3 TIBIAL NEXGEN POLYETHYLENE CONSTRAINED CONDYLAR TIVANIUM PMMA STEMMED PRECOAT CS/1BX/1EA","SUP-ITM-10016780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","385.32","55.36","1815.62","58","992.25","1556.84","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","AETNA [1001]","HB CH AETNA HMO / PPO","797.54","58.3","","1634.24","1004.95","1718.99","42","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","998.64","73","","2123.89","1900.92","2123.89","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","797.54","58.3","","3729.00","1254.19","3729.00","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","725.04","53","","939.37","939.37","5593.65","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1162.80","85","","2323.25","1864.50","2882.25","16","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1368.00","100","","2909.44","1772.40","10952.08","45","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1368.00","100","","2323.25","2323.25","2323.25","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1368.00","100","","2882.25","1772.40","10169.17","187","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","998.64","73","","1659.41","1659.41","1659.41","1 through 10","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","both","","","1368.00","1026.00","WELLPOINT [1015]","HB CH WELLPOINT","1065.81","77.91","","2050.91","1468.48","2902.83","52","608.08","1368","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","811.22","59.3","","1548.60","1092.60","3613.79","82","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE 9MM SIZE 3 TIBIAL GENESIS II POLYETHYLENE CRUCIATE RETAINING RIGHT","SUP-ITM-10121214","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1368.00","1026.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1073.20","78.45","","2085.51","998.68","6202.11","56","684","1073.2","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1634.24","1004.95","1718.99","42","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2123.89","1900.92","2123.89","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","939.37","939.37","5593.65","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","2323.25","1864.50","2882.25","16","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","2909.44","1772.40","10952.08","45","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","2323.25","2323.25","2323.25","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","2882.25","1772.40","10169.17","187","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","1659.41","1659.41","1659.41","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","2050.91","1468.48","2902.83","52","1466.85","3300","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1548.60","1092.60","3613.79","82","1650","2588.85","percent of total billed charges",""
"KNEE BASEPLATE F 55.5X25MM FEMORAL NEXGEN ZIMALOY PRECOAT UNICOMPARTMENTAL HIGH FLEX LT MEDIAL RT LATERAL SIZE","SUP-ITM-10017421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","2085.51","998.68","6202.11","56","1650","2588.85","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","554.95","91.85","1421.75","94","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2490.03","2490.03","2490.03","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","750.00","750.00","750.00","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","1192.50","120.84","4149.90","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","750.00","75.00","750.00","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","657.00","121.50","1971.00","14","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","75.00","75.00","75.00","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","366.00","144.00","1971.00","45","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","667.50","667.50","667.50","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","123.77","123.77","123.77","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","483.51","229.32","1316.08","96","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","439.50","225.34","1872.27","197","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE SIZE 1 TIBIAL TRIATHLON REVISION TITANIUM STABILIZED","SUP-ITM-10034431","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","385.32","55.36","1815.62","58","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1634.24","1004.95","1718.99","42","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","2123.89","1900.92","2123.89","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","3729.00","1254.19","3729.00","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","939.37","939.37","5593.65","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1606.50","85","","2323.25","1864.50","2882.25","16","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1890.00","100","","2909.44","1772.40","10952.08","45","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1890.00","100","","2323.25","2323.25","2323.25","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1890.00","100","","2882.25","1772.40","10169.17","187","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","1659.41","1659.41","1659.41","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","2050.91","1468.48","2902.83","52","840.11","1890","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1548.60","1092.60","3613.79","82","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE SZ 3 IMPLANT TIBIAL BASE NON POROUS CEMENTED TI ALLOY GENESIS II LT 03A CS/1BX/1EA","SUP-ITM-10011025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","2085.51","998.68","6202.11","56","945","1482.71","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1634.24","1004.95","1718.99","42","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","2123.89","1900.92","2123.89","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1944.89","58.3","","3729.00","1254.19","3729.00","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","939.37","939.37","5593.65","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2835.60","85","","2323.25","1864.50","2882.25","16","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3336.00","100","","2909.44","1772.40","10952.08","45","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3336.00","100","","2323.25","2323.25","2323.25","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3336.00","100","","2882.25","1772.40","10169.17","187","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","1659.41","1659.41","1659.41","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","2050.91","1468.48","2902.83","52","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1548.60","1092.60","3613.79","82","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL ATTUNE CRUCIATE SACRIFICING FIXED BEARING CEMENTED","SUP-ITM-10197901","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","2085.51","998.68","6202.11","56","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1634.24","1004.95","1718.99","42","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","2123.89","1900.92","2123.89","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1944.89","58.3","","3729.00","1254.19","3729.00","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","939.37","939.37","5593.65","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2835.60","85","","2323.25","1864.50","2882.25","16","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3336.00","100","","2909.44","1772.40","10952.08","45","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3336.00","100","","2323.25","2323.25","2323.25","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3336.00","100","","2882.25","1772.40","10169.17","187","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","1659.41","1659.41","1659.41","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","2050.91","1468.48","2902.83","52","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1548.60","1092.60","3613.79","82","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 4 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10018361","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","2085.51","998.68","6202.11","56","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","554.95","91.85","1421.75","94","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","2490.03","2490.03","2490.03","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1944.89","58.3","","750.00","750.00","750.00","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","1192.50","120.84","4149.90","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2835.60","85","","750.00","75.00","750.00","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3336.00","100","","657.00","121.50","1971.00","14","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3336.00","100","","75.00","75.00","75.00","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3336.00","100","","366.00","144.00","1971.00","45","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","667.50","667.50","667.50","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1482.85","44.45","","123.77","123.77","123.77","1 through 10","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","483.51","229.32","1316.08","96","1482.85","3336","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","439.50","225.34","1872.27","197","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 5 TIBIAL LEGION RK TI REVISION CEMENTED FEMALE TAPERED LT","SUP-ITM-10022734","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","385.32","55.36","1815.62","58","1668","2617.09","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1634.24","1004.95","1718.99","42","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2123.89","1900.92","2123.89","1 through 10","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","3729.00","1254.19","3729.00","1 through 10","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","939.37","939.37","5593.65","1 through 10","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","2323.25","1864.50","2882.25","16","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","2909.44","1772.40","10952.08","45","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","2323.25","2323.25","2323.25","1 through 10","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","2882.25","1772.40","10169.17","187","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","1659.41","1659.41","1659.41","1 through 10","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","2050.91","1468.48","2902.83","52","1066.8","2400","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1548.60","1092.60","3613.79","82","1200","1882.8","percent of total billed charges",""
"KNEE BASEPLATE SZ 7 TIBIAL TRIATHLON PRIMARY COBALT CHROMIUM CEMENTED","SUP-ITM-10017025","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","2085.51","998.68","6202.11","56","1200","1882.8","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 4 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10021345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"KNEE BASEPLATE UNIVERSAL SIZE 5 TIBIAL TRIATHLON TITANIUM REVISION STABILIZED","SUP-ITM-10030197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE BEARING 12.5MM LG INSERT COMPONENT DEPUY MENISCAL BRIDGING STANDARD UHMWPE","SUP-ITM-10118794","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1634.24","1004.95","1718.99","42","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","2123.89","1900.92","2123.89","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.15","58.3","","3729.00","1254.19","3729.00","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","939.37","939.37","5593.65","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1274.49","85","","2323.25","1864.50","2882.25","16","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1499.40","100","","2909.44","1772.40","10952.08","45","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1499.40","100","","2323.25","2323.25","2323.25","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1499.40","100","","2882.25","1772.40","10169.17","187","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","1659.41","1659.41","1659.41","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","2050.91","1468.48","2902.83","52","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1548.60","1092.60","3613.79","82","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING 4MM LG COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC RT","SUP-ITM-10019766","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","2085.51","998.68","6202.11","56","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1634.24","1004.95","1718.99","42","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","2123.89","1900.92","2123.89","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.15","58.3","","3729.00","1254.19","3729.00","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","939.37","939.37","5593.65","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1274.49","85","","2323.25","1864.50","2882.25","16","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1499.40","100","","2909.44","1772.40","10952.08","45","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1499.40","100","","2323.25","2323.25","2323.25","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1499.40","100","","2882.25","1772.40","10169.17","187","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","1659.41","1659.41","1659.41","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","2050.91","1468.48","2902.83","52","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1548.60","1092.60","3613.79","82","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING 5MM LG OXFORD ARCOM POLYETHYLENE ANATOMIC MENISCAL RT","SUP-ITM-10024609","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","2085.51","998.68","6202.11","56","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","AETNA [1001]","HB CH AETNA HMO / PPO","2031.11","58.3","","1634.24","1004.95","1718.99","42","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2543.25","73","","2123.89","1900.92","2123.89","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.11","58.3","","3729.00","1254.19","3729.00","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.47","53","","939.37","939.37","5593.65","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2961.32","85","","2323.25","1864.50","2882.25","16","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3483.90","100","","2909.44","1772.40","10952.08","45","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3483.90","100","","2323.25","2323.25","2323.25","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3483.90","100","","2882.25","1772.40","10169.17","187","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2543.25","73","","1659.41","1659.41","1659.41","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","WELLPOINT [1015]","HB CH WELLPOINT","2714.31","77.91","","2050.91","1468.48","2902.83","52","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","2065.95","59.3","","1548.60","1092.60","3613.79","82","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD B4 RIGHT","SUP-ITM-10230006","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.12","78.45","","2085.51","998.68","6202.11","56","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","AETNA [1001]","HB CH AETNA HMO / PPO","2031.11","58.3","","1634.24","1004.95","1718.99","42","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2543.25","73","","2123.89","1900.92","2123.89","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.11","58.3","","3729.00","1254.19","3729.00","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.47","53","","939.37","939.37","5593.65","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2961.32","85","","2323.25","1864.50","2882.25","16","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3483.90","100","","2909.44","1772.40","10952.08","45","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3483.90","100","","2323.25","2323.25","2323.25","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3483.90","100","","2882.25","1772.40","10169.17","187","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2543.25","73","","1659.41","1659.41","1659.41","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","WELLPOINT [1015]","HB CH WELLPOINT","2714.31","77.91","","2050.91","1468.48","2902.83","52","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","2065.95","59.3","","1548.60","1092.60","3613.79","82","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD D3 LEFT TIBIAL","SUP-ITM-10233839","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.12","78.45","","2085.51","998.68","6202.11","56","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","AETNA [1001]","HB CH AETNA HMO / PPO","2031.11","58.3","","1634.24","1004.95","1718.99","42","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2543.25","73","","2123.89","1900.92","2123.89","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.11","58.3","","3729.00","1254.19","3729.00","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1846.47","53","","939.37","939.37","5593.65","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2961.32","85","","2323.25","1864.50","2882.25","16","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3483.90","100","","2909.44","1772.40","10952.08","45","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3483.90","100","","2323.25","2323.25","2323.25","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3483.90","100","","2882.25","1772.40","10169.17","187","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2543.25","73","","1659.41","1659.41","1659.41","1 through 10","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","both","","","3483.90","2612.92","WELLPOINT [1015]","HB CH WELLPOINT","2714.31","77.91","","2050.91","1468.48","2902.83","52","1548.59","3483.9","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","2065.95","59.3","","1548.60","1092.60","3613.79","82","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING LATERAL FIXED OXFORD F3 LEFT","SUP-ITM-10238790","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3483.90","2612.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.12","78.45","","2085.51","998.68","6202.11","56","1741.95","2733.12","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1634.24","1004.95","1718.99","42","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","2123.89","1900.92","2123.89","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.15","58.3","","3729.00","1254.19","3729.00","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","939.37","939.37","5593.65","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1274.49","85","","2323.25","1864.50","2882.25","16","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1499.40","100","","2909.44","1772.40","10952.08","45","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1499.40","100","","2323.25","2323.25","2323.25","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1499.40","100","","2882.25","1772.40","10169.17","187","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","1659.41","1659.41","1659.41","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","2050.91","1468.48","2902.83","52","666.48","1499.4","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1548.60","1092.60","3613.79","82","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING MEDIUM SIZE 4 COMPONENT TIBIAL OXFORD POLYETHYLENE MENISCAL ANATOMIC LEFT","SUP-ITM-10019827","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","2085.51","998.68","6202.11","56","749.7","1176.28","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"KNEE BEARING TIBIAL","SUP-ITM-10035494","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","1634.24","1004.95","1718.99","42","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","2123.89","1900.92","2123.89","1 through 10","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.72","58.3","","3729.00","1254.19","3729.00","1 through 10","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","939.37","939.37","5593.65","1 through 10","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","714.00","85","","2323.25","1864.50","2882.25","16","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","840.00","100","","2909.44","1772.40","10952.08","45","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","840.00","100","","2323.25","2323.25","2323.25","1 through 10","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","840.00","100","","2882.25","1772.40","10169.17","187","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","1659.41","1659.41","1659.41","1 through 10","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","2050.91","1468.48","2902.83","52","373.38","840","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","1548.60","1092.60","3613.79","82","420","658.98","percent of total billed charges",""
"KNEE COMPONENT 41MM PATELLA OVAL DOME 3 PEG PFC SIGMA 06 CS/1BX/1EA","SUP-ITM-10004958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","2085.51","998.68","6202.11","56","420","658.98","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","AETNA [1001]","HB CH AETNA HMO / PPO","4088.00","58.3","","1634.24","1004.95","1718.99","42","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5118.76","73","","2123.89","1900.92","2123.89","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4088.00","58.3","","3729.00","1254.19","3729.00","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3716.36","53","","939.37","939.37","5593.65","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5960.20","85","","2323.25","1864.50","2882.25","16","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7012.00","100","","2909.44","1772.40","10952.08","45","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7012.00","100","","2323.25","2323.25","2323.25","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7012.00","100","","2882.25","1772.40","10169.17","187","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5118.76","73","","1659.41","1659.41","1659.41","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","WELLPOINT [1015]","HB CH WELLPOINT","5463.05","77.91","","2050.91","1468.48","2902.83","52","3116.83","7012","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7012.00","5259.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4158.12","59.3","","1548.60","1092.60","3613.79","82","3506","5500.91","percent of total billed charges",""
"KNEE COMPONENT FULL KIT PRICE IPOLY XE KNEE COMPONET MEDIAL","SUP-ITM-10283598","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7012.00","5259.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5500.91","78.45","","2085.51","998.68","6202.11","56","3506","5500.91","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","1634.24","1004.95","1718.99","42","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","2123.89","1900.92","2123.89","1 through 10","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","3729.00","1254.19","3729.00","1 through 10","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","939.37","939.37","5593.65","1 through 10","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","739.50","85","","2323.25","1864.50","2882.25","16","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","870.00","100","","2909.44","1772.40","10952.08","45","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","870.00","100","","2323.25","2323.25","2323.25","1 through 10","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","870.00","100","","2882.25","1772.40","10169.17","187","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","1659.41","1659.41","1659.41","1 through 10","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","2050.91","1468.48","2902.83","52","386.72","870","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","1548.60","1092.60","3613.79","82","435","682.52","percent of total billed charges",""
"KNEE COMPONENT SURGICAL PLAN","SUP-ITM-10283596","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","2085.51","998.68","6202.11","56","435","682.52","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","AETNA [1001]","HB CH AETNA HMO / PPO","2766.92","58.3","","1634.24","1004.95","1718.99","42","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3464.58","73","","2123.89","1900.92","2123.89","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2766.92","58.3","","3729.00","1254.19","3729.00","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2515.38","53","","939.37","939.37","5593.65","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4034.10","85","","2323.25","1864.50","2882.25","16","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4746.00","100","","2909.44","1772.40","10952.08","45","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4746.00","100","","2323.25","2323.25","2323.25","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4746.00","100","","2882.25","1772.40","10169.17","187","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3464.58","73","","1659.41","1659.41","1659.41","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","WELLPOINT [1015]","HB CH WELLPOINT","3697.61","77.91","","2050.91","1468.48","2902.83","52","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1548.60","1092.60","3613.79","82","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT SZ 5 L FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3723.24","78.45","","2085.51","998.68","6202.11","56","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","AETNA [1001]","HB CH AETNA HMO / PPO","2766.92","58.3","","1634.24","1004.95","1718.99","42","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3464.58","73","","2123.89","1900.92","2123.89","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2766.92","58.3","","3729.00","1254.19","3729.00","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2515.38","53","","939.37","939.37","5593.65","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4034.10","85","","2323.25","1864.50","2882.25","16","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4746.00","100","","2909.44","1772.40","10952.08","45","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4746.00","100","","2323.25","2323.25","2323.25","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4746.00","100","","2882.25","1772.40","10169.17","187","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3464.58","73","","1659.41","1659.41","1659.41","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","WELLPOINT [1015]","HB CH WELLPOINT","3697.61","77.91","","2050.91","1468.48","2902.83","52","2109.6","4746","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1548.60","1092.60","3613.79","82","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT SZ 7 R FEMORAL REV CCR PERSONA PLS","SUP-ITM-10267966","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3723.24","78.45","","2085.51","998.68","6202.11","56","2373","3723.24","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","1634.24","1004.95","1718.99","42","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2557.04","73","","2123.89","1900.92","2123.89","1 through 10","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2042.13","58.3","","3729.00","1254.19","3729.00","1 through 10","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","939.37","939.37","5593.65","1 through 10","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2977.38","85","","2323.25","1864.50","2882.25","16","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3502.80","100","","2909.44","1772.40","10952.08","45","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3502.80","100","","2323.25","2323.25","2323.25","1 through 10","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3502.80","100","","2882.25","1772.40","10169.17","187","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2557.04","73","","1659.41","1659.41","1659.41","1 through 10","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","2050.91","1468.48","2902.83","52","1556.99","3502.8","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1548.60","1092.60","3613.79","82","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT TIBIAL STERILE LF","SUP-ITM-10268188","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","2085.51","998.68","6202.11","56","1751.4","2747.95","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","AETNA [1001]","HB CH AETNA HMO / PPO","8082.71","58.3","","554.95","91.85","1421.75","94","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","10120.72","73","","2490.03","2490.03","2490.03","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8082.71","58.3","","750.00","750.00","750.00","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7347.92","53","","1192.50","120.84","4149.90","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","11784.40","85","","750.00","75.00","750.00","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","13864.00","100","","657.00","121.50","1971.00","14","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","13864.00","100","","75.00","75.00","75.00","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","13864.00","100","","366.00","144.00","1971.00","45","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10120.72","73","","667.50","667.50","667.50","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6162.55","44.45","","123.77","123.77","123.77","1 through 10","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","both","","","13864.00","10398.00","WELLPOINT [1015]","HB CH WELLPOINT","10801.44","77.91","","483.51","229.32","1316.08","96","6162.55","13864","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13864.00","10398.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","8221.35","59.3","","439.50","225.34","1872.27","197","6932","10876.31","percent of total billed charges",""
"KNEE COMPONENT XS 66X73MM TIBIAL LPS COBALT CHROMIUM POROUS COATING CEMENT PROXIMAL","SUP-ITM-10119746","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","13864.00","10398.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","10876.31","78.45","","385.32","55.36","1815.62","58","6932","10876.31","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","AETNA [1001]","HB CH AETNA HMO / PPO","3539.98","58.3","","1634.24","1004.95","1718.99","42","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4432.56","73","","2123.89","1900.92","2123.89","1 through 10","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3539.98","58.3","","3729.00","1254.19","3729.00","1 through 10","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3218.16","53","","939.37","939.37","5593.65","1 through 10","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5161.20","85","","2323.25","1864.50","2882.25","16","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6072.00","100","","2909.44","1772.40","10952.08","45","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6072.00","100","","2323.25","2323.25","2323.25","1 through 10","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6072.00","100","","2882.25","1772.40","10169.17","187","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4432.56","73","","1659.41","1659.41","1659.41","1 through 10","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","both","","","6072.00","4554.00","WELLPOINT [1015]","HB CH WELLPOINT","4730.70","77.91","","2050.91","1468.48","2902.83","52","2699","6072","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3600.70","59.3","","1548.60","1092.60","3613.79","82","3036","4763.48","percent of total billed charges",""
"KNEE CONE SZ B 20MM TIBIAL IMPLANT","SUP-ITM-10175027","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6072.00","4554.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4763.48","78.45","","2085.51","998.68","6202.11","56","3036","4763.48","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","AETNA [1001]","HB CH AETNA HMO / PPO","2231.90","58.3","","1634.24","1004.95","1718.99","42","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2794.66","73","","2123.89","1900.92","2123.89","1 through 10","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2231.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2029.00","53","","939.37","939.37","5593.65","1 through 10","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3254.06","85","","2323.25","1864.50","2882.25","16","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3828.30","100","","2909.44","1772.40","10952.08","45","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3828.30","100","","2323.25","2323.25","2323.25","1 through 10","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3828.30","100","","2882.25","1772.40","10169.17","187","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2794.66","73","","1659.41","1659.41","1659.41","1 through 10","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","both","","","3828.30","2871.22","WELLPOINT [1015]","HB CH WELLPOINT","2982.63","77.91","","2050.91","1468.48","2902.83","52","1701.68","3828.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","2270.18","59.3","","1548.60","1092.60","3613.79","82","1914.15","3003.3","percent of total billed charges",""
"KNEE CONE SZ FIX TIBIAL PERSONA TRABECULAR LF METAL STERILE","SUP-ITM-10268197","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3828.30","2871.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3003.30","78.45","","2085.51","998.68","6202.11","56","1914.15","3003.3","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","AETNA [1001]","HB CH AETNA HMO / PPO","918.23","58.3","","554.95","91.85","1421.75","94","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","2490.03","2490.03","2490.03","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","918.23","58.3","","750.00","750.00","750.00","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","834.75","53","","1192.50","120.84","4149.90","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1338.75","85","","750.00","75.00","750.00","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1575.00","100","","657.00","121.50","1971.00","14","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1575.00","100","","75.00","75.00","75.00","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1575.00","100","","366.00","144.00","1971.00","45","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1149.75","73","","667.50","667.50","667.50","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","700.09","44.45","","123.77","123.77","123.77","1 through 10","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","both","","","1575.00","1181.25","WELLPOINT [1015]","HB CH WELLPOINT","1227.08","77.91","","483.51","229.32","1316.08","96","700.09","1575","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","933.98","59.3","","439.50","225.34","1872.27","197","787.5","1235.59","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTLESS - MUST BE ORDERED IN MULTIPLES OF 5","SUP-ITM-10319383","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1575.00","1181.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1235.59","78.45","","385.32","55.36","1815.62","58","787.5","1235.59","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","554.95","91.85","1421.75","94","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","2490.03","2490.03","2490.03","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","750.00","750.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","1192.50","120.84","4149.90","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1083.75","85","","750.00","75.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1275.00","100","","657.00","121.50","1971.00","14","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1275.00","100","","75.00","75.00","75.00","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1275.00","100","","366.00","144.00","1971.00","45","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","667.50","667.50","667.50","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","123.77","123.77","123.77","1 through 10","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","483.51","229.32","1316.08","96","566.74","1275","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","439.50","225.34","1872.27","197","637.5","1000.24","percent of total billed charges",""
"KNEE FIBERTAK DOUBLE KNOTTED---ORDER IN MULTIPLES OF 5---","SUP-ITM-10319384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","385.32","55.36","1815.62","58","637.5","1000.24","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA LT COMPETITOR 18","SUP-ITM-10020614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"KNEE HEAD LG AND N JOINT FEMORAL PATELLA RT COMPETITOR 18","SUP-ITM-10020618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","AETNA [1001]","HB CH AETNA HMO / PPO","874.15","58.3","","1634.24","1004.95","1718.99","42","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","2123.89","1900.92","2123.89","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.15","58.3","","3729.00","1254.19","3729.00","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","794.68","53","","939.37","939.37","5593.65","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1274.49","85","","2323.25","1864.50","2882.25","16","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1499.40","100","","2909.44","1772.40","10952.08","45","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1499.40","100","","2323.25","2323.25","2323.25","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1499.40","100","","2882.25","1772.40","10169.17","187","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1094.56","73","","1659.41","1659.41","1659.41","1 through 10","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","both","","","1499.40","1124.55","WELLPOINT [1015]","HB CH WELLPOINT","1168.18","77.91","","2050.91","1468.48","2902.83","52","666.48","1499.4","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.14","59.3","","1548.60","1092.60","3613.79","82","749.7","1176.28","percent of total billed charges",""
"KNEE IMPLANT 10MM COMPONENT ARTICULAR SURFACE PERSONA POLYETHYLENE VIVACITE E CRUCIATE RETAINING FIXED LT 4 5 CD","SUP-ITM-10202666","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1499.40","1124.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.28","78.45","","2085.51","998.68","6202.11","56","749.7","1176.28","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","AETNA [1001]","HB CH AETNA HMO / PPO","2740.10","58.3","","1634.24","1004.95","1718.99","42","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","2123.89","1900.92","2123.89","1 through 10","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2740.10","58.3","","3729.00","1254.19","3729.00","1 through 10","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2491.00","53","","939.37","939.37","5593.65","1 through 10","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3995.00","85","","2323.25","1864.50","2882.25","16","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4700.00","100","","2909.44","1772.40","10952.08","45","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4700.00","100","","2323.25","2323.25","2323.25","1 through 10","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4700.00","100","","2882.25","1772.40","10169.17","187","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","1659.41","1659.41","1659.41","1 through 10","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","WELLPOINT [1015]","HB CH WELLPOINT","3661.77","77.91","","2050.91","1468.48","2902.83","52","2089.15","4700","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2787.10","59.3","","1548.60","1092.60","3613.79","82","2350","3687.15","percent of total billed charges",""
"KNEE IMPLANT 120MM RECONSTRUCTION EXTENSION PC GLOBAL MRS ONC 03","SUP-ITM-10022600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3687.15","78.45","","2085.51","998.68","6202.11","56","2350","3687.15","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","AETNA [1001]","HB CH AETNA HMO / PPO","1830.94","58.3","","1634.24","1004.95","1718.99","42","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2292.60","73","","2123.89","1900.92","2123.89","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1830.94","58.3","","3729.00","1254.19","3729.00","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1664.49","53","","939.37","939.37","5593.65","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2669.47","85","","2323.25","1864.50","2882.25","16","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3140.55","100","","2909.44","1772.40","10952.08","45","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3140.55","100","","2323.25","2323.25","2323.25","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3140.55","100","","2882.25","1772.40","10169.17","187","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2292.60","73","","1659.41","1659.41","1659.41","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","WELLPOINT [1015]","HB CH WELLPOINT","2446.80","77.91","","2050.91","1468.48","2902.83","52","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1548.60","1092.60","3613.79","82","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED LT FEM 6 9 TIB CD","SUP-ITM-10120460","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2463.76","78.45","","2085.51","998.68","6202.11","56","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","AETNA [1001]","HB CH AETNA HMO / PPO","1830.94","58.3","","1634.24","1004.95","1718.99","42","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2292.60","73","","2123.89","1900.92","2123.89","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1830.94","58.3","","3729.00","1254.19","3729.00","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1664.49","53","","939.37","939.37","5593.65","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2669.47","85","","2323.25","1864.50","2882.25","16","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3140.55","100","","2909.44","1772.40","10952.08","45","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3140.55","100","","2323.25","2323.25","2323.25","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3140.55","100","","2882.25","1772.40","10169.17","187","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2292.60","73","","1659.41","1659.41","1659.41","1 through 10","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","both","","","3140.55","2355.41","WELLPOINT [1015]","HB CH WELLPOINT","2446.80","77.91","","2050.91","1468.48","2902.83","52","1395.97","3140.55","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1862.35","59.3","","1548.60","1092.60","3613.79","82","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 14MM COMPONENT ARTICULAR SURFACE PERSONA VIVACITE E CONTRAINED POSTERIOR STABILIZED RT FEM 3 5 TIB CD","SUP-ITM-10120488","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3140.55","2355.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2463.76","78.45","","2085.51","998.68","6202.11","56","1570.28","2463.76","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","1634.24","1004.95","1718.99","42","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","2123.89","1900.92","2123.89","1 through 10","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.72","58.3","","3729.00","1254.19","3729.00","1 through 10","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","939.37","939.37","5593.65","1 through 10","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","714.00","85","","2323.25","1864.50","2882.25","16","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","840.00","100","","2909.44","1772.40","10952.08","45","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","840.00","100","","2323.25","2323.25","2323.25","1 through 10","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","840.00","100","","2882.25","1772.40","10169.17","187","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","1659.41","1659.41","1659.41","1 through 10","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","2050.91","1468.48","2902.83","52","373.38","840","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","1548.60","1092.60","3613.79","82","420","658.98","percent of total billed charges",""
"KNEE IMPLANT 32MM PATELLA GENESIS II POLYETHYLENE RESURFACING OVAL","SUP-ITM-10041410","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","2085.51","998.68","6202.11","56","420","658.98","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"KNEE IMPLANT 5.0 6.0 10MM COMPONENT ARTICULAR SURFACE NEXGEN LPS FIXED FLEX SIZE GH","SUP-ITM-10017907","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","AETNA [1001]","HB CH AETNA HMO / PPO","4664.00","58.3","","1634.24","1004.95","1718.99","42","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","2123.89","1900.92","2123.89","1 through 10","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4664.00","58.3","","3729.00","1254.19","3729.00","1 through 10","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4240.00","53","","939.37","939.37","5593.65","1 through 10","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6800.00","85","","2323.25","1864.50","2882.25","16","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8000.00","100","","2909.44","1772.40","10952.08","45","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8000.00","100","","2323.25","2323.25","2323.25","1 through 10","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8000.00","100","","2882.25","1772.40","10169.17","187","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","1659.41","1659.41","1659.41","1 through 10","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","WELLPOINT [1015]","HB CH WELLPOINT","6232.80","77.91","","2050.91","1468.48","2902.83","52","3556","8000","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4744.00","59.3","","1548.60","1092.60","3613.79","82","4000","6276","percent of total billed charges",""
"KNEE IMPLANT 6.0X2.0MM COMPONENT FEMORAL RESURFACING HEMICAP ARTHROSCOPY ARTICULAR OFFSET U202-0621-W","SUP-ITM-10138513","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","2085.51","998.68","6202.11","56","4000","6276","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1634.24","1004.95","1718.99","42","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2123.89","1900.92","2123.89","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","939.37","939.37","5593.65","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","2323.25","1864.50","2882.25","16","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","2909.44","1772.40","10952.08","45","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","2323.25","2323.25","2323.25","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","2882.25","1772.40","10169.17","187","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","1659.41","1659.41","1659.41","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","2050.91","1468.48","2902.83","52","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1548.60","1092.60","3613.79","82","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT 66X61 54MM SIZE 5 COMPONENT FEMORAL LEGION TOTAL COBALT CEMENETED NONPOROUS POSTERIOR STABILIZED NARROW LT N","SUP-ITM-10175571","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","2085.51","998.68","6202.11","56","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","AETNA [1001]","HB CH AETNA HMO / PPO","7274.67","58.3","","1634.24","1004.95","1718.99","42","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9108.94","73","","2123.89","1900.92","2123.89","1 through 10","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7274.67","58.3","","3729.00","1254.19","3729.00","1 through 10","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6613.34","53","","939.37","939.37","5593.65","1 through 10","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10606.30","85","","2323.25","1864.50","2882.25","16","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12478.00","100","","2909.44","1772.40","10952.08","45","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12478.00","100","","2323.25","2323.25","2323.25","1 through 10","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12478.00","100","","2882.25","1772.40","10169.17","187","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9108.94","73","","1659.41","1659.41","1659.41","1 through 10","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","both","","","12478.00","9358.50","WELLPOINT [1015]","HB CH WELLPOINT","9721.61","77.91","","2050.91","1468.48","2902.83","52","5546.47","12478","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12478.00","9358.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7399.45","59.3","","1548.60","1092.60","3613.79","82","6239","9788.99","percent of total billed charges",""
"KNEE IMPLANT 80MM SMALL TIBIAL COMPONENT PROXIMALIMAL MRS ONC 04A","SUP-ITM-10013863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12478.00","9358.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9788.99","78.45","","2085.51","998.68","6202.11","56","6239","9788.99","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1634.24","1004.95","1718.99","42","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2123.89","1900.92","2123.89","1 through 10","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","3729.00","1254.19","3729.00","1 through 10","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","939.37","939.37","5593.65","1 through 10","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","2323.25","1864.50","2882.25","16","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","2909.44","1772.40","10952.08","45","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","2323.25","2323.25","2323.25","1 through 10","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","2882.25","1772.40","10169.17","187","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","1659.41","1659.41","1659.41","1 through 10","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","2050.91","1468.48","2902.83","52","400.05","900","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1548.60","1092.60","3613.79","82","450","706.05","percent of total billed charges",""
"KNEE IMPLANT 8X27MM PATELLA SYMMETRIC TRIATHLON 06","SUP-ITM-10017404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","2085.51","998.68","6202.11","56","450","706.05","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","AETNA [1001]","HB CH AETNA HMO / PPO","5135.06","58.3","","1634.24","1004.95","1718.99","42","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6429.84","73","","2123.89","1900.92","2123.89","1 through 10","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5135.06","58.3","","3729.00","1254.19","3729.00","1 through 10","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4668.24","53","","939.37","939.37","5593.65","1 through 10","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7486.80","85","","2323.25","1864.50","2882.25","16","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8808.00","100","","2909.44","1772.40","10952.08","45","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8808.00","100","","2323.25","2323.25","2323.25","1 through 10","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8808.00","100","","2882.25","1772.40","10169.17","187","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6429.84","73","","1659.41","1659.41","1659.41","1 through 10","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","both","","","8808.00","6606.00","WELLPOINT [1015]","HB CH WELLPOINT","6862.31","77.91","","2050.91","1468.48","2902.83","52","3915.16","8808","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8808.00","6606.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5223.14","59.3","","1548.60","1092.60","3613.79","82","4404","6909.88","percent of total billed charges",""
"KNEE IMPLANT CAPITATION CONFORMIS DUO IPOLY","SUP-ITM-10155867","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8808.00","6606.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6909.88","78.45","","2085.51","998.68","6202.11","56","4404","6909.88","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","AETNA [1001]","HB CH AETNA HMO / PPO","2573.36","58.3","","1634.24","1004.95","1718.99","42","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","2123.89","1900.92","2123.89","1 through 10","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2573.36","58.3","","3729.00","1254.19","3729.00","1 through 10","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2339.42","53","","939.37","939.37","5593.65","1 through 10","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3751.90","85","","2323.25","1864.50","2882.25","16","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4414.00","100","","2909.44","1772.40","10952.08","45","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4414.00","100","","2323.25","2323.25","2323.25","1 through 10","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4414.00","100","","2882.25","1772.40","10169.17","187","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","1659.41","1659.41","1659.41","1 through 10","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","WELLPOINT [1015]","HB CH WELLPOINT","3438.95","77.91","","2050.91","1468.48","2902.83","52","1962.02","4414","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2617.50","59.3","","1548.60","1092.60","3613.79","82","2207","3462.78","percent of total billed charges",""
"KNEE IMPLANT COMPONENT 140MM HUMERAL SHOULDER MRS TAPER MALE FEMALE","SUP-ITM-10030832","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3462.78","78.45","","2085.51","998.68","6202.11","56","2207","3462.78","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","AETNA [1001]","HB CH AETNA HMO / PPO","2766.92","58.3","","1634.24","1004.95","1718.99","42","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3464.58","73","","2123.89","1900.92","2123.89","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2766.92","58.3","","3729.00","1254.19","3729.00","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2515.38","53","","939.37","939.37","5593.65","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4034.10","85","","2323.25","1864.50","2882.25","16","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4746.00","100","","2909.44","1772.40","10952.08","45","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4746.00","100","","2323.25","2323.25","2323.25","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4746.00","100","","2882.25","1772.40","10169.17","187","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3464.58","73","","1659.41","1659.41","1659.41","1 through 10","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","both","","","4746.00","3559.50","WELLPOINT [1015]","HB CH WELLPOINT","3697.61","77.91","","2050.91","1468.48","2902.83","52","2109.6","4746","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2814.38","59.3","","1548.60","1092.60","3613.79","82","2373","3723.24","percent of total billed charges",""
"KNEE IMPLANT COMPONENT FEMORAL NEXGEN COMPLETE LEGACY ZIMALOY CONSTRAINED CONDYLAR LT SIZE C","SUP-ITM-10012215","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4746.00","3559.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3723.24","78.45","","2085.51","998.68","6202.11","56","2373","3723.24","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 12 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING STANDARD RIGHT","SUP-ITM-10101459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT SIZE 5 FEMORAL PERSONA COBALT CEMENT CRUCIATE RETAINING NARROW LEFT","SUP-ITM-10101426","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","AETNA [1001]","HB CH AETNA HMO / PPO","1428.93","58.3","","1634.24","1004.95","1718.99","42","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1789.23","73","","2123.89","1900.92","2123.89","1 through 10","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1428.93","58.3","","3729.00","1254.19","3729.00","1 through 10","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1299.03","53","","939.37","939.37","5593.65","1 through 10","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2083.35","85","","2323.25","1864.50","2882.25","16","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2451.00","100","","2909.44","1772.40","10952.08","45","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2451.00","100","","2323.25","2323.25","2323.25","1 through 10","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2451.00","100","","2882.25","1772.40","10169.17","187","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1789.23","73","","1659.41","1659.41","1659.41","1 through 10","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","both","","","2451.00","1838.25","WELLPOINT [1015]","HB CH WELLPOINT","1909.57","77.91","","2050.91","1468.48","2902.83","52","1089.47","2451","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1453.44","59.3","","1548.60","1092.60","3613.79","82","1225.5","1922.81","percent of total billed charges",""
"KNEE IMPLANT COMPONENT UNIVERSAL TIBIAL TITANIUM MODULAR ROTATING HINGE STANDARD","SUP-ITM-10006906","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2451.00","1838.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1922.81","78.45","","2085.51","998.68","6202.11","56","1225.5","1922.81","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","AETNA [1001]","HB CH AETNA HMO / PPO","7299.16","58.3","","1634.24","1004.95","1718.99","42","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9139.60","73","","2123.89","1900.92","2123.89","1 through 10","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7299.16","58.3","","3729.00","1254.19","3729.00","1 through 10","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6635.60","53","","939.37","939.37","5593.65","1 through 10","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10642.00","85","","2323.25","1864.50","2882.25","16","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12520.00","100","","2909.44","1772.40","10952.08","45","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12520.00","100","","2323.25","2323.25","2323.25","1 through 10","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12520.00","100","","2882.25","1772.40","10169.17","187","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9139.60","73","","1659.41","1659.41","1659.41","1 through 10","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","both","","","12520.00","9390.00","WELLPOINT [1015]","HB CH WELLPOINT","9754.33","77.91","","2050.91","1468.48","2902.83","52","5565.14","12520","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12520.00","9390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7424.36","59.3","","1548.60","1092.60","3613.79","82","6260","9821.94","percent of total billed charges",""
"KNEE IMPLANT SM 1987 13 105 DIST FEM REPL COMPONENT LOW PROFILE","SUP-ITM-10016704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","12520.00","9390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9821.94","78.45","","2085.51","998.68","6202.11","56","6260","9821.94","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1634.24","1004.95","1718.99","42","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","2123.89","1900.92","2123.89","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2142.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","939.37","939.37","5593.65","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3123.75","85","","2323.25","1864.50","2882.25","16","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3675.00","100","","2909.44","1772.40","10952.08","45","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3675.00","100","","2323.25","2323.25","2323.25","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3675.00","100","","2882.25","1772.40","10169.17","187","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","1659.41","1659.41","1659.41","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","2050.91","1468.48","2902.83","52","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1548.60","1092.60","3613.79","82","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161467","SUP-ITM-10026605","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","2085.51","998.68","6202.11","56","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","AETNA [1001]","HB CH AETNA HMO / PPO","2142.53","58.3","","1634.24","1004.95","1718.99","42","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","2123.89","1900.92","2123.89","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2142.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1947.75","53","","939.37","939.37","5593.65","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3123.75","85","","2323.25","1864.50","2882.25","16","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3675.00","100","","2909.44","1772.40","10952.08","45","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3675.00","100","","2323.25","2323.25","2323.25","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3675.00","100","","2882.25","1772.40","10169.17","187","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2682.75","73","","1659.41","1659.41","1659.41","1 through 10","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3675.00","2756.25","WELLPOINT [1015]","HB CH WELLPOINT","2863.19","77.91","","2050.91","1468.48","2902.83","52","1633.54","3675","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2179.28","59.3","","1548.60","1092.60","3613.79","82","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SMALL COMPONENT FEMORAL OXFORD COBALT ALLOY TWIN PEGGED CEMENTED PARTIAL 161468","SUP-ITM-10104811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3675.00","2756.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2883.04","78.45","","2085.51","998.68","6202.11","56","1837.5","2883.04","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 1 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021731","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS LT","SUP-ITM-10021733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 2 COMPONENT FEMORAL TRIATHLON PKR LT MEDIAL RT LATERAL","SUP-ITM-10026836","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1634.24","1004.95","1718.99","42","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2123.89","1900.92","2123.89","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","939.37","939.37","5593.65","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","2323.25","1864.50","2882.25","16","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","2909.44","1772.40","10952.08","45","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","2323.25","2323.25","2323.25","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","2882.25","1772.40","10169.17","187","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","1659.41","1659.41","1659.41","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","2050.91","1468.48","2902.83","52","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1548.60","1092.60","3613.79","82","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION PS COBALT CHROMIUM POSTERIOR STABILIZING CEMENTED LT","SUP-ITM-10050450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","2085.51","998.68","6202.11","56","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","554.95","91.85","1421.75","94","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2490.03","2490.03","2490.03","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","750.00","750.00","750.00","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","1192.50","120.84","4149.90","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","750.00","75.00","750.00","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","657.00","121.50","1971.00","14","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","75.00","75.00","75.00","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","366.00","144.00","1971.00","45","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","667.50","667.50","667.50","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","123.77","123.77","123.77","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","483.51","229.32","1316.08","96","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","439.50","225.34","1872.27","197","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL LEGION RK REVISION OXINIUM OXIDIZED ZIRCONIUM CEMENTED LT","SUP-ITM-10021267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","385.32","55.36","1815.62","58","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 5 COMPONENT FEMORAL TRIATHLON CRUCIATE RETAINING PERI APATITE BEADED CEMENTLESS RT","SUP-ITM-10021738","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL LEGION CR OXINIUM OXIDIZED ZIRCONIUM CRUCIATE RETAINING CEMENTED LT","SUP-ITM-10018013","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1634.24","1004.95","1718.99","42","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","2123.89","1900.92","2123.89","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2895.47","58.3","","3729.00","1254.19","3729.00","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","939.37","939.37","5593.65","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4221.53","85","","2323.25","1864.50","2882.25","16","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4966.50","100","","2909.44","1772.40","10952.08","45","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4966.50","100","","2323.25","2323.25","2323.25","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4966.50","100","","2882.25","1772.40","10169.17","187","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","1659.41","1659.41","1659.41","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","2050.91","1468.48","2902.83","52","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1548.60","1092.60","3613.79","82","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING NARROW RT","SUP-ITM-10120421","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","2085.51","998.68","6202.11","56","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 6 COMPONENT FEMORAL TRIATHLON COBALT CEMENTED CRUCIATE RETAINING LT","SUP-ITM-10016300","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","554.95","91.85","1421.75","94","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2490.03","2490.03","2490.03","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","750.00","750.00","750.00","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","1192.50","120.84","4149.90","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","750.00","75.00","750.00","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","657.00","121.50","1971.00","14","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","75.00","75.00","75.00","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","366.00","144.00","1971.00","45","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","667.50","667.50","667.50","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1466.85","44.45","","123.77","123.77","123.77","1 through 10","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","483.51","229.32","1316.08","96","1466.85","3300","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","439.50","225.34","1872.27","197","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL GENESIS II SPC NONPOROUS CRUCIATE RETAINING RT","SUP-ITM-10017954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","385.32","55.36","1815.62","58","1650","2588.85","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1634.24","1004.95","1718.99","42","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","2123.89","1900.92","2123.89","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2550.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","939.37","939.37","5593.65","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3718.75","85","","2323.25","1864.50","2882.25","16","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4375.00","100","","2909.44","1772.40","10952.08","45","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4375.00","100","","2323.25","2323.25","2323.25","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4375.00","100","","2882.25","1772.40","10169.17","187","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","1659.41","1659.41","1659.41","1 through 10","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","2050.91","1468.48","2902.83","52","1944.69","4375","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1548.60","1092.60","3613.79","82","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL LEGION OXIDIZED ZIRCONIUM CR CEMENTED STABILIZED POSTERIOR RT","SUP-ITM-10029949","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","2085.51","998.68","6202.11","56","2187.5","3432.19","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","AETNA [1001]","HB CH AETNA HMO / PPO","2895.47","58.3","","1634.24","1004.95","1718.99","42","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","2123.89","1900.92","2123.89","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2895.47","58.3","","3729.00","1254.19","3729.00","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2632.25","53","","939.37","939.37","5593.65","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4221.53","85","","2323.25","1864.50","2882.25","16","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4966.50","100","","2909.44","1772.40","10952.08","45","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4966.50","100","","2323.25","2323.25","2323.25","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4966.50","100","","2882.25","1772.40","10169.17","187","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3625.55","73","","1659.41","1659.41","1659.41","1 through 10","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","both","","","4966.50","3724.87","WELLPOINT [1015]","HB CH WELLPOINT","3869.40","77.91","","2050.91","1468.48","2902.83","52","2207.61","4966.5","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2945.13","59.3","","1548.60","1092.60","3613.79","82","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT SZ 8 COMPONENT FEMORAL PERSONA COBALT POROUS CRUCIATE RETAINING STD RT","SUP-ITM-10120443","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4966.50","3724.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3896.22","78.45","","2085.51","998.68","6202.11","56","2483.25","3896.22","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","AETNA [1001]","HB CH AETNA HMO / PPO","1093.13","58.3","","1634.24","1004.95","1718.99","42","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1368.75","73","","2123.89","1900.92","2123.89","1 through 10","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1093.13","58.3","","3729.00","1254.19","3729.00","1 through 10","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","993.75","53","","939.37","939.37","5593.65","1 through 10","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1593.75","85","","2323.25","1864.50","2882.25","16","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1875.00","100","","2909.44","1772.40","10952.08","45","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1875.00","100","","2323.25","2323.25","2323.25","1 through 10","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1875.00","100","","2882.25","1772.40","10169.17","187","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1368.75","73","","1659.41","1659.41","1659.41","1 through 10","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","both","","","1875.00","1406.25","WELLPOINT [1015]","HB CH WELLPOINT","1460.81","77.91","","2050.91","1468.48","2902.83","52","833.44","1875","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1875.00","1406.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1111.88","59.3","","1548.60","1092.60","3613.79","82","937.5","1470.94","percent of total billed charges",""
"KNEE IMPLANT TIBIAL PATELLA CRUCIFORM LCS METAL BACKED GVF STANDARD","SUP-ITM-10118949","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1875.00","1406.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1470.94","78.45","","2085.51","998.68","6202.11","56","937.5","1470.94","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","AETNA [1001]","HB CH AETNA HMO / PPO","1393.95","58.3","","1634.24","1004.95","1718.99","42","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1745.43","73","","2123.89","1900.92","2123.89","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1393.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1267.23","53","","939.37","939.37","5593.65","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2032.35","85","","2323.25","1864.50","2882.25","16","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2391.00","100","","2909.44","1772.40","10952.08","45","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2391.00","100","","2323.25","2323.25","2323.25","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2391.00","100","","2882.25","1772.40","10169.17","187","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1745.43","73","","1659.41","1659.41","1659.41","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","WELLPOINT [1015]","HB CH WELLPOINT","1862.83","77.91","","2050.91","1468.48","2902.83","52","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1417.86","59.3","","1548.60","1092.60","3613.79","82","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 10MM SIZE 9 TIBIAL SCORPIO FLEX CRUCIATE RETAINING","SUP-ITM-10036016","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1875.74","78.45","","2085.51","998.68","6202.11","56","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"KNEE INSERT 11MM SIZE 4 IMPLANT CRUCIATE RETAINING THICK TRIATHLON CR 08","SUP-ITM-10019404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 11MM SM TIBIAL OSTEON THICK","SUP-ITM-10006898","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"KNEE INSERT 12MM SZ 3 4 JOURNEY II BCS CROSSLINKED POLYETHYLENE RIGHT","SUP-ITM-10174257","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","554.95","91.85","1421.75","94","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2490.03","2490.03","2490.03","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","750.00","750.00","750.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","1192.50","120.84","4149.90","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","750.00","75.00","750.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","657.00","121.50","1971.00","14","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","75.00","75.00","75.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","366.00","144.00","1971.00","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","667.50","667.50","667.50","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1202.82","44.45","","123.77","123.77","123.77","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","483.51","229.32","1316.08","96","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","439.50","225.34","1872.27","197","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 2.5 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10020909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","385.32","55.36","1815.62","58","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"KNEE INSERT 15MM SIZE 4 TIBIAL SIGMA PFC POLYETHYLENE ROTATING PLATFORM STABILIZED","SUP-ITM-10008548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 15MM SZ 2 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004866","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","AETNA [1001]","HB CH AETNA HMO / PPO","886.74","58.3","","1634.24","1004.95","1718.99","42","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1110.33","73","","2123.89","1900.92","2123.89","1 through 10","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","886.74","58.3","","3729.00","1254.19","3729.00","1 through 10","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","806.13","53","","939.37","939.37","5593.65","1 through 10","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1292.85","85","","2323.25","1864.50","2882.25","16","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1521.00","100","","2909.44","1772.40","10952.08","45","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1521.00","100","","2323.25","2323.25","2323.25","1 through 10","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1521.00","100","","2882.25","1772.40","10169.17","187","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1110.33","73","","1659.41","1659.41","1659.41","1 through 10","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","both","","","1521.00","1140.75","WELLPOINT [1015]","HB CH WELLPOINT","1185.01","77.91","","2050.91","1468.48","2902.83","52","676.08","1521","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1521.00","1140.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","901.95","59.3","","1548.60","1092.60","3613.79","82","760.5","1193.22","percent of total billed charges",""
"KNEE INSERT 16CM TIBIAL TRIAL BUMPER GLOBAL MODULAR DISTAL REPLACEMENT","SUP-ITM-10006902","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1521.00","1140.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1193.22","78.45","","2085.51","998.68","6202.11","56","760.5","1193.22","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","AETNA [1001]","HB CH AETNA HMO / PPO","1393.95","58.3","","1634.24","1004.95","1718.99","42","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1745.43","73","","2123.89","1900.92","2123.89","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1393.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1267.23","53","","939.37","939.37","5593.65","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2032.35","85","","2323.25","1864.50","2882.25","16","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2391.00","100","","2909.44","1772.40","10952.08","45","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2391.00","100","","2323.25","2323.25","2323.25","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2391.00","100","","2882.25","1772.40","10169.17","187","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1745.43","73","","1659.41","1659.41","1659.41","1 through 10","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","both","","","2391.00","1793.25","WELLPOINT [1015]","HB CH WELLPOINT","1862.83","77.91","","2050.91","1468.48","2902.83","52","1062.8","2391","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1417.86","59.3","","1548.60","1092.60","3613.79","82","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 16MM SIZE 3 TRIATHLON POLYETHYLENE TOTAL STABILIZED","SUP-ITM-10031441","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2391.00","1793.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1875.74","78.45","","2085.51","998.68","6202.11","56","1195.5","1875.74","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 16MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10006869","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","554.95","91.85","1421.75","94","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2490.03","2490.03","2490.03","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","750.00","750.00","750.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","1192.50","120.84","4149.90","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","750.00","75.00","750.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","657.00","121.50","1971.00","14","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","75.00","75.00","75.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","366.00","144.00","1971.00","45","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","667.50","667.50","667.50","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","634.75","44.45","","123.77","123.77","123.77","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","483.51","229.32","1316.08","96","634.75","1428","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","439.50","225.34","1872.27","197","714","1120.27","percent of total billed charges",""
"KNEE INSERT 17.5MM SIZE 4.0 IMPLANT TIBIAL ROTATING PLATFORM STABILIZED PFC SIGMA 08","SUP-ITM-10008549","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","385.32","55.36","1815.62","58","714","1120.27","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","AETNA [1001]","HB CH AETNA HMO / PPO","780.05","58.3","","1634.24","1004.95","1718.99","42","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","976.74","73","","2123.89","1900.92","2123.89","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","780.05","58.3","","3729.00","1254.19","3729.00","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","709.14","53","","939.37","939.37","5593.65","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1137.30","85","","2323.25","1864.50","2882.25","16","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1338.00","100","","2909.44","1772.40","10952.08","45","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1338.00","100","","2323.25","2323.25","2323.25","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1338.00","100","","2882.25","1772.40","10169.17","187","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","976.74","73","","1659.41","1659.41","1659.41","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","WELLPOINT [1015]","HB CH WELLPOINT","1042.44","77.91","","2050.91","1468.48","2902.83","52","594.74","1338","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.43","59.3","","1548.60","1092.60","3613.79","82","669","1049.66","percent of total billed charges",""
"KNEE INSERT 2 8MM SIZE 1 JOURNEY DEUCE RT LEFT","SUP-ITM-10022190","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.66","78.45","","2085.51","998.68","6202.11","56","669","1049.66","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"KNEE INSERT 2 9MM SIZE 1 GENESIS II POLYETHYLENE CRUCIATE RETAINING","SUP-ITM-10011123","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 20.0MM SIZE 4.0 SIGMA PFC PLUS STABILIZED","SUP-ITM-10012917","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 2.5 TIBIAL PFC SIGMA POLYETHYLENE FIXED BEARING STABILIZED PLUS","SUP-ITM-10005237","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 20MM SIZE 4.0 TIBIAL SIGMA PFC TC3 POLYETHYLENE ROTATING PLATFORM","SUP-ITM-10022987","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 20MM TIBIAL MODULAR ROTATING HINGE M2","SUP-ITM-10035447","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 22.5MM SIZE 4.0 SIGMA PFC STABILIZED PLUS","SUP-ITM-10005276","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","AETNA [1001]","HB CH AETNA HMO / PPO","1577.60","58.3","","1634.24","1004.95","1718.99","42","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","2123.89","1900.92","2123.89","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1577.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1434.18","53","","939.37","939.37","5593.65","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2300.10","85","","2323.25","1864.50","2882.25","16","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2706.00","100","","2909.44","1772.40","10952.08","45","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2706.00","100","","2323.25","2323.25","2323.25","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2706.00","100","","2882.25","1772.40","10169.17","187","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1975.38","73","","1659.41","1659.41","1659.41","1 through 10","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2706.00","2029.50","WELLPOINT [1015]","HB CH WELLPOINT","2108.24","77.91","","2050.91","1468.48","2902.83","52","1202.82","2706","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1604.66","59.3","","1548.60","1092.60","3613.79","82","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 22.5MM SZ 3 SIGMA TIBIAL PFC FIXED BEARING TC3","SUP-ITM-10004877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2706.00","2029.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2122.86","78.45","","2085.51","998.68","6202.11","56","1353","2122.86","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","AETNA [1001]","HB CH AETNA HMO / PPO","780.05","58.3","","1634.24","1004.95","1718.99","42","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","976.74","73","","2123.89","1900.92","2123.89","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","780.05","58.3","","3729.00","1254.19","3729.00","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","709.14","53","","939.37","939.37","5593.65","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1137.30","85","","2323.25","1864.50","2882.25","16","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1338.00","100","","2909.44","1772.40","10952.08","45","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1338.00","100","","2323.25","2323.25","2323.25","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1338.00","100","","2882.25","1772.40","10169.17","187","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","976.74","73","","1659.41","1659.41","1659.41","1 through 10","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","both","","","1338.00","1003.50","WELLPOINT [1015]","HB CH WELLPOINT","1042.44","77.91","","2050.91","1468.48","2902.83","52","594.74","1338","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.43","59.3","","1548.60","1092.60","3613.79","82","669","1049.66","percent of total billed charges",""
"KNEE INSERT 6 8MM SIZE 5 JOURNEY POLYETHYLENE UNICOMPARTMENTAL LT RIGHT","SUP-ITM-10022202","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1338.00","1003.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.66","78.45","","2085.51","998.68","6202.11","56","669","1049.66","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","AETNA [1001]","HB CH AETNA HMO / PPO","4088.00","58.3","","1634.24","1004.95","1718.99","42","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5118.76","73","","2123.89","1900.92","2123.89","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4088.00","58.3","","3729.00","1254.19","3729.00","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3716.36","53","","939.37","939.37","5593.65","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5960.20","85","","2323.25","1864.50","2882.25","16","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7012.00","100","","2909.44","1772.40","10952.08","45","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7012.00","100","","2323.25","2323.25","2323.25","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7012.00","100","","2882.25","1772.40","10169.17","187","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5118.76","73","","1659.41","1659.41","1659.41","1 through 10","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","both","","","7012.00","5259.00","WELLPOINT [1015]","HB CH WELLPOINT","5463.05","77.91","","2050.91","1468.48","2902.83","52","3116.83","7012","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7012.00","5259.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4158.12","59.3","","1548.60","1092.60","3613.79","82","3506","5500.91","percent of total billed charges",""
"KNEE INSERT ITOTAL IDENTITY CR 1PC IPOLY XE","SUP-ITM-10261428","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7012.00","5259.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5500.91","78.45","","2085.51","998.68","6202.11","56","3506","5500.91","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"KNEE INSERT TIBIAL 4 11MM SIZE 3 GENESIS II POLYETHYLENE POSTERIOR STABILIZING","SUP-ITM-10016125","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","AETNA [1001]","HB CH AETNA HMO / PPO","99.17","58.3","","1634.24","1004.95","1718.99","42","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","124.17","73","","2123.89","1900.92","2123.89","1 through 10","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.17","58.3","","3729.00","1254.19","3729.00","1 through 10","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.15","53","","939.37","939.37","5593.65","1 through 10","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","144.59","85","","2323.25","1864.50","2882.25","16","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","170.10","100","","2909.44","1772.40","10952.08","45","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","170.10","100","","2323.25","2323.25","2323.25","1 through 10","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","170.10","100","","2882.25","1772.40","10169.17","187","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.17","73","","1659.41","1659.41","1659.41","1 through 10","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","both","","","170.10","127.57","WELLPOINT [1015]","HB CH WELLPOINT","132.52","77.91","","2050.91","1468.48","2902.83","52","75.61","170.1","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.87","59.3","","1548.60","1092.60","3613.79","82","85.05","133.44","percent of total billed charges",""
"KNEE INSERT TIBIAL IMPLANT BAR LOCKING MODULAR 15B","SUP-ITM-10001591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.44","78.45","","2085.51","998.68","6202.11","56","85.05","133.44","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","AETNA [1001]","HB CH AETNA HMO / PPO","1752.50","58.3","","1634.24","1004.95","1718.99","42","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","2123.89","1900.92","2123.89","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.18","53","","939.37","939.37","5593.65","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.10","85","","2323.25","1864.50","2882.25","16","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3006.00","100","","2909.44","1772.40","10952.08","45","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3006.00","100","","2323.25","2323.25","2323.25","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3006.00","100","","2882.25","1772.40","10169.17","187","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.38","73","","1659.41","1659.41","1659.41","1 through 10","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","both","","","3006.00","2254.50","WELLPOINT [1015]","HB CH WELLPOINT","2341.97","77.91","","2050.91","1468.48","2902.83","52","1336.17","3006","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.56","59.3","","1548.60","1092.60","3613.79","82","1503","2358.21","percent of total billed charges",""
"KNEE INSERTX13MM SM DURACON ENCAPSULATING METAL TIBIAL","SUP-ITM-10035483","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3006.00","2254.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.21","78.45","","2085.51","998.68","6202.11","56","1503","2358.21","percent of total billed charges",""
"Knee Joint Replacement,MINOR","302","DRG","","","","","","","","inpatient","","","51396.39","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","38416.08","38416.08","38416.08","1 through 10","14476.57","167223.83","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","AETNA [1001]","HB CH AETNA HMO / PPO","3635.59","58.3","","1634.24","1004.95","1718.99","42","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4552.28","73","","2123.89","1900.92","2123.89","1 through 10","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3635.59","58.3","","3729.00","1254.19","3729.00","1 through 10","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3305.08","53","","939.37","939.37","5593.65","1 through 10","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5300.60","85","","2323.25","1864.50","2882.25","16","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6236.00","100","","2909.44","1772.40","10952.08","45","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6236.00","100","","2323.25","2323.25","2323.25","1 through 10","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6236.00","100","","2882.25","1772.40","10169.17","187","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4552.28","73","","1659.41","1659.41","1659.41","1 through 10","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","both","","","6236.00","4677.00","WELLPOINT [1015]","HB CH WELLPOINT","4858.47","77.91","","2050.91","1468.48","2902.83","52","2771.9","6236","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6236.00","4677.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3697.95","59.3","","1548.60","1092.60","3613.79","82","3118","4892.14","percent of total billed charges",""
"KNEE POST 50.3MM MD COMPONENT FEMORAL AVON COBALT CEMENTED 4 PEG","SUP-ITM-10012085","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6236.00","4677.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4892.14","78.45","","2085.51","998.68","6202.11","56","3118","4892.14","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","AETNA [1001]","HB CH AETNA HMO / PPO","708.35","58.3","","1634.24","1004.95","1718.99","42","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","886.95","73","","2123.89","1900.92","2123.89","1 through 10","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","708.35","58.3","","3729.00","1254.19","3729.00","1 through 10","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","643.95","53","","939.37","939.37","5593.65","1 through 10","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1032.75","85","","2323.25","1864.50","2882.25","16","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1215.00","100","","2909.44","1772.40","10952.08","45","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1215.00","100","","2323.25","2323.25","2323.25","1 through 10","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1215.00","100","","2882.25","1772.40","10169.17","187","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","886.95","73","","1659.41","1659.41","1659.41","1 through 10","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","both","","","1215.00","911.25","WELLPOINT [1015]","HB CH WELLPOINT","946.61","77.91","","2050.91","1468.48","2902.83","52","540.07","1215","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","1548.60","1092.60","3613.79","82","607.5","953.17","percent of total billed charges",""
"KNEE POST TAPER 11X22MM FEMORAL HEMICAP TITANIUM","SUP-ITM-10072458","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1215.00","911.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","953.17","78.45","","2085.51","998.68","6202.11","56","607.5","953.17","percent of total billed charges",""
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","55362.29","41521.72","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","20180.77","","Case rate ($19,592.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,624.35, add-ons for qualifying new technology services are included. If operating cost exceeds $65,148.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,039.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,775.41 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,285.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,478.32. The transfer capital threshold is the transfer adjustment factor * $1,478.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","20099.95","20099.95","20099.95","1 through 10","19201.12","20678.8879","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection With Cc","486","MS-DRG","","","","","","","","inpatient","","","55362.29","41521.72","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","19201.12","","Case rate ($19,592.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,624.35, add-ons for qualifying new technology services are included. If operating cost exceeds $65,148.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,039.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,775.41 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,285.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,478.32. The transfer capital threshold is the transfer adjustment factor * $1,478.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","21368.08","21368.08","21368.08","1 through 10","19201.12","20678.8879","other","Inpatient DRG"
"Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC","487","MS-DRG","","","","","","","","inpatient","","","46908.31","35181.23","MEDICARE [2001]","HB BWF MEDICARE","16138.73","","Case rate ($16,138.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,783.48, add-ons for qualifying new technology services are included. If operating cost exceeds $60,307.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,668.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $14,692.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,444.24 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,107.24. The transfer capital threshold is the transfer adjustment factor * $1,107.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15963.84","15963.84","15963.84","1 through 10","14464.78","16138.73","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC","488","MS-DRG","","","","","","","","inpatient","","","52713.97","39535.48","MEDICARE [2001]","HB BWF MEDICARE","18183.53","","Case rate ($18,183.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,652.88, add-ons for qualifying new technology services are included. If operating cost exceeds $62,176.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,811.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $16,593.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,313.63 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,250.54. The transfer capital threshold is the transfer adjustment factor * $1,250.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19794.05","19794.05","19794.05","1 through 10","16293.81","18183.53","other","Inpatient DRG"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC","489","MS-DRG","","","","","","","","inpatient","","","37346.21","28009.66","MEDICARE [2001]","HB BWF MEDICARE","10622.15","","Case rate ($10,622.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,638.90, add-ons for qualifying new technology services are included. If operating cost exceeds $56,162.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,350.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,493.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,299.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.53. The transfer capital threshold is the transfer adjustment factor * $789.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12565.14","12565.14","12565.14","1 through 10","10409.71","11463.95","other","Inpatient Replacement Plans DRG"
"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC","489","MS-DRG","","","","","","","","inpatient","","","37346.21","28009.66","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","10409.71","","Case rate ($10,622.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,638.90, add-ons for qualifying new technology services are included. If operating cost exceeds $56,162.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,350.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $9,493.37 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,299.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $789.53. The transfer capital threshold is the transfer adjustment factor * $789.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11265.44","11265.44","11265.44","1 through 10","10409.71","11463.95","other","Inpatient DRG"
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","AETNA [1001]","HB CH AETNA HMO / PPO","3999.38","58.3","","1634.24","1004.95","1718.99","42","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5007.80","73","","2123.89","1900.92","2123.89","1 through 10","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3999.38","58.3","","3729.00","1254.19","3729.00","1 through 10","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3635.80","53","","939.37","939.37","5593.65","1 through 10","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5831.00","85","","2323.25","1864.50","2882.25","16","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6860.00","100","","2909.44","1772.40","10952.08","45","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6860.00","100","","2323.25","2323.25","2323.25","1 through 10","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6860.00","100","","2882.25","1772.40","10169.17","187","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5007.80","73","","1659.41","1659.41","1659.41","1 through 10","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","both","","","6860.00","5145.00","WELLPOINT [1015]","HB CH WELLPOINT","5344.63","77.91","","2050.91","1468.48","2902.83","52","3049.27","6860","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6860.00","5145.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4067.98","59.3","","1548.60","1092.60","3613.79","82","3430","5381.67","percent of total billed charges",""
"KNEE SPACER 64X47 70 42 17MM MD INTERSPACE SS GENTAMICIN HIGH RELEASE CLASSIC","SUP-ITM-10050515","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6860.00","5145.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5381.67","78.45","","2085.51","998.68","6202.11","56","3430","5381.67","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","AETNA [1001]","HB CH AETNA HMO / PPO","514.21","58.3","","1634.24","1004.95","1718.99","42","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","643.86","73","","2123.89","1900.92","2123.89","1 through 10","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.21","58.3","","3729.00","1254.19","3729.00","1 through 10","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","467.46","53","","939.37","939.37","5593.65","1 through 10","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","749.70","85","","2323.25","1864.50","2882.25","16","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","882.00","100","","2909.44","1772.40","10952.08","45","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","882.00","100","","2323.25","2323.25","2323.25","1 through 10","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","882.00","100","","2882.25","1772.40","10169.17","187","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","643.86","73","","1659.41","1659.41","1659.41","1 through 10","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","WELLPOINT [1015]","HB CH WELLPOINT","687.17","77.91","","2050.91","1468.48","2902.83","52","392.05","882","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.03","59.3","","1548.60","1092.60","3613.79","82","441","691.93","percent of total billed charges",""
"KNEE SPACER 9MM SIZE SM COMPONENT PATELLA AVON POLYETHYLENE OFFSET THICK ROUND","SUP-ITM-10012086","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.93","78.45","","2085.51","998.68","6202.11","56","441","691.93","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"KNEE STEM 102X9MM FEMORAL DISTAL MODULAR REPLACEMENT SY CEMENTED STRAIGHT MINUS BODY","SUP-ITM-10017472","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"KNEE STEM 10X20MM SM MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10019262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","AETNA [1001]","HB CH AETNA HMO / PPO","3635.01","58.3","","1634.24","1004.95","1718.99","42","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4551.55","73","","2123.89","1900.92","2123.89","1 through 10","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3635.01","58.3","","3729.00","1254.19","3729.00","1 through 10","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3304.55","53","","939.37","939.37","5593.65","1 through 10","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5299.75","85","","2323.25","1864.50","2882.25","16","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6235.00","100","","2909.44","1772.40","10952.08","45","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6235.00","100","","2323.25","2323.25","2323.25","1 through 10","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6235.00","100","","2882.25","1772.40","10169.17","187","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4551.55","73","","1659.41","1659.41","1659.41","1 through 10","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","WELLPOINT [1015]","HB CH WELLPOINT","4857.69","77.91","","2050.91","1468.48","2902.83","52","2771.46","6235","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6235.00","4676.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3697.36","59.3","","1548.60","1092.60","3613.79","82","3117.5","4891.36","percent of total billed charges",""
"KNEE STEM 11MM 127 TIBIAL MODULAR REPLACEMENT SY","SUP-ITM-10009171","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6235.00","4676.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4891.36","78.45","","2085.51","998.68","6202.11","56","3117.5","4891.36","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","AETNA [1001]","HB CH AETNA HMO / PPO","528.20","58.3","","1634.24","1004.95","1718.99","42","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","2123.89","1900.92","2123.89","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","528.20","58.3","","3729.00","1254.19","3729.00","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.18","53","","939.37","939.37","5593.65","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","770.10","85","","2323.25","1864.50","2882.25","16","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","906.00","100","","2909.44","1772.40","10952.08","45","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","906.00","100","","2323.25","2323.25","2323.25","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","906.00","100","","2882.25","1772.40","10169.17","187","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","1659.41","1659.41","1659.41","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","WELLPOINT [1015]","HB CH WELLPOINT","705.86","77.91","","2050.91","1468.48","2902.83","52","402.72","906","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","1548.60","1092.60","3613.79","82","453","710.76","percent of total billed charges",""
"KNEE STEM 12MMX80 SHORT FEMORAL LEGION TITANIUM EXTENSION","SUP-ITM-10021285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","710.76","78.45","","2085.51","998.68","6202.11","56","453","710.76","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","AETNA [1001]","HB CH AETNA HMO / PPO","528.20","58.3","","1634.24","1004.95","1718.99","42","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","2123.89","1900.92","2123.89","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","528.20","58.3","","3729.00","1254.19","3729.00","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.18","53","","939.37","939.37","5593.65","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","770.10","85","","2323.25","1864.50","2882.25","16","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","906.00","100","","2909.44","1772.40","10952.08","45","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","906.00","100","","2323.25","2323.25","2323.25","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","906.00","100","","2882.25","1772.40","10169.17","187","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","1659.41","1659.41","1659.41","1 through 10","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","WELLPOINT [1015]","HB CH WELLPOINT","705.86","77.91","","2050.91","1468.48","2902.83","52","402.72","906","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","1548.60","1092.60","3613.79","82","453","710.76","percent of total billed charges",""
"KNEE STEM 12X50MM FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10021442","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","710.76","78.45","","2085.51","998.68","6202.11","56","453","710.76","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"KNEE STEM 13X27 W 37MM FEMORAL DISTAL MODULAR REPLACEMENT SY TAPER CEMENTED STRAIGHT","SUP-ITM-10018274","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","AETNA [1001]","HB CH AETNA HMO / PPO","1280.01","58.3","","1634.24","1004.95","1718.99","42","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1602.75","73","","2123.89","1900.92","2123.89","1 through 10","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1280.01","58.3","","3729.00","1254.19","3729.00","1 through 10","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1163.64","53","","939.37","939.37","5593.65","1 through 10","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1866.22","85","","2323.25","1864.50","2882.25","16","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2195.55","100","","2909.44","1772.40","10952.08","45","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2195.55","100","","2323.25","2323.25","2323.25","1 through 10","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2195.55","100","","2882.25","1772.40","10169.17","187","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1602.75","73","","1659.41","1659.41","1659.41","1 through 10","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","both","","","2195.55","1646.66","WELLPOINT [1015]","HB CH WELLPOINT","1710.55","77.91","","2050.91","1468.48","2902.83","52","975.92","2195.55","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2195.55","1646.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","1301.96","59.3","","1548.60","1092.60","3613.79","82","1097.78","1722.41","percent of total billed charges",""
"KNEE STEM 145MM 100 OD 16 EXTENDER TIVANIUM TIBIAL SOLID SCREW PRIMARY STRAIGHT IMPL NEXGEN","SUP-ITM-10016404","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2195.55","1646.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1722.41","78.45","","2085.51","998.68","6202.11","56","1097.78","1722.41","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","AETNA [1001]","HB CH AETNA HMO / PPO","961.95","58.3","","1634.24","1004.95","1718.99","42","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","2123.89","1900.92","2123.89","1 through 10","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","961.95","58.3","","3729.00","1254.19","3729.00","1 through 10","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","874.50","53","","939.37","939.37","5593.65","1 through 10","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1402.50","85","","2323.25","1864.50","2882.25","16","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.00","100","","2909.44","1772.40","10952.08","45","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1650.00","100","","2323.25","2323.25","2323.25","1 through 10","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.00","100","","2882.25","1772.40","10169.17","187","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1204.50","73","","1659.41","1659.41","1659.41","1 through 10","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","both","","","1650.00","1237.50","WELLPOINT [1015]","HB CH WELLPOINT","1285.52","77.91","","2050.91","1468.48","2902.83","52","733.43","1650","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","978.45","59.3","","1548.60","1092.60","3613.79","82","825","1294.43","percent of total billed charges",""
"KNEE STEM 14X50MM CEMENTED ATTUNE REVISION ROTATING PLATFORM","SUP-ITM-10197892","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1650.00","1237.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1294.43","78.45","","2085.51","998.68","6202.11","56","825","1294.43","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"KNEE STEM 15MMX220 FEMORAL LEGION TITANIUM PRESSFIT STRAIGHT","SUP-ITM-10021270","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","AETNA [1001]","HB CH AETNA HMO / PPO","1774.01","58.3","","1634.24","1004.95","1718.99","42","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2221.32","73","","2123.89","1900.92","2123.89","1 through 10","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1774.01","58.3","","3729.00","1254.19","3729.00","1 through 10","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1612.74","53","","939.37","939.37","5593.65","1 through 10","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2586.47","85","","2323.25","1864.50","2882.25","16","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3042.90","100","","2909.44","1772.40","10952.08","45","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3042.90","100","","2323.25","2323.25","2323.25","1 through 10","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3042.90","100","","2882.25","1772.40","10169.17","187","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2221.32","73","","1659.41","1659.41","1659.41","1 through 10","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","both","","","3042.90","2282.17","WELLPOINT [1015]","HB CH WELLPOINT","2370.72","77.91","","2050.91","1468.48","2902.83","52","1352.57","3042.9","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3042.90","2282.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","1804.44","59.3","","1548.60","1092.60","3613.79","82","1521.45","2387.16","percent of total billed charges",""
"KNEE STEM 16X135MM EXTENSION PERSONA REV STRAIGHT SPLINE","SUP-ITM-10268345","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3042.90","2282.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2387.16","78.45","","2085.51","998.68","6202.11","56","1521.45","2387.16","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","AETNA [1001]","HB CH AETNA HMO / PPO","1689.53","58.3","","1634.24","1004.95","1718.99","42","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2115.54","73","","2123.89","1900.92","2123.89","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1689.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1535.94","53","","939.37","939.37","5593.65","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2463.30","85","","2323.25","1864.50","2882.25","16","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2898.00","100","","2909.44","1772.40","10952.08","45","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2898.00","100","","2323.25","2323.25","2323.25","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2898.00","100","","2882.25","1772.40","10169.17","187","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2115.54","73","","1659.41","1659.41","1659.41","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","WELLPOINT [1015]","HB CH WELLPOINT","2257.83","77.91","","2050.91","1468.48","2902.83","52","1288.16","2898","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1718.51","59.3","","1548.60","1092.60","3613.79","82","1449","2273.48","percent of total billed charges",""
"KNEE STEM 17MMX100 FEMORAL TRIATHLON TS TITANIUM REVISION NONCEMENTED","SUP-ITM-10031446","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2273.48","78.45","","2085.51","998.68","6202.11","56","1449","2273.48","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","AETNA [1001]","HB CH AETNA HMO / PPO","1689.53","58.3","","1634.24","1004.95","1718.99","42","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2115.54","73","","2123.89","1900.92","2123.89","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1689.53","58.3","","3729.00","1254.19","3729.00","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1535.94","53","","939.37","939.37","5593.65","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2463.30","85","","2323.25","1864.50","2882.25","16","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2898.00","100","","2909.44","1772.40","10952.08","45","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2898.00","100","","2323.25","2323.25","2323.25","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2898.00","100","","2882.25","1772.40","10169.17","187","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2115.54","73","","1659.41","1659.41","1659.41","1 through 10","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","both","","","2898.00","2173.50","WELLPOINT [1015]","HB CH WELLPOINT","2257.83","77.91","","2050.91","1468.48","2902.83","52","1288.16","2898","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1718.51","59.3","","1548.60","1092.60","3613.79","82","1449","2273.48","percent of total billed charges",""
"KNEE STEM 19X100MM FLUT TRIATHLON PRESS FIT IMPLANT 11","SUP-ITM-10050484","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2898.00","2173.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2273.48","78.45","","2085.51","998.68","6202.11","56","1449","2273.48","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"KNEE STEM 203X11MM LONG MODULAR REPLACEMENT SY CEMENTED CURVED","SUP-ITM-10030836","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"KNEE STEM 9MM 127 TIBIAL MODULAR REPLACEMENT SY EXTENSION","SUP-ITM-10035492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","AETNA [1001]","HB CH AETNA HMO / PPO","4562.56","58.3","","1634.24","1004.95","1718.99","42","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","2123.89","1900.92","2123.89","1 through 10","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4562.56","58.3","","3729.00","1254.19","3729.00","1 through 10","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4147.78","53","","939.37","939.37","5593.65","1 through 10","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6652.10","85","","2323.25","1864.50","2882.25","16","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7826.00","100","","2909.44","1772.40","10952.08","45","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7826.00","100","","2323.25","2323.25","2323.25","1 through 10","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7826.00","100","","2882.25","1772.40","10169.17","187","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5712.98","73","","1659.41","1659.41","1659.41","1 through 10","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","both","","","7826.00","5869.50","WELLPOINT [1015]","HB CH WELLPOINT","6097.24","77.91","","2050.91","1468.48","2902.83","52","3478.66","7826","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4640.82","59.3","","1548.60","1092.60","3613.79","82","3913","6139.5","percent of total billed charges",""
"KNEE STEM IMPLANT HIP FEMORAL GMRS PROXIMALIMAL STANDARD NEUTRAL ONC 01A CS/1BX/1EA","SUP-ITM-10013788","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7826.00","5869.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6139.50","78.45","","2085.51","998.68","6202.11","56","3913","6139.5","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","AETNA [1001]","HB CH AETNA HMO / PPO","2040.50","58.3","","1634.24","1004.95","1718.99","42","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","2123.89","1900.92","2123.89","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2040.50","58.3","","3729.00","1254.19","3729.00","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1855.00","53","","939.37","939.37","5593.65","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2975.00","85","","2323.25","1864.50","2882.25","16","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3500.00","100","","2909.44","1772.40","10952.08","45","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3500.00","100","","2323.25","2323.25","2323.25","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3500.00","100","","2882.25","1772.40","10169.17","187","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2555.00","73","","1659.41","1659.41","1659.41","1 through 10","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","both","","","3500.00","2625.00","WELLPOINT [1015]","HB CH WELLPOINT","2726.85","77.91","","2050.91","1468.48","2902.83","52","1555.75","3500","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2075.50","59.3","","1548.60","1092.60","3613.79","82","1750","2745.75","percent of total billed charges",""
"KNEE TIBIA SZ 1 40X61MM BASEPLATE TRIATHLON TOTAL TRITANIUM POROUS UNCEMENTED STERILE","SUP-ITM-10208662","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3500.00","2625.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2745.75","78.45","","2085.51","998.68","6202.11","56","1750","2745.75","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1634.24","1004.95","1718.99","42","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","2123.89","1900.92","2123.89","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","3729.00","1254.19","3729.00","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","939.37","939.37","5593.65","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1606.50","85","","2323.25","1864.50","2882.25","16","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1890.00","100","","2909.44","1772.40","10952.08","45","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1890.00","100","","2323.25","2323.25","2323.25","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1890.00","100","","2882.25","1772.40","10169.17","187","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","1659.41","1659.41","1659.41","1 through 10","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","2050.91","1468.48","2902.83","52","840.11","1890","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1548.60","1092.60","3613.79","82","945","1482.71","percent of total billed charges",""
"KNEE TRAY SZ 2.5 TIBIAL PFC SIGMA FIXED BEARING KEEL TITANIUM CEMENTED","SUP-ITM-10004961","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","2085.51","998.68","6202.11","56","945","1482.71","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","1634.24","1004.95","1718.99","42","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","2123.89","1900.92","2123.89","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","816.78","58.3","","3729.00","1254.19","3729.00","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","939.37","939.37","5593.65","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1190.85","85","","2323.25","1864.50","2882.25","16","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1401.00","100","","2909.44","1772.40","10952.08","45","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1401.00","100","","2323.25","2323.25","2323.25","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1401.00","100","","2882.25","1772.40","10169.17","187","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","1659.41","1659.41","1659.41","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","2050.91","1468.48","2902.83","52","622.74","1401","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","1548.60","1092.60","3613.79","82","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 10MM SM SIZE 1 BLOCK AUGMENT TIBIAL MODULAR FULL FLAT LEFT","SUP-ITM-10013992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","2085.51","998.68","6202.11","56","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","554.95","91.85","1421.75","94","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2490.03","2490.03","2490.03","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","750.00","750.00","750.00","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","1192.50","120.84","4149.90","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","750.00","75.00","750.00","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","657.00","121.50","1971.00","14","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","75.00","75.00","75.00","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","366.00","144.00","1971.00","45","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","667.50","667.50","667.50","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","123.77","123.77","123.77","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","483.51","229.32","1316.08","96","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","439.50","225.34","1872.27","197","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 15MM SZ 4 20DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005149","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","385.32","55.36","1815.62","58","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1830.28","315.58","1830.28","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","4170.85","4170.85","4170.85","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","649.55","649.55","649.55","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","8998.38","2542.37","8998.38","20","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1891.61","1609.14","3664.18","25","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 8MM SZ 2.5 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10005488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1470.68","1310.06","2481.69","19","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE 9MM SZ 4 10DEG TIBIAL PFC MODULAR PLUS CEMENTED HEMI","SUP-ITM-10004942","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","AETNA [1001]","HB CH AETNA HMO / PPO","816.78","58.3","","1634.24","1004.95","1718.99","42","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","2123.89","1900.92","2123.89","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","816.78","58.3","","3729.00","1254.19","3729.00","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","742.53","53","","939.37","939.37","5593.65","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1190.85","85","","2323.25","1864.50","2882.25","16","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1401.00","100","","2909.44","1772.40","10952.08","45","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1401.00","100","","2323.25","2323.25","2323.25","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1401.00","100","","2882.25","1772.40","10169.17","187","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1022.73","73","","1659.41","1659.41","1659.41","1 through 10","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","both","","","1401.00","1050.75","WELLPOINT [1015]","HB CH WELLPOINT","1091.52","77.91","","2050.91","1468.48","2902.83","52","622.74","1401","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","830.79","59.3","","1548.60","1092.60","3613.79","82","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE AUGMENT 10MM HALF SIZE 5 TIBIAL TRIATHLON LT MEDIAL RT LATERAL BLOCK","SUP-ITM-10043004","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1401.00","1050.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1099.08","78.45","","2085.51","998.68","6202.11","56","700.5","1099.08","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","AETNA [1001]","HB CH AETNA HMO / PPO","528.20","58.3","","1634.24","1004.95","1718.99","42","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","2123.89","1900.92","2123.89","1 through 10","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","528.20","58.3","","3729.00","1254.19","3729.00","1 through 10","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.18","53","","939.37","939.37","5593.65","1 through 10","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","770.10","85","","2323.25","1864.50","2882.25","16","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","906.00","100","","2909.44","1772.40","10952.08","45","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","906.00","100","","2323.25","2323.25","2323.25","1 through 10","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","906.00","100","","2882.25","1772.40","10169.17","187","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","661.38","73","","1659.41","1659.41","1659.41","1 through 10","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","both","","","906.00","679.50","WELLPOINT [1015]","HB CH WELLPOINT","705.86","77.91","","2050.91","1468.48","2902.83","52","402.72","906","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","1548.60","1092.60","3613.79","82","453","710.76","percent of total billed charges",""
"KNEE WEDGE SZ 1.5 4MM FEMORAL DISTAL PFC SIGMA LT","SUP-ITM-10118402","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","906.00","679.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","710.76","78.45","","2085.51","998.68","6202.11","56","453","710.76","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","AETNA [1001]","HB CH AETNA HMO / PPO","857.62","58.3","","1634.24","1004.95","1718.99","42","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1073.87","73","","2123.89","1900.92","2123.89","1 through 10","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","857.62","58.3","","3729.00","1254.19","3729.00","1 through 10","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.66","53","","939.37","939.37","5593.65","1 through 10","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1250.39","85","","2323.25","1864.50","2882.25","16","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1471.05","100","","2909.44","1772.40","10952.08","45","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1471.05","100","","2323.25","2323.25","2323.25","1 through 10","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1471.05","100","","2882.25","1772.40","10169.17","187","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1073.87","73","","1659.41","1659.41","1659.41","1 through 10","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","both","","","1471.05","1103.29","WELLPOINT [1015]","HB CH WELLPOINT","1146.10","77.91","","2050.91","1468.48","2902.83","52","653.88","1471.05","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1471.05","1103.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","872.33","59.3","","1548.60","1092.60","3613.79","82","735.53","1154.04","percent of total billed charges",""
"KNEE WEDGE SZ7 5MM FEMORAL PERSONA DISTAL","SUP-ITM-10268289","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1471.05","1103.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1154.04","78.45","","2085.51","998.68","6202.11","56","735.53","1154.04","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","both","","","42.68","32.01","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","27.06","63.4","","49.88","49.88","49.88","1 through 10","18.97","242.21","percent of total billed charges",""
"Ko Immobil Knee Prefab Ots T1","PX-27000328","CDM","L1830","HCPCS","0274","RC","","","","outpatient","","","42.68","32.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","25.31","59.3","","66.15","22.05","66.15","1 through 10","21.34","208.64","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","161.33","percent of total billed charges",""
"Lacosamide 80299","PX-30003299","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","14.12","173.37","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","both","","","60.00","45.00","AETNA [1001]","HB CH AETNA HMO / PPO","34.98","58.3","","32.89","32.89","32.89","1 through 10","5.92","43.8","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","60.00","45.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","35.58","59.3","","33.99","33.99","58.00","1 through 10","6.23","47.07","percent of total billed charges",""
"Lactate Dehydrogenase (Ldh)","PX-30000538","CDM","83615","CPT","0301","RC","","","","outpatient","","","60.00","45.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.07","78.45","","44.59","26.42","44.59","1 through 10","6.23","47.07","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","both","","","106.00","79.50","AETNA [1001]","HB CH AETNA HMO / PPO","61.80","58.3","","58.40","56.40","257.42","1 through 10","11.34","77.38","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","106.00","79.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.86","59.3","","60.36","6.66","103.00","1 through 10","11.01","83.16","percent of total billed charges",""
"Lactate/Lactic Acid","PX-30000537","CDM","83605","CPT","0301","RC","","","","outpatient","","","106.00","79.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.16","78.45","","46.93","29.79","79.19","1 through 10","11.01","83.16","percent of total billed charges",""
"Laparoscopic Cholecystectomy Without C.D.E. With Cc","418","MS-DRG","","","","","","","","inpatient","","","55676.82","41757.61","MEDICARE [2001]","HB BWF MEDICARE","17403.73","","Case rate ($17,403.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,939.98, add-ons for qualifying new technology services are included. If operating cost exceeds $61,463.71 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,756.67, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $15,868.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,600.74 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,195.89. The transfer capital threshold is the transfer adjustment factor * $1,195.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6930.15","1545.04","16630.21","1 through 10","15596.3","17403.73","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. With McC","417","MS-DRG","","","","","","","","inpatient","","","58619.61","43964.71","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","21865.69","","Case rate ($22,311.93). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,347.75, add-ons for qualifying new technology services are included. If operating cost exceeds $67,871.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,247.86, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $20,285.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,008.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,687.09. The transfer capital threshold is the transfer adjustment factor * $1,687.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","21467.67","21467.67","21467.67","1 through 10","21865.69","23501.2085","other","Inpatient DRG"
"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC","419","MS-DRG","","","","","","","","inpatient","","","46399.80","34799.85","MEDICARE [2001]","HB BWF MEDICARE","12914.80","","Case rate ($12,914.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,935.29, add-ons for qualifying new technology services are included. If operating cost exceeds $58,459.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,526.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,609.99 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,596.05 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $965.57. The transfer capital threshold is the transfer adjustment factor * $965.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6297.49","2987.45","13264.33","1 through 10","12656.5","14019.94","other","Inpatient Replacement Plans DRG"
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","both","","","1625.00","1218.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","697.13","9004.88","per diem",""
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","outpatient","","","1625.00","1218.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5255.62","","Case rate ($5,255.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","7599.63","7599.63","7599.63","1 through 10","812.5","7178","other","ASC "
"Laps Abd Prtm&Omentum Dx W/WO Spec Br/Wa Spx","PX-75000284","CDM","49320","CPT","0750","RC","","","","outpatient","","","1625.00","1218.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","4136.27","","Case rate ($4,136.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9720.23","9720.23","9720.23","1 through 10","812.5","7178","other","Multiple Surgery"
"Laryngoscopy Flex","PX-76000771","CDM","31575","CPT","0761","RC","","","","outpatient","","","505.00","378.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","187.51","","Case rate ($187.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","491.00","132.57","491.00","1 through 10","163.97","567.68","other","ASC "
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","AETNA [1001]","HB CH AETNA HMO / PPO","1681.49","58.3","","554.95","91.85","1421.75","94","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2105.47","73","","2490.03","2490.03","2490.03","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1681.49","58.3","","750.00","750.00","750.00","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1528.63","53","","1192.50","120.84","4149.90","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2451.57","85","","750.00","75.00","750.00","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2884.20","100","","657.00","121.50","1971.00","14","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2884.20","100","","75.00","75.00","75.00","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2884.20","100","","366.00","144.00","1971.00","45","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2105.47","73","","667.50","667.50","667.50","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1282.03","44.45","","123.77","123.77","123.77","1 through 10","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","both","","","2884.20","2163.15","WELLPOINT [1015]","HB CH WELLPOINT","2247.08","77.91","","483.51","229.32","1316.08","96","1282.03","2884.2","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2884.20","2163.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","1710.33","59.3","","439.50","225.34","1872.27","197","1442.1","2262.65","percent of total billed charges",""
"LATERAL PLATE 85MM LG 9 HOLE BONE HUMERAL A.L.P.S. LEFT","SUP-ITM-10071492","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2884.20","2163.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2262.65","78.45","","385.32","55.36","1815.62","58","1442.1","2262.65","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","141.00","105.75","AETNA [1001]","HB CH AETNA HMO / PPO","82.20","58.3","","77.68","77.68","77.68","1 through 10","11.87","102.93","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","both","","","141.00","105.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","74.73","53","","72.61","72.61","72.61","1 through 10","11.87","102.93","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","141.00","105.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","83.61","59.3","","80.28","80.28","80.28","1 through 10","12.49","110.61","percent of total billed charges",""
"LEAD","PX-30000545","CDM","83655","CPT","0301","RC","","","","outpatient","","","141.00","105.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","110.61","78.45","","100.85","100.85","100.85","1 through 10","12.49","110.61","percent of total billed charges",""
"LEAD ELECTRODE 52MMX60CM TRIAL OCTRODE 8 NEUROSTIMULATOR","SUP-ITM-10018946","CDM","C1897","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2502.46","2502.46","2502.46","1 through 10","1590","3000","percent of total billed charges",""
"Lead Extension","PX-27002349","CDM","C1883","HCPCS","0278","RC","","","","both","","","200.00","150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","106.00","53","","1892.10","1892.10","1892.10","1 through 10","106","200","percent of total billed charges",""
"LEAD EXTENSION 30CM NEUROSTIMULATOR SINGLE 8","SUP-ITM-10020901","CDM","C1883","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","1892.10","1892.10","1892.10","1 through 10","1423.05","2685","percent of total billed charges",""
"LEAD EXTENSION 35CM NEUROMODULATION SPINE PRECISION LINEAR ST 8 CONTACT","SUP-ITM-10077210","CDM","C1883","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","1892.10","1892.10","1892.10","1 through 10","1431","2700","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","both","","","9232.30","6924.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4893.12","53","","3922.00","3922.00","3922.00","1 through 10","4893.12","9232.3","percent of total billed charges",""
"LEAD IMPLANTABLE 45CM REACTIV8","SUP-ITM-10283220","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9232.30","6924.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","5474.75","59.3","","3013.82","3013.82","3013.82","1 through 10","4103.76","7242.74","percent of total billed charges",""
"LEAD IMPLANTABLE 65CM REACTIV8","SUP-ITM-10283219","CDM","C1778","HCPCS","0278","RC","","","","both","","","9528.30","7146.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5050.00","53","","3922.00","3922.00","3922.00","1 through 10","5050","9528.3","percent of total billed charges",""
"LEAD IMPLANTABLE 65CM REACTIV8","SUP-ITM-10283219","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9528.30","7146.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","5650.28","59.3","","3013.82","3013.82","3013.82","1 through 10","4235.33","7474.95","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2438.00","53","","3922.00","3922.00","3922.00","1 through 10","2438","4600","percent of total billed charges",""
"LEAD MRI 74CM SAFE AVISTA","SUP-ITM-10191385","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2727.80","59.3","","3013.82","3013.82","3013.82","1 through 10","2044.7","3608.7","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","3922.00","3922.00","3922.00","1 through 10","1749","3300","percent of total billed charges",""
"LEAD NEUROMODULATION 1.0X16 50CM SPINAL INFINEON PERCUTANEOUS TRIAL","SUP-ITM-10126480","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","3013.82","3013.82","3013.82","1 through 10","1466.85","2588.85","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","3922.00","3922.00","3922.00","1 through 10","1987.5","3750","percent of total billed charges",""
"LEAD NEUROMODULATION 70CM SPINAL PRECISION LINEAR 8 CONTACT ENHANCED","SUP-ITM-10077213","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","3013.82","3013.82","3013.82","1 through 10","1666.88","2941.88","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 1X8 3 12 6 9 66MM 75CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10017606","CDM","C1778","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2318.75","53","","3922.00","3922.00","3922.00","1 through 10","2318.75","4375","percent of total billed charges",""
"LEAD NEUROSTIMULATOR 1X8 3 12 6 9 66MM 75CM STANDARD ELECTRODE PERCUTANEOUS","SUP-ITM-10017606","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","3013.82","3013.82","3013.82","1 through 10","1944.69","3432.19","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","3922.00","3922.00","3922.00","1 through 10","1590","3000","percent of total billed charges",""
"Lead Neurostimulator T1","PX-27000114","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","3013.82","3013.82","3013.82","1 through 10","1333.5","2353.5","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","both","","","4161.25","3120.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2205.46","53","","3922.00","3922.00","3922.00","1 through 10","2205.46","4161.25","percent of total billed charges",""
"Lead Neurostimulator T2","PX-27000115","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4161.25","3120.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2467.62","59.3","","3013.82","3013.82","3013.82","1 through 10","1849.68","3264.5","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","both","","","5919.46","4439.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3137.31","53","","3922.00","3922.00","3922.00","1 through 10","3137.31","5919.46","percent of total billed charges",""
"Lead Neurostimulator T3","PX-27000116","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","5919.46","4439.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","3510.24","59.3","","3013.82","3013.82","3013.82","1 through 10","2631.2","4643.82","percent of total billed charges",""
"Lead Neurostimulator Test Kit T1","PX-27000191","CDM","C1897","HCPCS","0278","RC","","","","both","","","2502.46","1876.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2502.46","100","","2502.46","2502.46","2502.46","1 through 10","1326.3","2502.46","percent of total billed charges",""
"Lead Neurostimulator Test Kit T3","PX-27002377","CDM","C1897","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2502.46","2502.46","2502.46","1 through 10","2120","4000","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","3922.00","3922.00","3922.00","1 through 10","2120","4000","percent of total billed charges",""
"LEAD OCTRODE 60CM NEUROSTIMULATOR","SUP-ITM-10019318","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","3013.82","3013.82","3013.82","1 through 10","1778","3138","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","3922.00","3922.00","3922.00","1 through 10","2120","4000","percent of total billed charges",""
"LEAD OCTRODE 90CM KIT RECHARGEABLE","SUP-ITM-10046831","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","3013.82","3013.82","3013.82","1 through 10","1778","3138","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","both","","","10000.00","7500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5300.00","53","","3922.00","3922.00","3922.00","1 through 10","5300","10000","percent of total billed charges",""
"LEAD PADDLE 2X8 65CM MRI SURGICAL NOTE NEW CHANGES","SUP-ITM-10073304","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","10000.00","7500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5930.00","59.3","","3013.82","3013.82","3013.82","1 through 10","4445","7845","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","both","","","8600.00","6450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4558.00","53","","3922.00","3922.00","3922.00","1 through 10","4558","8600","percent of total billed charges",""
"LEAD PADDLE 50CM NEUROSTIMULATOR","SUP-ITM-10203891","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","8600.00","6450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5099.80","59.3","","3013.82","3013.82","3013.82","1 through 10","3822.7","6746.7","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","both","","","6750.00","5062.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3577.50","53","","3922.00","3922.00","3922.00","1 through 10","3577.5","6750","percent of total billed charges",""
"LEAD RESPIRATORY SENSING","SUP-ITM-10237951","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","6750.00","5062.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4002.75","59.3","","3013.82","3013.82","3013.82","1 through 10","3000.38","5295.38","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","3922.00","3922.00","3922.00","1 through 10","2067","3900","percent of total billed charges",""
"LEAD STIMULATION","SUP-ITM-10209083","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","3013.82","3013.82","3013.82","1 through 10","1733.55","3059.55","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4770.00","53","","3922.00","3922.00","3922.00","1 through 10","4770","9000","percent of total billed charges",""
"LEAD STIMULATOR 60CM LAMITRODE 16CH 5 COLUMN PENTA","SUP-ITM-10086854","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5337.00","59.3","","3013.82","3013.82","3013.82","1 through 10","4000.5","7060.5","percent of total billed charges",""
"LEAD TRIAL 90CM","SUP-ITM-10158038","CDM","C1897","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1950.00","100","","2502.46","2502.46","2502.46","1 through 10","1033.5","1950","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","3922.00","3922.00","3922.00","1 through 10","1749","3300","percent of total billed charges",""
"LEAD TRIAL NEUROSTIMULATOR 1X16 70CM INFINION","SUP-ITM-10280226","CDM","C1778","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","3013.82","3013.82","3013.82","1 through 10","1466.85","2588.85","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","0.01","0.01","AETNA [1001]","HB CH AETNA HMO / PPO","0.01","58.3","","0.09","0.09","3.99","52","0.01","0.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","0.01","0.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","0.01","53","","13.37","3.28","13.37","1 through 10","0.01","0.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","both","","","0.01","0.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","0.01","100","","0.07","0.07","0.07","1 through 10","0.01","0.06","percent of total billed charges",""
"Lidocaine Inj 10mg","PX-63600144","CDM","J2001","HCPCS","0636","RC","","","","outpatient","","","0.01","0.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.01","52.2","","1.44","1.44","5.77","1 through 10","0.01","0.01","percent of total billed charges",""
"Lig Hemorrhoid Intern 2/More Grp","PX-75000239","CDM","46946","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2101.12","","Case rate ($2,101.12). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","14812.89","14812.89","14812.89","1 through 10","2101.12","7939.38","other","Multiple Surgery"
"Lig Hemorrhoid Intern Sgl Col/Group","PX-75000238","CDM","46945","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2669.73","","Case rate ($2,669.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3775.00","3775.00","3775.00","1 through 10","2101.12","7939.38","other","ASC "
"Ligate Fistula Av Angioaccess","PX-76001166","CDM","37607","CPT","0761","RC","","","","both","","","8953.00","6714.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","3663.09","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","3409.31","3409.31","3409.31","1 through 10","2377.37","6975.28","other","OPPS APC"
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","956","MS-DRG","","","","","","","","inpatient","","","84548.24","63411.18","MEDICARE [2001]","HB BWF MEDICARE","38299.55","","Case rate ($38,299.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $35,043.40, add-ons for qualifying new technology services are included. If operating cost exceeds $80,567.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,221.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $35,300.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $34,704.17 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,660.29. The transfer capital threshold is the transfer adjustment factor * $2,660.29. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","38002.76","38002.76","38002.76","1 through 10","34287.19","38299.55","other","Inpatient DRG"
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","AETNA [1001]","HB CH AETNA HMO / PPO","47.22","58.3","","44.79","44.79","44.79","12","6.75","59.13","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","both","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.00","44.45","","60.74","60.74","60.74","1 through 10","6.75","59.13","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.03","59.3","","46.29","46.29","46.30","15","7.1","63.54","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","81.00","60.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","60.74","60.74","60.74","1 through 10","7.1","63.54","percent of total billed charges",""
"Lipase","PX-30000551","CDM","83690","CPT","0301","RC","","","","outpatient","","","81.00","60.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.54","78.45","","35.99","35.99","60.74","1 through 10","7.1","63.54","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","AETNA [1001]","HB CH AETNA HMO / PPO","63.55","58.3","","60.10","60.10","60.10","288","13.12","87.77","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.77","53","","56.18","56.18","56.18","1 through 10","13.12","87.77","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","79.57","73","","77.38","60.10","77.38","1 through 10","13.12","87.77","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.45","44.45","","81.49","48.29","81.49","12","13.12","87.77","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","both","","","109.00","81.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.45","44.45","","48.29","48.29","48.29","1 through 10","13.12","87.77","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.64","59.3","","62.12","62.12","62.12","297","13.81","85.51","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","64.64","59.3","","62.12","62.12","62.12","1 through 10","13.81","85.51","percent of total billed charges",""
"Lipid Panel","PX-30000173","CDM","80061","CPT","0301","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.51","78.45","","81.49","48.29","81.49","234","13.81","85.51","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","76.00","57.00","AETNA [1001]","HB CH AETNA HMO / PPO","44.31","58.3","","41.96","41.96","41.96","1 through 10","6.48","55.48","percent of total billed charges",""
"Lithium","PX-30000185","CDM","80178","CPT","0301","RC","","","","both","","","76.00","57.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","55.48","73","","41.96","41.96","41.96","1 through 10","6.48","55.48","percent of total billed charges",""
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","496","MS-DRG","","","","","","","","inpatient","","","54276.35","40707.26","MEDICARE [2001]","HB BWF MEDICARE","18536.58","","Case rate ($18,536.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,975.66, add-ons for qualifying new technology services are included. If operating cost exceeds $62,499.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,836.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,922.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,636.42 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,275.28. The transfer capital threshold is the transfer adjustment factor * $1,275.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19737.33","19737.33","19737.33","1 through 10","16609.61","18536.58","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With McC","495","MS-DRG","","","","","","","","inpatient","","","109924.91","82443.68","MEDICARE [2001]","HB BWF MEDICARE","36914.51","","Case rate ($36,914.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $33,777.16, add-ons for qualifying new technology services are included. If operating cost exceeds $79,300.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,124.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,012.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $33,437.92 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,563.22. The transfer capital threshold is the transfer adjustment factor * $2,563.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35022.05","35022.05","35022.05","1 through 10","33048.3","36914.51","other","Inpatient DRG"
"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC","497","MS-DRG","","","","","","","","inpatient","","","43358.59","32518.94","MEDICARE [2001]","HB BWF MEDICARE","12528.30","","Case rate ($12,528.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,482.75, add-ons for qualifying new technology services are included. If operating cost exceeds $57,006.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,415.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 1.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,334.85 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,143.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $854.22. The transfer capital threshold is the transfer adjustment factor * $854.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13511.23","13511.23","13601.26","1 through 10","11235.33","12528.3","other","Inpatient DRG"
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","554.95","91.85","1421.75","94","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2490.03","2490.03","2490.03","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","750.00","750.00","750.00","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","1192.50","120.84","4149.90","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","750.00","75.00","750.00","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","657.00","121.50","1971.00","14","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","75.00","75.00","75.00","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","366.00","144.00","1971.00","45","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","667.50","667.50","667.50","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","123.77","123.77","123.77","1 through 10","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","483.51","229.32","1316.08","96","400.05","900","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","439.50","225.34","1872.27","197","450","706.05","percent of total billed charges",""
"LOOP DEVICE 10MM FIXATION SUTURE ENDOBUTTON CL ULTRA TITANIUM POLYESTER BRAIDED ULTRABRAID LEAD DURABRAID FLIP","SUP-ITM-10113253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","385.32","55.36","1815.62","58","450","706.05","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","130.07","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","129.95","129.95","129.95","26","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","AETNA [1001]","HB CH AETNA HMO / PPO","493.22","58.3","","466.64","466.64","466.64","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","14","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","1 through 10","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","FALLON HEALTH [1008]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","609.97","72.1","","620.54","596.68","620.54","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","536.36","63.4","","545.65","525.07","545.65","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","218","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","123.76","126.29","1 through 10","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","1 through 10","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","117.60","123.77","63","119.97","804.55","other","OPPS APC"
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.67","35.54","","374.96","374.96","374.96","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","both","","","846.00","634.50","WELLPOINT [1015]","HB CH WELLPOINT","659.12","77.91","","648.19","648.19","648.19","1 through 10","119.97","804.55","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","846.00","634.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","488.14","57.7","","496.27","496.27","496.27","25","243.42","511.83","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","846.00","634.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","511.83","60.5","","520.96","520.96","520.96","1 through 10","243.42","511.83","percent of total billed charges",""
"Low Dose CT Lung Screening","PX-35000096","CDM","71271","CPT","0352","RC","","","","outpatient","","","846.00","634.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","300.67","35.54","","286.65","286.65","286.65","1 through 10","243.42","511.83","percent of total billed charges",""
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","58814.28","44110.71","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","24401.01","","Case rate ($23,690.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $69,252.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,353.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $21,558.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,389.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,792.92. The transfer capital threshold is the transfer adjustment factor * $1,792.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","19487.92","19487.92","19487.92","1 through 10","23216.49","26033.07","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","493","MS-DRG","","","","","","","","inpatient","","","58814.28","44110.71","MEDICARE [2001]","HB BWF MEDICARE","25922.86","","Case rate ($25,922.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,728.35, add-ons for qualifying new technology services are included. If operating cost exceeds $69,252.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,353.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4.2)) / 2. The base transfer operating payment is the transfer adjustment factor * $23,790.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,389.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,792.92. The transfer capital threshold is the transfer adjustment factor * $1,792.92. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23400.06","0.03","23964.43","1 through 10","23216.49","26033.07","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC","492","MS-DRG","","","","","","","","inpatient","","","110169.21","82626.91","MEDICARE [2001]","HB BWF MEDICARE","37377.55","","Case rate ($37,377.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $34,200.48, add-ons for qualifying new technology services are included. If operating cost exceeds $79,724.21 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,156.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $34,442.62 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $33,861.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,595.67. The transfer capital threshold is the transfer adjustment factor * $2,595.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35324.27","35324.27","35324.27","1 through 10","33462.48","37377.55","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","47710.78","35783.08","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","20580.37","","Case rate ($20,580.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,844.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,367.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,979.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,822.62 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,504.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.52. The transfer capital threshold is the transfer adjustment factor * $1,418.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17107.01","17107.01","17107.01","1 through 10","18437.74","20580.37","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","47710.78","35783.08","MEDICARE [2001]","HB BWF MEDICARE","20580.37","","Case rate ($20,580.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,844.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,367.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,979.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $18,822.62 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,504.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.52. The transfer capital threshold is the transfer adjustment factor * $1,418.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16458.87","16458.87","18998.58","1 through 10","18437.74","20580.37","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","47710.78","35783.08","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","18437.74","","Case rate ($18,814.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,844.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,367.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,979.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,056.27 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,504.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.52. The transfer capital threshold is the transfer adjustment factor * $1,418.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17073.68","17073.68","17073.68","1 through 10","18437.74","20580.37","other","Inpatient DRG"
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC","494","MS-DRG","","","","","","","","inpatient","","","47710.78","35783.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","18437.74","","Case rate ($18,814.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,844.13, add-ons for qualifying new technology services are included. If operating cost exceeds $64,367.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,979.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,056.27 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,504.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,418.52. The transfer capital threshold is the transfer adjustment factor * $1,418.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17074.28","17074.28","17074.28","1 through 10","18437.74","20580.37","other","Inpatient DRG"
"Lumbar Puncture Diagnostic","PX-76001462","CDM","62270","CPT","0761","RC","","","","outpatient","","","1159.00","869.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","101.86","101.86","101.86","1 through 10","497.21","1873.9","other","Multiple Surgery"
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB CH AETNA HMO / PPO","384.78","58.3","","1830.28","315.58","1830.28","1 through 10","293.37","660","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","481.80","73","","4170.85","4170.85","4170.85","1 through 10","293.37","660","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.37","44.45","","649.55","649.55","649.55","1 through 10","293.37","660","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","WELLPOINT [1015]","HB CH WELLPOINT","514.21","77.91","","8998.38","2542.37","8998.38","20","293.37","660","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","1891.61","1609.14","3664.18","25","330","517.77","percent of total billed charges",""
"LUMBAR ROD 5.5X45.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10030490","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","1470.68","1310.06","2481.69","19","330","517.77","percent of total billed charges",""
"LUMBAR ROD 5.5X480MM EXPEDIUM TITANIUM END TO CONNECTOR","SUP-ITM-10045818","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","1830.28","315.58","1830.28","1 through 10","266.7","600","percent of total billed charges",""
"LUMBAR ROD 5.5X480MM EXPEDIUM TITANIUM END TO CONNECTOR","SUP-ITM-10045818","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","4170.85","4170.85","4170.85","1 through 10","266.7","600","percent of total billed charges",""
"LUMBAR ROD 5.5X480MM EXPEDIUM TITANIUM END TO CONNECTOR","SUP-ITM-10045818","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","649.55","649.55","649.55","1 through 10","266.7","600","percent of total billed charges",""
"LUMBAR ROD 5.5X480MM EXPEDIUM TITANIUM END TO CONNECTOR","SUP-ITM-10045818","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","8998.38","2542.37","8998.38","20","266.7","600","percent of total billed charges",""
"LUMBAR ROD 5.5X480MM EXPEDIUM TITANIUM END TO CONNECTOR","SUP-ITM-10045818","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","1891.61","1609.14","3664.18","25","300","470.7","percent of total billed charges",""
"LUMBAR ROD 5.5X480MM EXPEDIUM TITANIUM END TO CONNECTOR","SUP-ITM-10045818","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1470.68","1310.06","2481.69","19","300","470.7","percent of total billed charges",""
"LUMBAR SPACER 10X45MM CLYDESDALE IB PEEK PARALLEL","SUP-ITM-10058914","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","AETNA [1001]","HB CH AETNA HMO / PPO","4343.35","58.3","","1830.28","315.58","1830.28","1 through 10","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 10X45MM CLYDESDALE IB PEEK PARALLEL","SUP-ITM-10058914","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5438.50","73","","4170.85","4170.85","4170.85","1 through 10","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 10X45MM CLYDESDALE IB PEEK PARALLEL","SUP-ITM-10058914","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3311.53","44.45","","649.55","649.55","649.55","1 through 10","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 10X45MM CLYDESDALE IB PEEK PARALLEL","SUP-ITM-10058914","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","WELLPOINT [1015]","HB CH WELLPOINT","5804.30","77.91","","8998.38","2542.37","8998.38","20","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 10X45MM CLYDESDALE IB PEEK PARALLEL","SUP-ITM-10058914","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4417.85","59.3","","1891.61","1609.14","3664.18","25","3725","5844.53","percent of total billed charges",""
"LUMBAR SPACER 10X45MM CLYDESDALE IB PEEK PARALLEL","SUP-ITM-10058914","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5844.53","78.45","","1470.68","1310.06","2481.69","19","3725","5844.53","percent of total billed charges",""
"LUMBAR SPACER 8X30MM EXTENSURE ALLOGRAFT","SUP-ITM-10093860","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","AETNA [1001]","HB CH AETNA HMO / PPO","3323.10","58.3","","1830.28","315.58","1830.28","1 through 10","2533.65","5700","percent of total billed charges",""
"LUMBAR SPACER 8X30MM EXTENSURE ALLOGRAFT","SUP-ITM-10093860","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4161.00","73","","4170.85","4170.85","4170.85","1 through 10","2533.65","5700","percent of total billed charges",""
"LUMBAR SPACER 8X30MM EXTENSURE ALLOGRAFT","SUP-ITM-10093860","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2533.65","44.45","","649.55","649.55","649.55","1 through 10","2533.65","5700","percent of total billed charges",""
"LUMBAR SPACER 8X30MM EXTENSURE ALLOGRAFT","SUP-ITM-10093860","CDM","C1889","HCPCS","0278","RC","","","","both","","","5700.00","4275.00","WELLPOINT [1015]","HB CH WELLPOINT","4440.87","77.91","","8998.38","2542.37","8998.38","20","2533.65","5700","percent of total billed charges",""
"LUMBAR SPACER 8X30MM EXTENSURE ALLOGRAFT","SUP-ITM-10093860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3380.10","59.3","","1891.61","1609.14","3664.18","25","2850","4471.65","percent of total billed charges",""
"LUMBAR SPACER 8X30MM EXTENSURE ALLOGRAFT","SUP-ITM-10093860","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","5700.00","4275.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4471.65","78.45","","1470.68","1310.06","2481.69","19","2850","4471.65","percent of total billed charges",""
"LUMBAR SPACER 8X45MM 6DEG CLYDESDALE IB PEEK","SUP-ITM-10058910","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","AETNA [1001]","HB CH AETNA HMO / PPO","4343.35","58.3","","1830.28","315.58","1830.28","1 through 10","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 8X45MM 6DEG CLYDESDALE IB PEEK","SUP-ITM-10058910","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5438.50","73","","4170.85","4170.85","4170.85","1 through 10","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 8X45MM 6DEG CLYDESDALE IB PEEK","SUP-ITM-10058910","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3311.53","44.45","","649.55","649.55","649.55","1 through 10","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 8X45MM 6DEG CLYDESDALE IB PEEK","SUP-ITM-10058910","CDM","C1889","HCPCS","0278","RC","","","","both","","","7450.00","5587.50","WELLPOINT [1015]","HB CH WELLPOINT","5804.30","77.91","","8998.38","2542.37","8998.38","20","3311.53","7450","percent of total billed charges",""
"LUMBAR SPACER 8X45MM 6DEG CLYDESDALE IB PEEK","SUP-ITM-10058910","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4417.85","59.3","","1891.61","1609.14","3664.18","25","3725","5844.53","percent of total billed charges",""
"LUMBAR SPACER 8X45MM 6DEG CLYDESDALE IB PEEK","SUP-ITM-10058910","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7450.00","5587.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5844.53","78.45","","1470.68","1310.06","2481.69","19","3725","5844.53","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","both","","","218.00","163.50","AETNA [1001]","HB CH AETNA HMO / PPO","127.09","58.3","","120.20","120.20","120.20","1 through 10","18.15","159.14","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","218.00","163.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.27","59.3","","124.23","124.23","124.23","11","19.09","171.02","percent of total billed charges",""
"Luteinizing Hormone (Lh)","PX-30000482","CDM","83002","CPT","0301","RC","","","","outpatient","","","218.00","163.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","171.02","78.45","","162.99","96.59","162.99","1 through 10","19.09","171.02","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","AETNA [1001]","HB CH AETNA HMO / PPO","98.53","58.3","","92.99","92.99","185.98","1 through 10","16.69","123.37","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","both","","","169.00","126.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.57","53","","86.92","86.92","86.92","1 through 10","16.69","123.37","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","169.00","126.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.22","59.3","","96.10","96.10","96.10","1 through 10","14.72","132.58","percent of total billed charges",""
"Lyme Disease Antibody","PX-30000893","CDM","86618","CPT","0302","RC","","","","outpatient","","","169.00","126.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","132.58","78.45","","126.08","74.72","126.09","1 through 10","14.72","132.58","percent of total billed charges",""
"Lyme Disease Antibody Confirm","PX-30000891","CDM","86617","CPT","0302","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","200.72","200.72","200.72","1 through 10","15.18","132.86","percent of total billed charges",""
"Lymphoma And Non-Acute Leukemia With McC","840","MS-DRG","","","","","","","","inpatient","","","26435.58","19826.68","MEDICARE [2001]","HB BWF MEDICARE","32972.20","","Case rate ($32,972.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,173.02, add-ons for qualifying new technology services are included. If operating cost exceeds $75,696.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,847.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $30,346.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,833.78 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,286.94. The transfer capital threshold is the transfer adjustment factor * $2,286.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19181.85","19181.85","19181.85","1 through 10","29521.98","32972.2","other","Inpatient DRG"
"Lymphoma And Non-Acute Leukemia Without Cc/McC","842","MS-DRG","","","","","","","","inpatient","","","9951.21","7463.41","MEDICARE [2001]","HB BWF MEDICARE","10531.94","","Case rate ($10,531.94). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,657.63, add-ons for qualifying new technology services are included. If operating cost exceeds $55,181.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,275.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $9,478.38 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,318.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $714.31. The transfer capital threshold is the transfer adjustment factor * $714.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10710.69","10710.69","10710.69","1 through 10","9449.62","10531.94","other","Inpatient DRG"
"M/Phmtrc Alys in Situ Hybridization Ea Probe Mnl","PX-31000493","CDM","88368","CPT","0310","RC","","","","both","","","878.00","658.50","WELLPOINT [1015]","HB CH WELLPOINT","684.05","77.91","","2380.61","2380.61","2380.61","1 through 10","405.83","1456.11","percent of total billed charges",""
"M/Phmtrc Alys in Situ Hybridization Ea Probe Mnl","PX-31000493","CDM","88368","CPT","0310","RC","","","","outpatient","","","878.00","658.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","688.79","78.45","","656.56","656.56","656.56","1 through 10","324.26","926.86","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","both","","","555.00","416.25","MEDICARE [2001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","203.50","186.42","203.50","1 through 10","193.33","768.52","other","OPPS APC"
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","both","","","555.00","416.25","TRICARE [160005]","HB BWF TRICARE","193.33","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","203.50","203.50","203.50","1 through 10","193.33","768.52","other","Tricare OPPS"
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","both","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.70","44.45","","415.15","415.15","415.15","1 through 10","193.33","768.52","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","both","","","555.00","416.25","WELLPOINT [1015]","HB CH WELLPOINT","432.40","77.91","","965.30","425.30","965.30","14","193.33","768.52","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","outpatient","","","555.00","416.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.12","59.3","","316.44","316.44","949.32","13","256.54","489.19","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl Each Multiprb","PX-31000497","CDM","88377","CPT","0310","RC","","","","outpatient","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","415.15","246.03","540.00","13","256.54","489.19","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl per Spec Each","PX-31000494","CDM","88369","CPT","0310","RC","","","","both","","","359.00","269.25","WELLPOINT [1015]","HB CH WELLPOINT","279.70","77.91","","972.87","972.87","972.87","1 through 10","159.58","359","percent of total billed charges",""
"M/Phmtrc Alys Ish Quant/Semiq Mnl per Spec Each","PX-31000494","CDM","88369","CPT","0310","RC","","","","outpatient","","","359.00","269.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.64","78.45","","268.31","268.31","268.31","1 through 10","179.5","281.64","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.75","103.75","103.75","1 through 10","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","185.00","216.03","1 through 10","174.24","768.52","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","207.76","53","","201.93","201.93","201.93","1 through 10","174.24","768.52","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","MEDICARE [2001]","HB BWF MEDICARE","203.50","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","67.83","67.83","67.83","1 through 10","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","92.19","92.19","92.19","1 through 10","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","292.91","292.91","1 through 10","174.24","768.52","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","199.43","","APC Price ($203.50). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","60.97","60.97","60.97","1 through 10","174.24","768.52","other","OPPS APC"
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","both","","","392.00","294.00","WELLPOINT [1015]","HB CH WELLPOINT","305.41","77.91","","1443.08","300.08","1524.00","74","174.24","768.52","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","401.46","223.27","669.80","76","196","489.19","percent of total billed charges",""
"M/Phmtrc Alys Tumor Imhchem Ea Antibody Manual","PX-31000047","CDM","88360","CPT","0310","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","173.58","878.74","80","196","489.19","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0300","RC","","","","inpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","44.48","70.6","","46.90","46.90","46.90","1 through 10","35.28","44.48","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","75","6.57","45.99","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","45.99","73","","44.53","43.07","44.53","1 through 10","6.57","45.99","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","1 through 10","6.57","45.99","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","45.99","73","","34.59","34.59","34.59","1 through 10","6.57","45.99","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","both","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.00","44.45","","46.90","27.79","46.90","1 through 10","6.57","45.99","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","35.75","35.75","132.50","102","6.9","49.42","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","63.00","47.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","46.90","46.90","93.79","1 through 10","6.9","49.42","percent of total billed charges",""
"Magnesium","PX-30000563","CDM","83735","CPT","0301","RC","","","","outpatient","","","63.00","47.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","49.42","78.45","","46.90","27.79","93.80","70","6.9","49.42","percent of total billed charges",""
"Major Biliary Tract Procedures,MODERATE","261","DRG","","","","","","","","inpatient","","","22713.82","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","28484.4192","","Fee schedule rate ($41,804.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28484.4192","41804.24","41804.24","1 through 10","12971.57","68976.36","case rate",""
"Major Bladder Procedures Without Cc/McC","655","MS-DRG","","","","","","","","inpatient","","","53112.98","39834.73","MEDICARE [2001]","HB BWF MEDICARE","21691.04","","Case rate ($21,691.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,859.53, add-ons for qualifying new technology services are included. If operating cost exceeds $65,383.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,057.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $19,855.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,520.29 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,496.35. The transfer capital threshold is the transfer adjustment factor * $1,496.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","20906.73","20906.73","20906.73","1 through 10","19431.21","21691.04","other","Inpatient DRG"
"Major Bladder Procedures,MAJOR","441","DRG","","","","","","","","inpatient","","","97025.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","75976.22","","Standard inlier is a Case rate ($75,976.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $84,208, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($10,784.50) for the length of stay and the standard reimbursement.","72522.75","72522.75","72522.75","1 through 10","27342.53","106605.11","case rate",""
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","55568.13","41676.10","MEDICARE [2001]","HB BWF MEDICARE","25800.79","","Case rate ($25,800.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,616.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,140.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,345.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $23,677.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,277.52 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,784.37. The transfer capital threshold is the transfer adjustment factor * $1,784.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","21557.74","1 through 10","23107.3","25800.79","other","Inpatient DRG"
"Major Chest Procedures With Cc","164","MS-DRG","","","","","","","","inpatient","","","55568.13","41676.10","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","23107.30","","Case rate ($23,578.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $23,616.76, add-ons for qualifying new technology services are included. If operating cost exceeds $69,140.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,345.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $21,455.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,277.52 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,784.37. The transfer capital threshold is the transfer adjustment factor * $1,784.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","22655.20","22655.20","22707.03","1 through 10","23107.3","25800.79","other","Inpatient DRG"
"Major Chest Trauma With Cc","184","MS-DRG","","","","","","","","inpatient","","","38784.71","29088.53","MEDICARE [2001]","HB BWF MEDICARE","11073.65","","Case rate ($11,073.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,152.87, add-ons for qualifying new technology services are included. If operating cost exceeds $55,676.60 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,313.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,982.13 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,813.63 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $752.28. The transfer capital threshold is the transfer adjustment factor * $752.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","9934.17","11073.65","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","36381.58","27286.18","MEDICARE [2001]","HB BWF MEDICARE","14425.74","","Case rate ($14,425.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,448.70, add-ons for qualifying new technology services are included. If operating cost exceeds $59,972.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,642.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,004.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,109.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,081.58. The transfer capital threshold is the transfer adjustment factor * $1,081.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15928.00","15928.00","15928.00","1 through 10","14137.23","15704.42","other","Inpatient Replacement Plans DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","36381.58","27286.18","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14137.23","","Case rate ($14,425.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,448.70, add-ons for qualifying new technology services are included. If operating cost exceeds $59,972.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,642.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,004.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,109.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,081.58. The transfer capital threshold is the transfer adjustment factor * $1,081.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14366.36","14366.36","14366.36","1 through 10","14137.23","15704.42","other","Inpatient DRG"
"Major Chest Trauma With McC","183","MS-DRG","","","","","","","","inpatient","","","36381.58","27286.18","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14137.23","","Case rate ($14,425.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,448.70, add-ons for qualifying new technology services are included. If operating cost exceeds $59,972.43 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,642.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,004.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,109.46 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,081.58. The transfer capital threshold is the transfer adjustment factor * $1,081.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14400.29","14400.29","14400.29","1 through 10","14137.23","15704.42","other","Inpatient DRG"
"Major Chest Trauma Without Cc/McC","185","MS-DRG","","","","","","","","inpatient","","","28722.62","21541.96","MEDICARE [2001]","HB BWF MEDICARE","8273.28","","Case rate ($8,273.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,592.72, add-ons for qualifying new technology services are included. If operating cost exceeds $53,116.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,116.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $7,378.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,253.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $556.02. The transfer capital threshold is the transfer adjustment factor * $556.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7984.20","7984.20","7984.20","1 through 10","7429.29","8273.28","other","Inpatient DRG"
"Major Esophageal Disorders With Cc","369","MS-DRG","","","","","","","","inpatient","","","35304.97","26478.73","MEDICARE [2001]","HB BWF MEDICARE","10429.04","","Case rate ($10,429.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,563.56, add-ons for qualifying new technology services are included. If operating cost exceeds $55,087.29 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,267.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,382.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,224.32 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $707.10. The transfer capital threshold is the transfer adjustment factor * $707.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10301.41","0.03","10369.63","1 through 10","9357.58","10429.04","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","30936.79","23202.59","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","15446.51","","Case rate ($14,996.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $60,544.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,686.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,531.96 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,681.26 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.41. The transfer capital threshold is the transfer adjustment factor * $1,125.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","15894.58","15894.58","15894.58","1 through 10","14696.68","16340.85","other","Inpatient DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","30936.79","23202.59","MEDICARE [2001]","HB BWF MEDICARE","14996.61","","Case rate ($14,996.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $60,544.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,686.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,531.96 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,681.26 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.41. The transfer capital threshold is the transfer adjustment factor * $1,125.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16856.75","16856.75","16856.75","1 through 10","14696.68","16340.85","other","Inpatient Replacement Plans DRG"
"Major Esophageal Disorders With McC","368","MS-DRG","","","","","","","","inpatient","","","30936.79","23202.59","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14696.68","","Case rate ($14,996.61). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,020.50, add-ons for qualifying new technology services are included. If operating cost exceeds $60,544.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,686.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $13,531.96 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,681.26 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,125.41. The transfer capital threshold is the transfer adjustment factor * $1,125.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15119.43","15119.43","15119.43","1 through 10","14696.68","16340.85","other","Inpatient DRG"
"Major Esophageal Disorders,MAJOR","242","DRG","","","","","","","","inpatient","","","51110.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26307.67","","Standard inlier is a Case rate ($26,307.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,771, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,734.26) for the length of stay and the standard reimbursement.","25111.86","25111.86","25111.86","1 through 10","6442.94","85801.28","case rate",""
"Major Esophageal Disorders,MAJOR","242","DRG","","","","","","","","inpatient","","","51110.55","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10155.63","","Case rate ($11,228.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,658.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11226.04","11226.04","11226.04","1 through 10","6442.94","85801.28","case rate",""
"Major Esophageal Disorders,MAJOR","242","DRG","","","","","","","","inpatient","","","51110.55","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10155.63","","Case rate ($11,228.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,658.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11226.04","11226.04","11226.04","1 through 10","6442.94","85801.28","case rate",""
"Major Esophageal Disorders,MODERATE","242","DRG","","","","","","","","inpatient","","","18364.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18344.26","","Standard inlier is a Case rate ($18,344.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,167, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,603.89) for the length of stay and the standard reimbursement.","18344.26","18344.26","18344.26","1 through 10","6442.94","85801.28","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","58754.88","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13432.9734","","Standard inlier is a Case rate ($25,981.12). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,460, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,687.91) for the length of stay and the standard reimbursement.","13432.9734","24800.16","24800.16","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","58754.88","","FALLON HEALTH [1008]","HB BWF MEDICAID","10610.30","","Case rate ($11,731.51). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,161.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11728.63","11728.63","11728.63","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","58754.88","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10610.30","","Case rate ($11,731.51). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,161.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11728.63","11728.63","11728.63","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MAJOR","248","DRG","","","","","","","","inpatient","","","58754.88","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10610.30","","Case rate ($11,731.51). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,161.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7190.04","7190.04","7190.04","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","21269.04","","MASSHEALTH [3001]","HB BWF MEDICAID","6778.80","","Case rate ($7,495.13). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,925.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7493.29","7493.29","7493.29","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","21269.04","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","18083.61","","Fee schedule rate ($18,083.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18083.61","18083.61","18083.61","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal And Peritoneal Infections,MODERATE","248","DRG","","","","","","","","inpatient","","","21269.04","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6778.80","","Case rate ($7,495.13). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,925.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7493.29","7493.29","7786.45","1 through 10","4392.73","40300.79","case rate",""
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","27141.35","20356.01","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10638.85","","Case rate ($10,638.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,755.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,279.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,282.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,577.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,416.15 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.81. The transfer capital threshold is the transfer adjustment factor * $721.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9477.46","9477.46","9477.46","1 through 10","9545.25","10638.85","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","27141.35","20356.01","HUMANA [1012]","HB BWF MEDICARE","10638.85","","Case rate ($10,638.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,755.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,279.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,282.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,577.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,416.15 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.81. The transfer capital threshold is the transfer adjustment factor * $721.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9398.65","9398.65","9398.65","1 through 10","9545.25","10638.85","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","27141.35","20356.01","MEDICARE [2001]","HB BWF MEDICARE","10638.85","","Case rate ($10,638.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,755.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,279.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,282.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $9,577.82 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,416.15 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.81. The transfer capital threshold is the transfer adjustment factor * $721.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10485.98","0.03","10485.98","11","9545.25","10638.85","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","372","MS-DRG","","","","","","","","inpatient","","","27141.35","20356.01","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9545.25","","Case rate ($9,740.05). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,755.38, add-ons for qualifying new technology services are included. If operating cost exceeds $55,279.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,282.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $8,679.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,416.15 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $721.81. The transfer capital threshold is the transfer adjustment factor * $721.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","20702.73","20702.73","20702.73","1 through 10","9545.25","10638.85","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","47526.82","35645.11","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","16665.00","","Case rate ($16,665). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,691.60, add-ons for qualifying new technology services are included. If operating cost exceeds $62,215.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,814.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,072.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,352.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,253.51. The transfer capital threshold is the transfer adjustment factor * $1,253.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15878.33","15878.33","15878.33","1 through 10","16331.7","18200.87","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","47526.82","35645.11","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","16331.70","","Case rate ($16,665). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,691.60, add-ons for qualifying new technology services are included. If operating cost exceeds $62,215.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,814.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,072.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,352.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,253.51. The transfer capital threshold is the transfer adjustment factor * $1,253.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9424.53","9424.53","9424.53","1 through 10","16331.7","18200.87","other","Inpatient DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","47526.82","35645.11","FALLON HEALTH [1008]","HB BWF MEDICARE","16665.00","","Case rate ($16,665). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,691.60, add-ons for qualifying new technology services are included. If operating cost exceeds $62,215.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,814.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,072.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,352.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,253.51. The transfer capital threshold is the transfer adjustment factor * $1,253.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15828.29","15828.29","15828.29","1 through 10","16331.7","18200.87","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections With McC","371","MS-DRG","","","","","","","","inpatient","","","47526.82","35645.11","MEDICARE [2001]","HB BWF MEDICARE","16665.00","","Case rate ($16,665). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,691.60, add-ons for qualifying new technology services are included. If operating cost exceeds $62,215.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,814.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,072.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,352.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,253.51. The transfer capital threshold is the transfer adjustment factor * $1,253.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17515.12","17515.12","17632.34","1 through 10","16331.7","18200.87","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","19063.63","14297.72","MEDICARE [2001]","HB BWF MEDICARE","7036.76","","Case rate ($7,036.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,047.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,571.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,075.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,183.27 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,708.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $514.24. The transfer capital threshold is the transfer adjustment factor * $514.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7415.51","7415.51","7415.51","1 through 10","6896.02","7247.86","other","Inpatient Replacement Plans DRG"
"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC","373","MS-DRG","","","","","","","","inpatient","","","19063.63","14297.72","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6896.02","","Case rate ($7,036.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,047.67, add-ons for qualifying new technology services are included. If operating cost exceeds $52,571.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,075.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $6,183.27 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,708.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $514.24. The transfer capital threshold is the transfer adjustment factor * $514.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6716.61","6716.61","6716.61","1 through 10","6896.02","7247.86","other","Inpatient DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","30396.12","22797.09","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","11994.97","","Case rate ($11,994.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,013.97, add-ons for qualifying new technology services are included. If operating cost exceeds $57,537.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,455.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,760.79 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,674.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $894.94. The transfer capital threshold is the transfer adjustment factor * $894.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11353.50","11353.50","11353.50","1 through 10","11755.07","12994.46","other","Inpatient Replacement Plans DRG"
"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc","809","MS-DRG","","","","","","","","inpatient","","","30396.12","22797.09","MEDICARE [2001]","HB BWF MEDICARE","11994.97","","Case rate ($11,994.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,013.97, add-ons for qualifying new technology services are included. If operating cost exceeds $57,537.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,455.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $10,760.79 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,674.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $894.94. The transfer capital threshold is the transfer adjustment factor * $894.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11117.90","11117.90","12483.10","1 through 10","11755.07","12994.46","other","Inpatient Replacement Plans DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","66858.02","50143.51","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","30937.50","","Case rate ($30,937.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $28,312.85, add-ons for qualifying new technology services are included. If operating cost exceeds $73,836.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,705.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $28,453.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $27,973.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,144.35. The transfer capital threshold is the transfer adjustment factor * $2,144.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","29476.93","29476.93","29476.93","1 through 10","27701.98","31135.8","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement","469","MS-DRG","","","","","","","","inpatient","","","66858.02","50143.51","MEDICARE [2001]","HB BWF MEDICARE","30937.50","","Case rate ($30,937.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $28,312.85, add-ons for qualifying new technology services are included. If operating cost exceeds $73,836.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,705.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $28,453.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $27,973.61 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,144.35. The transfer capital threshold is the transfer adjustment factor * $2,144.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","32753.38","0.03","32753.38","1 through 10","27701.98","31135.8","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","18642.51","","Case rate ($18,099.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,396.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 103%.","17914.34","17914.34","17914.34","1 through 10","17737.53","19800.16","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","19797.56","","Case rate ($19,797.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $18,094.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17155.52","17155.52","17155.52","1 through 10","17737.53","19800.16","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","HUMANA [1012]","HB BWF MEDICARE","19797.56","","Case rate ($19,797.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $18,094.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","2813.78","2813.78","2813.78","1 through 10","17737.53","19800.16","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","MEDICARE [2001]","HB BWF MEDICARE","19797.56","","Case rate ($19,797.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $18,094.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","18873.14","0.03","18999.58","76","17737.53","19800.16","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","19797.56","","Case rate ($19,797.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $18,094.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","15198.39","15198.39","17014.95","1 through 10","17737.53","19800.16","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","17737.53","","Case rate ($18,099.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,396.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","18698.54","18698.54","18698.54","1 through 10","17737.53","19800.16","other","Inpatient DRG"
"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC","470","MS-DRG","","","","","","","","inpatient","","","47122.79","35342.09","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","17737.53","","Case rate ($18,099.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,128.47, add-ons for qualifying new technology services are included. If operating cost exceeds $63,652.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,924.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $16,396.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,789.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,363.65. The transfer capital threshold is the transfer adjustment factor * $1,363.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts. Final payment is multiplied by 98%.","17026.95","17026.95","17059.37","1 through 10","17737.53","19800.16","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","62976.25","47232.19","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","28301.54","","Case rate ($28,301.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,903.01, add-ons for qualifying new technology services are included. If operating cost exceeds $71,426.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,520.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $26,002.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,563.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,959.62. The transfer capital threshold is the transfer adjustment factor * $1,959.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23098.36","23098.36","23098.36","1 through 10","25199.1498","28301.54","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","62976.25","47232.19","MEDICARE [2001]","HB BWF MEDICARE","28301.54","","Case rate ($28,301.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,903.01, add-ons for qualifying new technology services are included. If operating cost exceeds $71,426.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,520.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $26,002.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,563.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,959.62. The transfer capital threshold is the transfer adjustment factor * $1,959.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","25418.24","0.03","25589.10","28","25199.1498","28301.54","other","Inpatient DRG"
"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","483","MS-DRG","","","","","","","","inpatient","","","62976.25","47232.19","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","25344.17","","Case rate ($25,861.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,903.01, add-ons for qualifying new technology services are included. If operating cost exceeds $71,426.74 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,520.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $23,562.55 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,563.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,959.62. The transfer capital threshold is the transfer adjustment factor * $1,959.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","22968.75","21410.01","22976.25","11","25199.1498","28301.54","other","Inpatient DRG"
"Major Large Bowel Procedures,MINOR","231","DRG","","","","","","","","inpatient","","","64972.66","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","13857.59","","Fee schedule rate ($13,857.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17756.21","17756.21","17756.21","1 through 10","11778.95","47717.21","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","36852.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","44421.18","","Standard inlier is a Case rate ($44,421.18). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,761, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,305.76) for the length of stay and the standard reimbursement.","44421.18","44421.18","44421.18","1 through 10","11778.95","47717.21","case rate",""
"Major Large Bowel Procedures,MODERATE","231","DRG","","","","","","","","inpatient","","","36852.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","47717.21","","Standard inlier is a Case rate ($47,717.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $57,219, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,773.26) for the length of stay and the standard reimbursement.","79329.38","79329.38","79329.38","1 through 10","11778.95","47717.21","case rate",""
"Major Male Pelvic Procedures With Cc/McC","707","MS-DRG","","","","","","","","inpatient","","","63145.20","47358.90","MEDICARE [2001]","HB BWF MEDICARE","20517.82","","Case rate ($20,517.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,786.95, add-ons for qualifying new technology services are included. If operating cost exceeds $64,310.68 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,974.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $18,764.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,447.71 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,414.13. The transfer capital threshold is the transfer adjustment factor * $1,414.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19417.33","19417.33","19417.33","1 through 10","18381.79","20517.82","other","Inpatient DRG"
"Major Male Pelvic Procedures Without Cc/McC","708","MS-DRG","","","","","","","","inpatient","","","40574.28","30430.71","MEDICARE [2001]","HB BWF MEDICARE","15815.92","","Case rate ($15,815.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,488.36, add-ons for qualifying new technology services are included. If operating cost exceeds $60,012.09 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,645.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.4. The base transfer operating payment is the transfer adjustment factor * $14,392.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,149.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,084.62. The transfer capital threshold is the transfer adjustment factor * $1,084.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12363.95","12363.95","12363.95","1 through 10","14176.03","15815.92","other","Inpatient DRG"
"Major Male Pelvic Procedures,MODERATE","480","DRG","","","","","","","","inpatient","","","105520.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38592.48","","Standard inlier is a Case rate ($38,592.48). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,505, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,478.04) for the length of stay and the standard reimbursement.","38592.47","38592.47","38592.47","1 through 10","11018.12","74161.2","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","64581.34","","FALLON HEALTH [1008]","HB BWF MEDICAID","14359.54","","Case rate ($15,876.94). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,306.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15873.04","15873.04","15873.04","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,EXTREME","137","DRG","","","","","","","","inpatient","","","64581.34","","MASSHEALTH [3001]","HB BWF MEDICAID","14359.54","","Case rate ($15,876.94). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,306.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15873.04","15873.04","15873.04","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25667.21","","Standard inlier is a Case rate ($25,667.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,643.56) for the length of stay and the standard reimbursement.","24500.84","19250.40","25667.20","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27571.70","","Standard inlier is a Case rate ($27,571.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,913.69) for the length of stay and the standard reimbursement.","27571.69","27571.69","27571.69","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","FALLON HEALTH [1008]","HB BWF MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9225.81","9225.81","9225.81","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","35848.88","","Fee schedule rate ($35,848.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","35848.88","35848.88","35848.88","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","MASSHEALTH [3001]","HB BWF MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8885.22","2735.06","9225.82","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","32741.11","","Fee schedule rate ($32,741.11). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","31787.15","31787.15","31787.15","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9225.81","695.29","9225.81","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9225.81","563.98","9225.81","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MAJOR","137","DRG","","","","","","","","inpatient","","","37956.72","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9225.81","9225.81","9225.81","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","28756.99","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25667.21","","Standard inlier is a Case rate ($25,667.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,980, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,643.56) for the length of stay and the standard reimbursement.","18829.97","18829.97","18829.97","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","28756.99","","MASSHEALTH [3001]","HB BWF MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7622.09","7622.09","7622.09","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","28756.99","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7622.09","7622.09","7622.09","1 through 10","5034.41","75791.34","case rate",""
"Major Respiratory Infections And Inflammations,MODERATE","137","DRG","","","","","","","","inpatient","","","28756.99","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8346.13","","Case rate ($9,228.08). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,658.08, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7622.09","7622.09","7622.09","1 through 10","5034.41","75791.34","case rate",""
"Major Skin Disorders Without McC","596","MS-DRG","","","","","","","","inpatient","","","15611.87","11708.90","MEDICARE [2001]","HB BWF MEDICARE","11259.26","","Case rate ($11,259.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,322.57, add-ons for qualifying new technology services are included. If operating cost exceeds $55,846.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,326.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,154.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,983.33 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $765.28. The transfer capital threshold is the transfer adjustment factor * $765.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1566.79","1566.79","1566.79","1 through 10","10100.19","11259.26","other","Inpatient DRG"
"Major Small & Large Bowel Procedures,MAJOR","221","DRG","","","","","","","","inpatient","","","48854.09","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29137.122","","Fee schedule rate ($64,285.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29137.122","64285.36","64285.36","1 through 10","29137.122","106069.86","case rate",""
"Major Small & Large Bowel Procedures,MODERATE","221","DRG","","","","","","","","inpatient","","","49143.69","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29137.122","","Fee schedule rate ($38,030.69). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29137.122","38030.68","38030.68","1 through 10","29137.122","106069.86","case rate",""
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","48854.09","36640.57","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","22411.38","","Case rate ($22,411.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,447.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,971.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,255.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $20,377.41 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,108.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.72. The transfer capital threshold is the transfer adjustment factor * $1,694.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21443.79","21443.79","21443.79","1 through 10","21963.15","23374.6293","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","48854.09","36640.57","MEDICARE [2001]","HB BWF MEDICARE","22411.38","","Case rate ($22,411.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,447.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,971.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,255.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $20,377.41 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,108.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.72. The transfer capital threshold is the transfer adjustment factor * $1,694.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","63785.36","63785.36","63785.36","1 through 10","21963.15","23374.6293","other","Inpatient Replacement Plans DRG"
"Major Small And Large Bowel Procedures With Cc","330","MS-DRG","","","","","","","","inpatient","","","48854.09","36640.57","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","21963.15","","Case rate ($22,411.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,447.35, add-ons for qualifying new technology services are included. If operating cost exceeds $67,971.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,255.51, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $20,377.41 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,108.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,694.72. The transfer capital threshold is the transfer adjustment factor * $1,694.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","21301.57","21301.57","21301.57","1 through 10","21963.15","23374.6293","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","91318.07","68488.55","MEDICARE [2001]","HB BWF MEDICARE","46707.72","","Case rate ($46,707.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $42,730.34, add-ons for qualifying new technology services are included. If operating cost exceeds $88,254.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,810.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $43,118.94 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $42,391.10 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,249.54. The transfer capital threshold is the transfer adjustment factor * $3,249.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","45910.56","45910.56","45910.56","1 through 10","41808.13","46707.72","other","Inpatient DRG"
"Major Small And Large Bowel Procedures With McC","329","MS-DRG","","","","","","","","inpatient","","","91318.07","68488.55","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","41808.13","","Case rate ($42,661.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $42,730.34, add-ons for qualifying new technology services are included. If operating cost exceeds $88,254.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,810.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.4. The base transfer operating payment is the transfer adjustment factor * $39,072.58 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $42,391.10 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,249.54. The transfer capital threshold is the transfer adjustment factor * $3,249.54. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","38558.71","38558.71","38558.71","1 through 10","41808.13","46707.72","other","Inpatient DRG"
"Major Small And Large Bowel Procedures Without Cc/McC","331","MS-DRG","","","","","","","","inpatient","","","44116.71","33087.53","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15517.80","","Case rate ($15,834.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,859.74, add-ons for qualifying new technology services are included. If operating cost exceeds $61,383.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,750.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $14,305.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,520.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,189.74. The transfer capital threshold is the transfer adjustment factor * $1,189.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","27499.31","27499.31","27499.31","1 through 10","15517.8","16326.739","other","Inpatient DRG"
"Major Small Bowel Procedures,EXTREME","230","DRG","","","","","","","","inpatient","","","92096.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","118321.65","","Standard inlier is a Case rate ($118,321.65). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $133,033, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($16,796.22) for the length of stay and the standard reimbursement.","112474.15","112474.15","112474.15","1 through 10","17180.04","169330.14","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","36007.53","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","43425.87","","Standard inlier is a Case rate ($43,425.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $44,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,164.47) for the length of stay and the standard reimbursement.","43425.87","43425.87","43425.87","1 through 10","17180.04","169330.14","case rate",""
"Major Small Bowel Procedures,MODERATE","230","DRG","","","","","","","","inpatient","","","36007.53","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","46648.05","","Standard inlier is a Case rate ($46,648.05). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $56,197, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,621.49) for the length of stay and the standard reimbursement.","5151.23","5151.23","5151.23","1 through 10","17180.04","169330.14","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,EXTREME","220","DRG","","","","","","","","inpatient","","","733373.77","","MASSHEALTH [3001]","HB BWF MEDICAID","98142.95","","Case rate ($108,513.90). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $150,943.90, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","202538.34","202538.34","202538.34","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","45465.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36330.39","","Standard inlier is a Case rate ($36,330.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $46,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,156.94) for the length of stay and the standard reimbursement.","36330.38","36330.38","36330.38","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","45465.10","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24677.6376","","Fee schedule rate ($24,677.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24677.6376","24677.64","24677.64","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","45465.10","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10892.46","","Case rate ($12,043.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12040.53","12040.53","13448.74","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MINOR","220","DRG","","","","","","","","inpatient","","","45465.10","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10892.46","","Case rate ($12,043.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12040.53","12040.53","12040.53","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","46428.90","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36330.39","","Standard inlier is a Case rate ($36,330.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $46,343, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,156.94) for the length of stay and the standard reimbursement.","6032.45","6032.45","6032.45","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","46428.90","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","60581.78","","Fee schedule rate ($60,581.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","60581.78","60581.78","60581.78","1 through 10","10892.46","256820.24","case rate",""
"Major Stomach, Esophageal And Duodenal Procedures,MODERATE","220","DRG","","","","","","","","inpatient","","","46428.90","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10892.46","","Case rate ($12,043.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21001.16","21001.16","21001.16","1 through 10","10892.46","256820.24","case rate",""
"Major Thumb Or Joint Procedures","506","MS-DRG","","","","","","","","inpatient","","","28266.25","21199.69","MEDICARE [2001]","HB BWF MEDICARE","13949.68","","Case rate ($13,949.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,782.20, add-ons for qualifying new technology services are included. If operating cost exceeds $58,305.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,514.61, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,656.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,442.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $953.83. The transfer capital threshold is the transfer adjustment factor * $953.83. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15056.91","15056.91","15157.41","1 through 10","12506.72","13949.68","other","Inpatient DRG"
"Male Reproductive System Diagnoses Except Malignancy,MINOR","501","DRG","","","","","","","","inpatient","","","60388.06","","MASSHEALTH [3001]","HB BWF MEDICAID","4318.14","","Case rate ($4,774.45). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,204.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4773.28","4773.28","4773.28","1 through 10","4318.14","18001.57","case rate",""
"Male Reproductive System Diagnoses Except Malignancy,MODERATE","501","DRG","","","","","","","","inpatient","","","22551.17","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6004.28","","Case rate ($6,638.76). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,068.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6637.13","6637.13","6637.13","1 through 10","4318.14","18001.57","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MAJOR","252","DRG","","","","","","","","inpatient","","","42932.70","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11072.4972","","Fee schedule rate ($25,199.41). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11072.4972","25199.40","25199.40","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MINOR","252","DRG","","","","","","","","inpatient","","","5636.05","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13583.76","","Standard inlier is a Case rate ($13,583.76). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,928.27) for the length of stay and the standard reimbursement.","13583.76","13583.76","13583.76","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","20606.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16814.84","","Standard inlier is a Case rate ($16,814.84). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,386.93) for the length of stay and the standard reimbursement.","13451.86","13451.86","13451.86","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","20606.62","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11072.4972","","Fee schedule rate ($14,613.51). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11072.4972","14613.50","14613.50","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction And Complication Of Gastrointestinal Device Or Procedure,MODERATE","252","DRG","","","","","","","","inpatient","","","20606.62","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7653.85","","Case rate ($8,462.65). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,892.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8460.57","8460.57","8460.57","1 through 10","5850.92","87384.46","case rate",""
"Malfunction, Reaction, Complication Of Cardiac Or Vascular Device Or Procedure,MAJOR","206","DRG","","","","","","","","inpatient","","","40288.66","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12345.55","","Case rate ($13,650.13). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,080.13, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,357.54 and the sum of the standard inlier and any outlier amount.","13646.78","13646.78","13646.78","1 through 10","8467.5486","39789.1","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,EXTREME","466","DRG","","","","","","","","inpatient","","","39938.95","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","14811.92","","Case rate ($16,377.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,807.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,066.88 and the sum of the standard inlier and any outlier amount.","9619.80","1666.18","16373.10","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","20693.11","","Standard inlier is a Case rate ($20,693.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,876, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,937.47) for the length of stay and the standard reimbursement.","20693.11","20693.11","20693.11","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22228.53","","Standard inlier is a Case rate ($22,228.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,876, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,155.25) for the length of stay and the standard reimbursement.","22228.52","22228.52","22228.52","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8467.5486","","Fee schedule rate ($24,114.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8467.5486","24114.82","24114.82","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8890.8827","","Fee schedule rate ($25,320.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8890.8827","25320.44","25320.44","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","MASSHEALTH [3001]","HB BWF MEDICAID","8702.54","","Case rate ($9,622.16). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,052.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5623.36","5623.36","5623.36","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","24278.74","","Fee schedule rate ($24,278.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24278.74","24278.74","24278.74","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MAJOR","466","DRG","","","","","","","","inpatient","","","22807.72","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8702.54","","Case rate ($9,622.16). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,052.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9619.80","9619.80","9619.80","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","20692.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14561.91","","Standard inlier is a Case rate ($14,561.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,067.12) for the length of stay and the standard reimbursement.","13900.19","13900.19","13900.19","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","20692.84","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15642.40","","Standard inlier is a Case rate ($15,642.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,220.37) for the length of stay and the standard reimbursement.","15642.39","15642.39","15642.39","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Genitourinary Device Or Procedure,MODERATE","466","DRG","","","","","","","","inpatient","","","20692.84","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5458.22","","Case rate ($6,035.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,465.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","2259.75","1 through 10","5458.22","84492.18","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","45930.24","","MASSHEALTH [3001]","HB BWF MEDICAID","11600.73","","Case rate ($12,826.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,256.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7124.14","7124.14","7124.14","1 through 10","2023","54476.24","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MAJOR","349","DRG","","","","","","","","inpatient","","","45930.24","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11600.73","","Case rate ($12,826.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,256.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12823.45","12823.45","12823.45","1 through 10","2023","54476.24","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MINOR","349","DRG","","","","","","","","inpatient","","","14133.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12593.36","","Standard inlier is a Case rate ($12,593.36). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,568, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,787.68) for the length of stay and the standard reimbursement.","12021.09","12021.09","12021.09","1 through 10","2023","54476.24","case rate",""
"Malfunction, Reaction, Complication Of Orthopedic Device Or Procedure,MODERATE","349","DRG","","","","","","","","inpatient","","","14585.03","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7002.70","","Case rate ($7,742.69). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,172.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,433.83 and the sum of the standard inlier and any outlier amount.","4300.44","4300.44","4300.44","1 through 10","2023","54476.24","case rate",""
"Malignancy Of Hepatobiliary System And Pancreas,MAJOR","281","DRG","","","","","","","","inpatient","","","51966.40","","MASSHEALTH [3001]","HB BWF MEDICAID","12011.98","","Case rate ($13,281.31). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,711.31, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3709.00","3709.00","3709.00","1 through 10","8695.69","47534.1","case rate",""
"Malignancy Of Hepatobiliary System Or Pancreas With Cc","436","MS-DRG","","","","","","","","inpatient","","","38771.50","29078.62","MEDICARE [2001]","HB BWF MEDICARE","10753.81","","Case rate ($10,753.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,770.78, add-ons for qualifying new technology services are included. If operating cost exceeds $56,294.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,360.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,614.92 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,431.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.64. The transfer capital threshold is the transfer adjustment factor * $799.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11464.42","11464.42","11464.42","1 through 10","10538.73","11151.8253","other","Inpatient Replacement Plans DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","53029.03","39771.77","MEDICARE [2001]","HB BWF MEDICARE","18867.47","","Case rate ($18,867.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,278.15, add-ons for qualifying new technology services are included. If operating cost exceeds $62,801.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,859.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,229.75 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,938.92 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,298.47. The transfer capital threshold is the transfer adjustment factor * $1,298.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18394.01","18394.01","33680.98","1 through 10","16905.59","18867.47","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas With McC","435","MS-DRG","","","","","","","","inpatient","","","53029.03","39771.77","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16905.59","","Case rate ($17,250.60). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,278.15, add-ons for qualifying new technology services are included. If operating cost exceeds $62,801.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,859.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $15,612.88 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,938.92 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,298.47. The transfer capital threshold is the transfer adjustment factor * $1,298.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16470.42","16470.42","16470.42","1 through 10","16905.59","18867.47","other","Inpatient DRG"
"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/McC","437","MS-DRG","","","","","","","","inpatient","","","22695.66","17021.74","MEDICARE [2001]","HB BWF MEDICARE","8947.13","","Case rate ($8,947.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,208.77, add-ons for qualifying new technology services are included. If operating cost exceeds $53,732.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,164.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,004.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,869.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $603.25. The transfer capital threshold is the transfer adjustment factor * $603.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","7764.8428","8947.13","other","Inpatient DRG"
"Malignancy, Female Reproductive System With Cc","755","MS-DRG","","","","","","","","inpatient","","","48715.00","36536.25","MEDICARE [2001]","HB BWF MEDICARE","11312.73","","Case rate ($11,312.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,371.45, add-ons for qualifying new technology services are included. If operating cost exceeds $55,895.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,329.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $10,204.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,032.21 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $769.03. The transfer capital threshold is the transfer adjustment factor * $769.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11289.42","11289.42","11289.42","1 through 10","10148.02","11312.73","other","Inpatient DRG"
"Malignancy, Male Reproductive System With Cc","723","MS-DRG","","","","","","","","inpatient","","","19197.84","14398.38","MEDICARE [2001]","HB BWF MEDICARE","11866.56","","Case rate ($11,866.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,877.76, add-ons for qualifying new technology services are included. If operating cost exceeds $56,401.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,368.63, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $10,719.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,538.52 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $807.84. The transfer capital threshold is the transfer adjustment factor * $807.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11341.38","11341.38","11341.38","1 through 10","10643.42","11866.56","other","Inpatient DRG"
"Malignant Breast Disorders With Cc","598","MS-DRG","","","","","","","","inpatient","","","18924.71","14193.53","MEDICARE [2001]","HB BWF MEDICARE","10755.65","","Case rate ($10,755.65). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,772.63, add-ons for qualifying new technology services are included. If operating cost exceeds $56,296.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,360.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,616.62 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,433.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $799.78. The transfer capital threshold is the transfer adjustment factor * $799.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10906.82","10906.82","10906.82","1 through 10","10540.54","11078.32","other","Inpatient Replacement Plans DRG"
"Malignant Breast Disorders With McC","597","MS-DRG","","","","","","","","inpatient","","","20560.65","15420.49","MEDICARE [2001]","HB BWF MEDICARE","15689.01","","Case rate ($15,689.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,714.02, add-ons for qualifying new technology services are included. If operating cost exceeds $61,237.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,739.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $14,171.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,374.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,178.57. The transfer capital threshold is the transfer adjustment factor * $1,178.57. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","15375.23","17112.78","other","Inpatient Replacement Plans DRG"
"Malignant Breast Disorders,MAJOR","382","DRG","","","","","","","","inpatient","","","18924.71","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25272.74","","Fee schedule rate ($25,272.74). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($2,924.21) multiplied by length of stay and the outlier percent (100%).","2924.20","2924.20","2924.20","1 through 10","10485.24","50845.56","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33720.86","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21565.85","","Standard inlier is a Case rate ($21,565.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,772, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,061.36) for the length of stay and the standard reimbursement.","20585.85","20585.85","20585.85","1 through 10","9302.29","44370.97","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33720.86","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","24456.84","24456.84","24456.84","1 through 10","9302.29","44370.97","percent of total billed charges",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33720.86","","MASSHEALTH [3001]","HB BWF MEDICAID","15493.91","","Case rate ($17,131.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,561.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17126.98","17126.98","17126.98","1 through 10","9302.29","44370.97","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33720.86","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","15493.91","","Case rate ($17,131.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,561.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17126.98","17126.98","17126.98","1 through 10","9302.29","44370.97","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33720.86","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","15493.91","","Case rate ($17,131.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,561.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","173293.78","173293.78","173293.78","1 through 10","9302.29","44370.97","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MAJOR","421","DRG","","","","","","","","inpatient","","","33720.86","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","15493.91","","Case rate ($17,131.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,561.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5947.07","5947.07","5947.07","1 through 10","9302.29","44370.97","case rate",""
"Malnutrition, Failure To Thrive And Other Nutritional Disorders,MODERATE","421","DRG","","","","","","","","inpatient","","","23324.52","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9302.29","","Case rate ($10,285.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,715.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10282.75","10282.75","10282.75","1 through 10","9302.29","44370.97","case rate",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","AETNA [1001]","HB CH AETNA HMO / PPO","335.23","58.3","","316.95","316.95","316.95","16","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","419.75","73","","408.07","408.07","408.07","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","335.23","58.3","","316.95","316.95","316.95","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","419.75","73","","283.15","202.67","559.00","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","TRICARE [160005]","HB BWF TRICARE","546.25","95","","104.76","101.79","107.15","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","546.25","95","","107.15","107.15","107.15","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.59","44.45","","429.76","254.68","429.76","16","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","both","","","575.00","431.25","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","255.59","44.45","","254.68","254.68","254.68","1 through 10","105.01","546.25","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","274.55","","Case rate ($274.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","274.55","274.55","274.55","1213","226.79","524.54","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","274.55","","Case rate ($274.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","274.55","274.55","274.55","1 through 10","226.79","524.54","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","274.55","","Case rate ($274.55). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","274.55","274.55","274.55","1826","226.79","524.54","other","Multiple Imaging"
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","340.98","59.3","","327.57","327.57","327.57","269","226.79","524.54","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","451.09","78.45","","429.76","429.76","429.76","1 through 10","226.79","524.54","percent of total billed charges",""
"Mammogram Screen Bilat Digital (Incl. Cad)","PX-40000097","CDM","77067","HCPCS","0403","RC","","","","outpatient","","","575.00","431.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","451.09","78.45","","429.76","254.68","429.76","233","226.79","524.54","percent of total billed charges",""
"Manganese","PX-30000566","CDM","83785","CPT","0301","RC","","","","outpatient","","","290.00","217.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","227.51","78.45","","207.77","207.77","207.77","1 through 10","25.36","227.51","percent of total billed charges",""
"MARKER GOLD 17G 1.2X3MM","SUP-ITM-10318951","CDM","A4648","HCPCS","0278","RC","","","","both","","","203.25","152.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","203.25","100","","153.75","153.75","153.75","1 through 10","107.72","203.25","percent of total billed charges",""
"MARKER GOLD 17G 1.2X3MM","SUP-ITM-10318951","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","203.25","152.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","120.53","59.3","","90.10","90.10","90.10","1 through 10","90.34","159.45","percent of total billed charges",""
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","both","","","","","AETNA [1001]","HB CH AETNA HMO / PPO","","58.3","","554.95","91.85","1421.75","94","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","both","","","","","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","","73","","2490.03","2490.03","2490.03","1 through 10","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","both","","","","","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","","58.3","","750.00","750.00","750.00","1 through 10","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","both","","","","","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","","73","","667.50","667.50","667.50","1 through 10","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","both","","","","","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","","44.45","","123.77","123.77","123.77","1 through 10","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","","","CIGNA [1006]","HB CH CIGNA HMO / PPO","","59.3","","439.50","225.34","1872.27","197","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MARKER SCREW TYPE PUSH PIN PARTIAL THREAD","SUP-ITM-10277393","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","","","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","","78.45","","385.32","55.36","1815.62","58","","","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","both","","","1778.00","1333.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1778.00","100","","153.75","153.75","153.75","1 through 10","942.34","1778","percent of total billed charges",""
"Marker Tissue Implantable T1","PX-27000162","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","1778.00","1333.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1054.35","59.3","","90.10","90.10","90.10","1 through 10","790.32","1394.84","percent of total billed charges",""
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","both","","","4625.00","3468.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","5291.60","5291.60","5291.60","1 through 10","1984.13","4164.87","other","Multiple Surgery"
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","1984.13","4164.87","per diem",""
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1984.13","4164.87","per diem",""
"Marsup Cyst Bartholin's Gland","PX-76001332","CDM","56440","CPT","0761","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3904.56","3904.56","1 through 10","2125.14","4472.66","other","ASC "
"Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea","PX-30003058","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","18.62","121.6","percent of total billed charges",""
"Mass Spectrometry Qn","PX-30000569","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","18.62","121.6","percent of total billed charges",""
"Mastectomy For Malignancy With Cc/McC","582","MS-DRG","","","","","","","","inpatient","","","61435.60","46076.70","MEDICARE [2001]","HB BWF MEDICARE","18078.34","","Case rate ($18,078.34). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,107.25, add-ons for qualifying new technology services are included. If operating cost exceeds $63,630.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,922.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $16,377.08 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,768.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,362.03. The transfer capital threshold is the transfer adjustment factor * $1,362.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17664.16","17664.16","17664.16","1 through 10","17317.6168","18620.69","other","Inpatient Replacement Plans DRG"
"Mastectomy Partial","PX-76000261","CDM","19301","CPT","0761","RC","","","","both","","","6997.00","5247.75","AETNA [1001]","HB CH AETNA HMO / PPO","4079.25","58.3","","4687.96","4687.96","4687.96","1 through 10","3001.71","5451.36","percent of total billed charges",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","47548.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","32693.66","","Standard inlier is a Case rate ($32,693.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $42,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,640.73) for the length of stay and the standard reimbursement.","31207.58","31207.58","31207.58","1 through 10","11513.75","56243.21","case rate",""
"Mastectomy Procedures,MINOR","362","DRG","","","","","","","","inpatient","","","47548.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23419.1328","","Fee schedule rate ($23,419.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23419.1328","23419.14","23419.14","1 through 10","11513.75","56243.21","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","58672.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","43823.01","","Standard inlier is a Case rate ($43,823.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $42,872, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,220.85) for the length of stay and the standard reimbursement.","43823.01","43823.01","43823.01","1 through 10","11513.75","56243.21","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","58672.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","47074.66","","Standard inlier is a Case rate ($47,074.66). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $56,604, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,682.05) for the length of stay and the standard reimbursement.","47074.65","47074.65","47074.65","1 through 10","11513.75","56243.21","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","58672.25","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","24589.9696","","Fee schedule rate ($35,791.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24589.9696","35791.28","35791.28","1 through 10","11513.75","56243.21","case rate",""
"Mastectomy Procedures,MODERATE","362","DRG","","","","","","","","inpatient","","","58672.25","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","19636.13","","Case rate ($21,711.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,141.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21705.79","21705.79","21705.79","1 through 10","11513.75","56243.21","case rate",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","4327.48","3245.61","AETNA [1001]","HB CH AETNA HMO / PPO","2522.92","58.3","","1830.28","315.58","1830.28","1 through 10","1923.56","4327.48","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","4327.48","3245.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3159.06","73","","4170.85","4170.85","4170.85","1 through 10","1923.56","4327.48","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","4327.48","3245.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1923.56","44.45","","649.55","649.55","649.55","1 through 10","1923.56","4327.48","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","both","","","4327.48","3245.61","WELLPOINT [1015]","HB CH WELLPOINT","3371.54","77.91","","8998.38","2542.37","8998.38","20","1923.56","4327.48","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4327.48","3245.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","2566.20","59.3","","1891.61","1609.14","3664.18","25","2163.74","3394.91","percent of total billed charges",""
"MATRIX BONE 5ML ALLOGRAFT CELLULAR VIVIGEN 5CC","SUP-ITM-10188913","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4327.48","3245.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3394.91","78.45","","1470.68","1310.06","2481.69","19","2163.74","3394.91","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","7725.76","5794.32","AETNA [1001]","HB CH AETNA HMO / PPO","4504.12","58.3","","1830.28","315.58","1830.28","1 through 10","3434.1","7725.76","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","7725.76","5794.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5639.80","73","","4170.85","4170.85","4170.85","1 through 10","3434.1","7725.76","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","7725.76","5794.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3434.10","44.45","","649.55","649.55","649.55","1 through 10","3434.1","7725.76","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","both","","","7725.76","5794.32","WELLPOINT [1015]","HB CH WELLPOINT","6019.14","77.91","","8998.38","2542.37","8998.38","20","3434.1","7725.76","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7725.76","5794.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","4581.38","59.3","","1891.61","1609.14","3664.18","25","3862.88","6060.86","percent of total billed charges",""
"MATRIX IMPLANT 10ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188912","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7725.76","5794.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6060.86","78.45","","1470.68","1310.06","2481.69","19","3862.88","6060.86","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","AETNA [1001]","HB CH AETNA HMO / PPO","861.31","58.3","","1830.28","315.58","1830.28","1 through 10","656.7","1477.38","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1078.49","73","","4170.85","4170.85","4170.85","1 through 10","656.7","1477.38","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","656.70","44.45","","649.55","649.55","649.55","1 through 10","656.7","1477.38","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","both","","","1477.38","1108.03","WELLPOINT [1015]","HB CH WELLPOINT","1151.03","77.91","","8998.38","2542.37","8998.38","20","656.7","1477.38","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1477.38","1108.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","876.09","59.3","","1891.61","1609.14","3664.18","25","738.69","1159","percent of total billed charges",""
"MATRIX IMPLANT 1ML ALLOGRAFT VIVIGEN FORMABLE 2ND GEN BL","SUP-ITM-10188914","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1477.38","1108.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1159.00","78.45","","1470.68","1310.06","2481.69","19","738.69","1159","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","1830.28","315.58","1830.28","1 through 10","60.01","135","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","4170.85","4170.85","4170.85","1 through 10","60.01","135","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","649.55","649.55","649.55","1 through 10","60.01","135","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","8998.38","2542.37","8998.38","20","60.01","135","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","1891.61","1609.14","3664.18","25","67.5","105.91","percent of total billed charges",""
"MATRIX SPINE CAP SCREW TITANIUM LOCKING POLYAXIAL","SUP-ITM-10080444","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1470.68","1310.06","2481.69","19","67.5","105.91","percent of total billed charges",""
"MATRIX TISSUE 1X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287367","CDM","Q4116","HCPCS","0636","RC","","","","both","","","744.00","558.00","AETNA [1001]","HB CH AETNA HMO / PPO","433.75","58.3","","66.84","33.42","66.84","3696","92.01","579.65","percent of total billed charges",""
"MATRIX TISSUE 1X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287367","CDM","Q4116","HCPCS","0636","RC","","","","both","","","744.00","558.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","394.32","53","","16493.60","16493.60","16493.60","1 through 10","92.01","579.65","percent of total billed charges",""
"MATRIX TISSUE 1X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287367","CDM","Q4116","HCPCS","0636","RC","","","","both","","","744.00","558.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","543.12","73","","10382.90","10382.90","10382.90","1 through 10","92.01","579.65","percent of total billed charges",""
"MATRIX TISSUE 1X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287367","CDM","Q4116","HCPCS","0636","RC","","","","both","","","744.00","558.00","WELLPOINT [1015]","HB CH WELLPOINT","579.65","77.91","","31178.94","77.77","31197.77","2412","92.01","579.65","percent of total billed charges",""
"MATRIX TISSUE 1X4CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10287367","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","744.00","558.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","388.37","52.2","","67.43","30.35","93.27","9212","372","388.37","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2283.00","1712.25","AETNA [1001]","HB CH AETNA HMO / PPO","1330.99","58.3","","66.84","33.42","66.84","3696","92.01","1778.69","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2283.00","1712.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1209.99","53","","16493.60","16493.60","16493.60","1 through 10","92.01","1778.69","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2283.00","1712.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1666.59","73","","10382.90","10382.90","10382.90","1 through 10","92.01","1778.69","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","both","","","2283.00","1712.25","WELLPOINT [1015]","HB CH WELLPOINT","1778.69","77.91","","31178.94","77.77","31197.77","2412","92.01","1778.69","percent of total billed charges",""
"MATRIX TISSUE 4X7CM THIN 1-.2MM THICKNESS RANGE RECTANGLE ALLODERM SELECT REGENERATIVE","SUP-ITM-10286279","CDM","Q4116","HCPCS","0636","RC","","","","outpatient","","","2283.00","1712.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1191.73","52.2","","67.43","30.35","93.27","9212","1141.5","1191.73","percent of total billed charges",""
"Mayo, F8inv Hemophilia a F8 Gene Intron 1 and 22 Inversion Mutation","PX-31001309","CDM","81403","CPT","0310","RC","","","","outpatient","","","1294.00","970.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1015.14","78.45","","562.39","562.39","562.39","1 through 10","456.38","1015.14","percent of total billed charges",""
"Mayo, Ghnma Hemophilia a F8 Gene Next Gen Seq","PX-31001396","CDM","81407","CPT","0310","RC","","","","both","","","1739.00","1304.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","921.67","53","","1792.46","1792.46","1792.46","1 through 10","746.03","4493.69","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","146.50","146.50","146.50","1 through 10","55.5","222.03","percent of total billed charges",""
"Mayo, Ptnt Prothrombin G20210a Mutation, Blood","PX-31001431","CDM","81240","CPT","0310","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","192.20","184.27","384.40","1 through 10","55.5","222.03","percent of total billed charges",""
"Mcg Dna Probe","PX-31000129","CDM","88271","CPT","0311","RC","","","","outpatient","","","248.00","186.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","194.56","78.45","","185.28","185.28","185.28","1 through 10","64.82","194.56","percent of total billed charges",""
"Mcg Interphase Insitu 100","PX-31000135","CDM","88275","CPT","0311","RC","","","","outpatient","","","470.00","352.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","278.71","59.3","","267.80","267.80","267.80","1 through 10","126.08","368.72","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","24","60.9","343.29","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","302.22","302.22","302.22","1 through 10","60.9","343.29","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","234.74","234.74","234.74","1 through 10","60.9","343.29","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","242.60","727.80","33","176.68","603.55","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.56","242.56","242.56","1 through 10","176.68","603.55","percent of total billed charges",""
"Meconium, Tox Screen","PX-31000871","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","16","176.68","603.55","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","AETNA [1001]","HB CH AETNA HMO / PPO","2167.30","58.3","","554.95","91.85","1421.75","94","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2713.78","73","","2490.03","2490.03","2490.03","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2167.30","58.3","","750.00","750.00","750.00","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1970.28","53","","1192.50","120.84","4149.90","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3159.88","85","","750.00","75.00","750.00","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3717.50","100","","657.00","121.50","1971.00","14","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3717.50","100","","75.00","75.00","75.00","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3717.50","100","","366.00","144.00","1971.00","45","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2713.78","73","","667.50","667.50","667.50","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1652.43","44.45","","123.77","123.77","123.77","1 through 10","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","both","","","3717.50","2788.12","WELLPOINT [1015]","HB CH WELLPOINT","2896.30","77.91","","483.51","229.32","1316.08","96","1652.43","3717.5","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3717.50","2788.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2204.48","59.3","","439.50","225.34","1872.27","197","1858.75","2916.38","percent of total billed charges",""
"MEDIA SYSTEM IMPLANT L PATELLOFEMORAL LIGAMENT BIOCOMPOSITE","SUP-ITM-10132613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3717.50","2788.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2916.38","78.45","","385.32","55.36","1815.62","58","1858.75","2916.38","percent of total billed charges",""
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","62344.62","46758.46","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","16245.04","","Case rate ($15,771.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,797.02, add-ons for qualifying new technology services are included. If operating cost exceeds $61,320.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,745.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,247.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,457.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.94. The transfer capital threshold is the transfer adjustment factor * $1,184.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","16235.42","16235.42","16235.42","1 through 10","15456.44","16874.5896","other","Inpatient DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","62344.62","46758.46","MEDICARE [2001]","HB BWF MEDICARE","15771.88","","Case rate ($15,771.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,797.02, add-ons for qualifying new technology services are included. If operating cost exceeds $61,320.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,745.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,247.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,457.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.94. The transfer capital threshold is the transfer adjustment factor * $1,184.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17104.27","14906.62","17218.68","1 through 10","15456.44","16874.5896","other","Inpatient Replacement Plans DRG"
"Medical Back Problems With McC","551","MS-DRG","","","","","","","","inpatient","","","62344.62","46758.46","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15456.44","","Case rate ($15,771.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,797.02, add-ons for qualifying new technology services are included. If operating cost exceeds $61,320.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,745.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $14,247.70 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,457.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,184.94. The transfer capital threshold is the transfer adjustment factor * $1,184.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15462.31","15462.31","15462.31","1 through 10","15456.44","16874.5896","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","28868.55","21651.41","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10036.64","","Case rate ($10,036.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,204.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,728.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,240.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,017.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,865.56 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $679.60. The transfer capital threshold is the transfer adjustment factor * $679.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8890.10","8890.10","8890.10","1 through 10","9006.58","10036.64","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","28868.55","21651.41","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9006.58","","Case rate ($9,190.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,204.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,728.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,240.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,171.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,865.56 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $679.60. The transfer capital threshold is the transfer adjustment factor * $679.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8849.73","8849.73","8849.73","1 through 10","9006.58","10036.64","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","28868.55","21651.41","MEDICARE [2001]","HB BWF MEDICARE","10036.64","","Case rate ($10,036.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,204.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,728.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,240.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,017.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,865.56 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $679.60. The transfer capital threshold is the transfer adjustment factor * $679.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9834.67","9770.04","9834.67","24","9006.58","10036.64","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","28868.55","21651.41","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9006.58","","Case rate ($9,190.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,204.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,728.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,240.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,171.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,865.56 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $679.60. The transfer capital threshold is the transfer adjustment factor * $679.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8832.21","8832.21","8849.73","1 through 10","9006.58","10036.64","other","Inpatient DRG"
"Medical Back Problems Without McC","552","MS-DRG","","","","","","","","inpatient","","","28868.55","21651.41","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9006.58","","Case rate ($9,190.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,204.81, add-ons for qualifying new technology services are included. If operating cost exceeds $54,728.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,240.39, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,171.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,865.56 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $679.60. The transfer capital threshold is the transfer adjustment factor * $679.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8816.21","8816.21","8816.21","1 through 10","9006.58","10036.64","other","Inpatient DRG"
"Menstrual And Other Female Reproductive System Disorders With Cc/McC","760","MS-DRG","","","","","","","","inpatient","","","29961.37","22471.03","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9423.44","","Case rate ($9,615.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,630.88, add-ons for qualifying new technology services are included. If operating cost exceeds $55,154.61 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,273.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,564.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,291.64 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $712.26. The transfer capital threshold is the transfer adjustment factor * $712.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9043.56","9043.56","9043.56","1 through 10","9423.44","9904.22","other","Inpatient DRG"
"Menstrual And Other Female Reproductive System Disorders,MAJOR","532","DRG","","","","","","","","inpatient","","","24933.43","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8063.0292","","Fee schedule rate ($21,588.05). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8063.0292","21588.05","21588.05","1 through 10","3972.01","35619.95","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MAJOR","532","DRG","","","","","","","","inpatient","","","24933.43","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7549.90","","Case rate ($8,347.71). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,777.71, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8345.66","8345.66","8345.66","1 through 10","3972.01","35619.95","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MINOR","532","DRG","","","","","","","","inpatient","","","78512.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","9742.26","","Standard inlier is a Case rate ($9,742.26). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $21,642, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,382.95) for the length of stay and the standard reimbursement.","9299.55","9299.55","9299.55","1 through 10","3972.01","35619.95","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","20325.78","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13119.60","","Standard inlier is a Case rate ($13,119.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,178, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,862.27) for the length of stay and the standard reimbursement.","13119.59","13119.59","13119.59","1 through 10","3972.01","35619.95","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","20325.78","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5069.82","","Case rate ($5,605.56). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,035.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5604.18","5604.18","5604.18","1 through 10","3972.01","35619.95","case rate",""
"Menstrual And Other Female Reproductive System Disorders,MODERATE","532","DRG","","","","","","","","inpatient","","","20325.78","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5069.82","","Case rate ($5,605.56). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,035.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5604.18","5604.18","5604.18","1 through 10","3972.01","35619.95","case rate",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","74.28","1 through 10","15.93","98.55","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","69.43","69.43","69.43","1 through 10","15.93","98.55","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.77","76.77","76.77","1 through 10","16.76","105.91","percent of total billed charges",""
"Mercury","PX-30000571","CDM","83825","CPT","0301","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","96.30","96.30","96.30","1 through 10","16.76","105.91","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","1093.14","819.85","AETNA [1001]","HB CH AETNA HMO / PPO","637.30","58.3","","585.96","347.85","5016.82","1 through 10","485.9","1093.14","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","1093.14","819.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","929.17","85","","1295.16","1295.16","1295.16","1 through 10","485.9","1093.14","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","1093.14","819.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1093.14","100","","2700.00","1008.69","2700.00","1 through 10","485.9","1093.14","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","1093.14","819.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1093.14","100","","2520.00","797.10","5898.60","1 through 10","485.9","1093.14","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","1093.14","819.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","485.90","44.45","","1953.42","1953.42","1953.42","1 through 10","485.9","1093.14","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","both","","","1093.14","819.85","WELLPOINT [1015]","HB CH WELLPOINT","851.67","77.91","","1490.36","627.80","7327.37","1 through 10","485.9","1093.14","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1093.14","819.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","648.23","59.3","","536.35","188.54","1772.63","17","546.57","857.57","percent of total billed charges",""
"MESH COMPOSITE 12CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158109","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1093.14","819.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","857.57","78.45","","562.30","246.20","3344.28","1 through 10","546.57","857.57","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","both","","","797.10","597.82","AETNA [1001]","HB CH AETNA HMO / PPO","464.71","58.3","","585.96","347.85","5016.82","1 through 10","354.31","797.1","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","both","","","797.10","597.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","677.54","85","","1295.16","1295.16","1295.16","1 through 10","354.31","797.1","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","both","","","797.10","597.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","797.10","100","","2700.00","1008.69","2700.00","1 through 10","354.31","797.1","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","both","","","797.10","597.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","797.10","100","","2520.00","797.10","5898.60","1 through 10","354.31","797.1","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","both","","","797.10","597.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","354.31","44.45","","1953.42","1953.42","1953.42","1 through 10","354.31","797.1","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","both","","","797.10","597.82","WELLPOINT [1015]","HB CH WELLPOINT","621.02","77.91","","1490.36","627.80","7327.37","1 through 10","354.31","797.1","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","797.10","597.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","472.68","59.3","","536.35","188.54","1772.63","17","398.55","625.32","percent of total billed charges",""
"MESH COMPOSITE 9CM GRAFT SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM ROUND","SUP-ITM-10158108","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","797.10","597.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","625.32","78.45","","562.30","246.20","3344.28","1 through 10","398.55","625.32","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","both","","","3310.00","2482.50","AETNA [1001]","HB CH AETNA HMO / PPO","1929.73","58.3","","585.96","347.85","5016.82","1 through 10","1471.3","3310","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","both","","","3310.00","2482.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2813.50","85","","1295.16","1295.16","1295.16","1 through 10","1471.3","3310","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","both","","","3310.00","2482.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3310.00","100","","2700.00","1008.69","2700.00","1 through 10","1471.3","3310","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","both","","","3310.00","2482.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3310.00","100","","2520.00","797.10","5898.60","1 through 10","1471.3","3310","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","both","","","3310.00","2482.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1471.30","44.45","","1953.42","1953.42","1953.42","1 through 10","1471.3","3310","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","both","","","3310.00","2482.50","WELLPOINT [1015]","HB CH WELLPOINT","2578.82","77.91","","1490.36","627.80","7327.37","1 through 10","1471.3","3310","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3310.00","2482.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1962.83","59.3","","536.35","188.54","1772.63","17","1655","2596.7","percent of total billed charges",""
"MESH ENFORM 10X10 PREPERITONEAL BIOMATERIAL","SUP-ITM-10319702","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3310.00","2482.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2596.70","78.45","","562.30","246.20","3344.28","1 through 10","1655","2596.7","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","AETNA [1001]","HB CH AETNA HMO / PPO","1705.28","58.3","","585.96","347.85","5016.82","1 through 10","1300.16","2925","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2486.25","85","","1295.16","1295.16","1295.16","1 through 10","1300.16","2925","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2925.00","100","","2700.00","1008.69","2700.00","1 through 10","1300.16","2925","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2925.00","100","","2520.00","797.10","5898.60","1 through 10","1300.16","2925","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.16","44.45","","1953.42","1953.42","1953.42","1 through 10","1300.16","2925","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","WELLPOINT [1015]","HB CH WELLPOINT","2278.87","77.91","","1490.36","627.80","7327.37","1 through 10","1300.16","2925","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1734.53","59.3","","536.35","188.54","1772.63","17","1462.5","2294.66","percent of total billed charges",""
"MESH GRAFT .4.5IN LG VENTRIO ST POLYPROPYLENE SEPRA PATCH HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR CIRCLE CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10100386","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2294.66","78.45","","562.30","246.20","3344.28","1 through 10","1462.5","2294.66","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","AETNA [1001]","HB CH AETNA HMO / PPO","385.23","58.3","","585.96","347.85","5016.82","1 through 10","293.71","660.77","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","561.65","85","","1295.16","1295.16","1295.16","1 through 10","293.71","660.77","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","660.77","100","","2700.00","1008.69","2700.00","1 through 10","293.71","660.77","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","660.77","100","","2520.00","797.10","5898.60","1 through 10","293.71","660.77","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.71","44.45","","1953.42","1953.42","1953.42","1 through 10","293.71","660.77","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","both","","","660.77","495.58","WELLPOINT [1015]","HB CH WELLPOINT","514.81","77.91","","1490.36","627.80","7327.37","1 through 10","293.71","660.77","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","660.77","495.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.84","59.3","","536.35","188.54","1772.63","17","330.39","518.37","percent of total billed charges",""
"MESH GRAFT 1.3X1.55IN 3.3 3.9CM MED PERFIX POLYPROPYLENE MONOFILAMENT PLUG INGUINAL HERNIA SOFT TISSUE REPAIR CS/2EA","SUP-ITM-10003518","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","660.77","495.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","518.37","78.45","","562.30","246.20","3344.28","1 through 10","330.39","518.37","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","both","","","2397.90","1798.42","AETNA [1001]","HB CH AETNA HMO / PPO","1397.98","58.3","","585.96","347.85","5016.82","1 through 10","1065.87","2397.9","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","both","","","2397.90","1798.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2038.22","85","","1295.16","1295.16","1295.16","1 through 10","1065.87","2397.9","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","both","","","2397.90","1798.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2397.90","100","","2700.00","1008.69","2700.00","1 through 10","1065.87","2397.9","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","both","","","2397.90","1798.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2397.90","100","","2520.00","797.10","5898.60","1 through 10","1065.87","2397.9","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","both","","","2397.90","1798.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1065.87","44.45","","1953.42","1953.42","1953.42","1 through 10","1065.87","2397.9","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","both","","","2397.90","1798.42","WELLPOINT [1015]","HB CH WELLPOINT","1868.20","77.91","","1490.36","627.80","7327.37","1 through 10","1065.87","2397.9","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2397.90","1798.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","1421.95","59.3","","536.35","188.54","1772.63","17","1198.95","1881.15","percent of total billed charges",""
"MESH GRAFT 12X12 30.5X30.5CM POLYPROPYLENE HERNIA SOFT NONABSORBABLE CS/1EA","SUP-ITM-10215739","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2397.90","1798.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1881.15","78.45","","562.30","246.20","3344.28","1 through 10","1198.95","1881.15","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1320.27","990.20","AETNA [1001]","HB CH AETNA HMO / PPO","769.72","58.3","","585.96","347.85","5016.82","1 through 10","586.86","1320.27","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1320.27","990.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1122.23","85","","1295.16","1295.16","1295.16","1 through 10","586.86","1320.27","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1320.27","990.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1320.27","100","","2700.00","1008.69","2700.00","1 through 10","586.86","1320.27","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1320.27","990.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1320.27","100","","2520.00","797.10","5898.60","1 through 10","586.86","1320.27","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1320.27","990.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","586.86","44.45","","1953.42","1953.42","1953.42","1 through 10","586.86","1320.27","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","both","","","1320.27","990.20","WELLPOINT [1015]","HB CH WELLPOINT","1028.62","77.91","","1490.36","627.80","7327.37","1 through 10","586.86","1320.27","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1320.27","990.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","782.92","59.3","","536.35","188.54","1772.63","17","660.14","1035.75","percent of total billed charges",""
"MESH GRAFT 15.2CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025246","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1320.27","990.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1035.75","78.45","","562.30","246.20","3344.28","1 through 10","660.14","1035.75","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1033.44","775.08","AETNA [1001]","HB CH AETNA HMO / PPO","602.50","58.3","","585.96","347.85","5016.82","1 through 10","459.36","1033.44","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1033.44","775.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","878.42","85","","1295.16","1295.16","1295.16","1 through 10","459.36","1033.44","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1033.44","775.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1033.44","100","","2700.00","1008.69","2700.00","1 through 10","459.36","1033.44","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1033.44","775.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1033.44","100","","2520.00","797.10","5898.60","1 through 10","459.36","1033.44","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1033.44","775.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","459.36","44.45","","1953.42","1953.42","1953.42","1 through 10","459.36","1033.44","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","both","","","1033.44","775.08","WELLPOINT [1015]","HB CH WELLPOINT","805.15","77.91","","1490.36","627.80","7327.37","1 through 10","459.36","1033.44","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1033.44","775.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","612.83","59.3","","536.35","188.54","1772.63","17","516.72","810.73","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE CONTOURED RESORBABLE RIGHT","SUP-ITM-10146941","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1033.44","775.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","810.73","78.45","","562.30","246.20","3344.28","1 through 10","516.72","810.73","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","AETNA [1001]","HB CH AETNA HMO / PPO","504.41","58.3","","585.96","347.85","5016.82","1 through 10","384.58","865.2","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","735.42","85","","1295.16","1295.16","1295.16","1 through 10","384.58","865.2","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","865.20","100","","2700.00","1008.69","2700.00","1 through 10","384.58","865.2","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","865.20","100","","2520.00","797.10","5898.60","1 through 10","384.58","865.2","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","384.58","44.45","","1953.42","1953.42","1953.42","1 through 10","384.58","865.2","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","both","","","865.20","648.90","WELLPOINT [1015]","HB CH WELLPOINT","674.08","77.91","","1490.36","627.80","7327.37","1 through 10","384.58","865.2","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","865.20","648.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","513.06","59.3","","536.35","188.54","1772.63","17","432.6","678.75","percent of total billed charges",""
"MESH GRAFT 15CMX10 PROGRIP PET PLA LAPAROSCOPY TACK FREE RECTANGLE RESORBABLE FLAT SHEET","SUP-ITM-10151456","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","865.20","648.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","678.75","78.45","","562.30","246.20","3344.28","1 through 10","432.6","678.75","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","AETNA [1001]","HB CH AETNA HMO / PPO","588.07","58.3","","585.96","347.85","5016.82","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","857.39","85","","1295.16","1295.16","1295.16","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1008.69","100","","2700.00","1008.69","2700.00","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1008.69","100","","2520.00","797.10","5898.60","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","448.36","44.45","","1953.42","1953.42","1953.42","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","WELLPOINT [1015]","HB CH WELLPOINT","785.87","77.91","","1490.36","627.80","7327.37","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1008.69","756.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","598.15","59.3","","536.35","188.54","1772.63","17","504.35","791.32","percent of total billed charges",""
"MESH GRAFT 15X10CM COMPOSITE SYMBOTEX HERNIA 3D MONOFILAMENT POLYESTER ABSORBABLE COLLAGEN FILM RECTANGLE BX/1EA","SUP-ITM-10148177","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1008.69","756.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","791.32","78.45","","562.30","246.20","3344.28","1 through 10","504.35","791.32","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","AETNA [1001]","HB CH AETNA HMO / PPO","2028.84","58.3","","585.96","347.85","5016.82","1 through 10","1546.86","3480","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2958.00","85","","1295.16","1295.16","1295.16","1 through 10","1546.86","3480","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3480.00","100","","2700.00","1008.69","2700.00","1 through 10","1546.86","3480","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3480.00","100","","2520.00","797.10","5898.60","1 through 10","1546.86","3480","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1546.86","44.45","","1953.42","1953.42","1953.42","1 through 10","1546.86","3480","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","both","","","3480.00","2610.00","WELLPOINT [1015]","HB CH WELLPOINT","2711.27","77.91","","1490.36","627.80","7327.37","1 through 10","1546.86","3480","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3480.00","2610.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2063.64","59.3","","536.35","188.54","1772.63","17","1740","2730.06","percent of total billed charges",""
"MESH GRAFT 20CMX15 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP OVAL CS/1EA","SUP-ITM-10082640","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3480.00","2610.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2730.06","78.45","","562.30","246.20","3344.28","1 through 10","1740","2730.06","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","AETNA [1001]","HB CH AETNA HMO / PPO","2343.66","58.3","","585.96","347.85","5016.82","1 through 10","1786.89","4020","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3417.00","85","","1295.16","1295.16","1295.16","1 through 10","1786.89","4020","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4020.00","100","","2700.00","1008.69","2700.00","1 through 10","1786.89","4020","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4020.00","100","","2520.00","797.10","5898.60","1 through 10","1786.89","4020","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1786.89","44.45","","1953.42","1953.42","1953.42","1 through 10","1786.89","4020","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","both","","","4020.00","3015.00","WELLPOINT [1015]","HB CH WELLPOINT","3131.98","77.91","","1490.36","627.80","7327.37","1 through 10","1786.89","4020","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4020.00","3015.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2383.86","59.3","","536.35","188.54","1772.63","17","2010","3153.69","percent of total billed charges",""
"MESH GRAFT 25.4CMX20.3 VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE POCKET STRAP ELLIPTICAL CS/1EA","SUP-ITM-10082655","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4020.00","3015.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3153.69","78.45","","562.30","246.20","3344.28","1 through 10","2010","3153.69","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","4980.00","3735.00","AETNA [1001]","HB CH AETNA HMO / PPO","2903.34","58.3","","585.96","347.85","5016.82","1 through 10","2213.61","4980","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","4980.00","3735.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4233.00","85","","1295.16","1295.16","1295.16","1 through 10","2213.61","4980","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","4980.00","3735.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4980.00","100","","2700.00","1008.69","2700.00","1 through 10","2213.61","4980","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","4980.00","3735.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4980.00","100","","2520.00","797.10","5898.60","1 through 10","2213.61","4980","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","4980.00","3735.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2213.61","44.45","","1953.42","1953.42","1953.42","1 through 10","2213.61","4980","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","both","","","4980.00","3735.00","WELLPOINT [1015]","HB CH WELLPOINT","3879.92","77.91","","1490.36","627.80","7327.37","1 through 10","2213.61","4980","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4980.00","3735.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2953.14","59.3","","536.35","188.54","1772.63","17","2490","3906.81","percent of total billed charges",""
"MESH GRAFT 33CMX25.5 VENTRALIGHT ST POLYPROPYLENE HERNIA MONOFIL HYDROGEL ECHO PS POSITIONING SYSTEM REPAIR ELLIPSE CS/1EA","SUP-ITM-10082650","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4980.00","3735.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3906.81","78.45","","562.30","246.20","3344.28","1 through 10","2490","3906.81","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.51","551.63","AETNA [1001]","HB CH AETNA HMO / PPO","428.80","58.3","","585.96","347.85","5016.82","1 through 10","326.93","735.51","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.51","551.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","625.18","85","","1295.16","1295.16","1295.16","1 through 10","326.93","735.51","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.51","551.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","735.51","100","","2700.00","1008.69","2700.00","1 through 10","326.93","735.51","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.51","551.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","735.51","100","","2520.00","797.10","5898.60","1 through 10","326.93","735.51","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.51","551.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.93","44.45","","1953.42","1953.42","1953.42","1 through 10","326.93","735.51","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","both","","","735.51","551.63","WELLPOINT [1015]","HB CH WELLPOINT","573.04","77.91","","1490.36","627.80","7327.37","1 through 10","326.93","735.51","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","735.51","551.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","436.16","59.3","","536.35","188.54","1772.63","17","367.76","577.01","percent of total billed charges",""
"MESH GRAFT 9.1CM COMPOSITE PARIETEX MICROPOROUS POLYESTER OPTIMIZED ROUND HERNIA","SUP-ITM-10025244","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","735.51","551.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","577.01","78.45","","562.30","246.20","3344.28","1 through 10","367.76","577.01","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","AETNA [1001]","HB CH AETNA HMO / PPO","588.07","58.3","","585.96","347.85","5016.82","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","857.39","85","","1295.16","1295.16","1295.16","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1008.69","100","","2700.00","1008.69","2700.00","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1008.69","100","","2520.00","797.10","5898.60","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","448.36","44.45","","1953.42","1953.42","1953.42","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","both","","","1008.69","756.52","WELLPOINT [1015]","HB CH WELLPOINT","785.87","77.91","","1490.36","627.80","7327.37","1 through 10","448.36","1008.69","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1008.69","756.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","598.15","59.3","","536.35","188.54","1772.63","17","504.35","791.32","percent of total billed charges",""
"MESH HERNIA 1.7X12CM THICK ROUND VENTRAL OPTIMIZED COMPOSITE W/OUT FIXATION SUTURE PARIETEX","SUP-ITM-10025245","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1008.69","756.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","791.32","78.45","","562.30","246.20","3344.28","1 through 10","504.35","791.32","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","both","","","2544.12","1908.09","AETNA [1001]","HB CH AETNA HMO / PPO","1483.22","58.3","","585.96","347.85","5016.82","1 through 10","1130.86","2544.12","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","both","","","2544.12","1908.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2162.50","85","","1295.16","1295.16","1295.16","1 through 10","1130.86","2544.12","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","both","","","2544.12","1908.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2544.12","100","","2700.00","1008.69","2700.00","1 through 10","1130.86","2544.12","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","both","","","2544.12","1908.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2544.12","100","","2520.00","797.10","5898.60","1 through 10","1130.86","2544.12","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","both","","","2544.12","1908.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1130.86","44.45","","1953.42","1953.42","1953.42","1 through 10","1130.86","2544.12","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","both","","","2544.12","1908.09","WELLPOINT [1015]","HB CH WELLPOINT","1982.12","77.91","","1490.36","627.80","7327.37","1 through 10","1130.86","2544.12","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2544.12","1908.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1508.66","59.3","","536.35","188.54","1772.63","17","1272.06","1995.86","percent of total billed charges",""
"MESH HERNIA 25X15CM REPAIR SYMBOTEX COMPOSITE SOFT TISSUE","SUP-ITM-10158111","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2544.12","1908.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1995.86","78.45","","562.30","246.20","3344.28","1 through 10","1272.06","1995.86","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","585.96","347.85","5016.82","1 through 10","1233.49","2775","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2358.75","85","","1295.16","1295.16","1295.16","1 through 10","1233.49","2775","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2775.00","100","","2700.00","1008.69","2700.00","1 through 10","1233.49","2775","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2775.00","100","","2520.00","797.10","5898.60","1 through 10","1233.49","2775","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","1953.42","1953.42","1953.42","1 through 10","1233.49","2775","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","1490.36","627.80","7327.37","1 through 10","1233.49","2775","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","536.35","188.54","1772.63","17","1387.5","2176.99","percent of total billed charges",""
"MESH HERNIA 4.5IN CIRCULAR ABSORBABLE SEPRA TECHNOLOGY VENTRAL VENTRALIGHT ST POLYPROPYLENE IMPLANTABLE CS/1EA","SUP-ITM-10082651","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","562.30","246.20","3344.28","1 through 10","1387.5","2176.99","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1235.70","926.77","AETNA [1001]","HB CH AETNA HMO / PPO","720.41","58.3","","585.96","347.85","5016.82","1 through 10","549.27","1235.7","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1235.70","926.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1050.35","85","","1295.16","1295.16","1295.16","1 through 10","549.27","1235.7","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1235.70","926.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1235.70","100","","2700.00","1008.69","2700.00","1 through 10","549.27","1235.7","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1235.70","926.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1235.70","100","","2520.00","797.10","5898.60","1 through 10","549.27","1235.7","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1235.70","926.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","549.27","44.45","","1953.42","1953.42","1953.42","1 through 10","549.27","1235.7","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","both","","","1235.70","926.77","WELLPOINT [1015]","HB CH WELLPOINT","962.73","77.91","","1490.36","627.80","7327.37","1 through 10","549.27","1235.7","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1235.70","926.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","732.77","59.3","","536.35","188.54","1772.63","17","617.85","969.41","percent of total billed charges",""
"MESH HERNIA 5X7IN XL RT 3DMAX MID ANATOMICAL OPEN PORE MONOFILAMENT POLYPROPYLENE CS/1EA","SUP-ITM-10283105","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1235.70","926.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","969.41","78.45","","562.30","246.20","3344.28","1 through 10","617.85","969.41","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","AETNA [1001]","HB CH AETNA HMO / PPO","2404.88","58.3","","585.96","347.85","5016.82","1 through 10","1833.56","4125","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3506.25","85","","1295.16","1295.16","1295.16","1 through 10","1833.56","4125","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4125.00","100","","2700.00","1008.69","2700.00","1 through 10","1833.56","4125","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4125.00","100","","2520.00","797.10","5898.60","1 through 10","1833.56","4125","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1833.56","44.45","","1953.42","1953.42","1953.42","1 through 10","1833.56","4125","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","both","","","4125.00","3093.75","WELLPOINT [1015]","HB CH WELLPOINT","3213.79","77.91","","1490.36","627.80","7327.37","1 through 10","1833.56","4125","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2446.13","59.3","","536.35","188.54","1772.63","17","2062.5","3236.06","percent of total billed charges",""
"MESH HERNIA 8IN REPAIR VENTRALIGHT ST POLYPROPYLENE BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10117388","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","562.30","246.20","3344.28","1 through 10","2062.5","3236.06","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","AETNA [1001]","HB CH AETNA HMO / PPO","1860.94","58.3","","585.96","347.85","5016.82","1 through 10","1418.84","3192","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2713.20","85","","1295.16","1295.16","1295.16","1 through 10","1418.84","3192","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3192.00","100","","2700.00","1008.69","2700.00","1 through 10","1418.84","3192","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3192.00","100","","2520.00","797.10","5898.60","1 through 10","1418.84","3192","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1418.84","44.45","","1953.42","1953.42","1953.42","1 through 10","1418.84","3192","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","both","","","3192.00","2394.00","WELLPOINT [1015]","HB CH WELLPOINT","2486.89","77.91","","1490.36","627.80","7327.37","1 through 10","1418.84","3192","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3192.00","2394.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1892.86","59.3","","536.35","188.54","1772.63","17","1596","2504.12","percent of total billed charges",""
"MESH PELVIC L 24CM 4 W RECONSTRUCTIVE ANTERIOR POSTERIOR ABDOMINAL POLYPROPYLENE Y SHAPED RESTORELLE","SUP-ITM-10126340","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3192.00","2394.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2504.12","78.45","","562.30","246.20","3344.28","1 through 10","1596","2504.12","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","1830.28","315.58","1830.28","1 through 10","200.03","450","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","4170.85","4170.85","4170.85","1 through 10","200.03","450","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","649.55","649.55","649.55","1 through 10","200.03","450","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","8998.38","2542.37","8998.38","20","200.03","450","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","1891.61","1609.14","3664.18","25","225","353.03","percent of total billed charges",""
"MESH ROD 22X28MM 90 SPINE EXPEDIUM TITANIUM STRAIGHT ANTERIOR","SUP-ITM-10021559","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1470.68","1310.06","2481.69","19","225","353.03","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","AETNA [1001]","HB CH AETNA HMO / PPO","564.93","58.3","","585.96","347.85","5016.82","1 through 10","430.72","969","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","823.65","85","","1295.16","1295.16","1295.16","1 through 10","430.72","969","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","969.00","100","","2700.00","1008.69","2700.00","1 through 10","430.72","969","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","969.00","100","","2520.00","797.10","5898.60","1 through 10","430.72","969","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","430.72","44.45","","1953.42","1953.42","1953.42","1 through 10","430.72","969","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","both","","","969.00","726.75","WELLPOINT [1015]","HB CH WELLPOINT","754.95","77.91","","1490.36","627.80","7327.37","1 through 10","430.72","969","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","969.00","726.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","574.62","59.3","","536.35","188.54","1772.63","17","484.5","760.18","percent of total billed charges",""
"MESH SELF FIXATING 16CMX12 PROGRIP LAPAROSCOPIC","SUP-ITM-10158037","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","969.00","726.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","760.18","78.45","","562.30","246.20","3344.28","1 through 10","484.5","760.18","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1650.93","1238.20","AETNA [1001]","HB CH AETNA HMO / PPO","962.49","58.3","","585.96","347.85","5016.82","1 through 10","733.84","1650.93","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1650.93","1238.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1403.29","85","","1295.16","1295.16","1295.16","1 through 10","733.84","1650.93","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1650.93","1238.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1650.93","100","","2700.00","1008.69","2700.00","1 through 10","733.84","1650.93","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1650.93","1238.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1650.93","100","","2520.00","797.10","5898.60","1 through 10","733.84","1650.93","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1650.93","1238.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","733.84","44.45","","1953.42","1953.42","1953.42","1 through 10","733.84","1650.93","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","both","","","1650.93","1238.20","WELLPOINT [1015]","HB CH WELLPOINT","1286.24","77.91","","1490.36","627.80","7327.37","1 through 10","733.84","1650.93","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1650.93","1238.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","979.00","59.3","","536.35","188.54","1772.63","17","825.47","1295.15","percent of total billed charges",""
"MESH SURGICAL 10CMX15 GYNE PS PROLENE POLYPROPYLENE NONABSORBABLE PROLAPSE PK/1EA","SUP-ITM-10010558","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1650.93","1238.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1295.15","78.45","","562.30","246.20","3344.28","1 through 10","825.47","1295.15","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","AETNA [1001]","HB CH AETNA HMO / PPO","101.91","58.3","","585.96","347.85","5016.82","1 through 10","77.7","174.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","148.58","85","","1295.16","1295.16","1295.16","1 through 10","77.7","174.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","174.80","100","","2700.00","1008.69","2700.00","1 through 10","77.7","174.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","174.80","100","","2520.00","797.10","5898.60","1 through 10","77.7","174.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.70","44.45","","1953.42","1953.42","1953.42","1 through 10","77.7","174.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","both","","","174.80","131.10","WELLPOINT [1015]","HB CH WELLPOINT","136.19","77.91","","1490.36","627.80","7327.37","1 through 10","77.7","174.8","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","174.80","131.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.66","59.3","","536.35","188.54","1772.63","17","87.4","137.13","percent of total billed charges",""
"MESH SURGICAL 15CM 8 HERNIA PROLENE POLYPROPYLENE NONABSORBABLE REPAIR BX/6EA","SUP-ITM-10005612","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","174.80","131.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.13","78.45","","562.30","246.20","3344.28","1 through 10","87.4","137.13","percent of total billed charges",""
"MESH SURGICAL 17X22X12MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007240","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","AETNA [1001]","HB CH AETNA HMO / PPO","2550.63","58.3","","1830.28","315.58","1830.28","1 through 10","1944.69","4375","percent of total billed charges",""
"MESH SURGICAL 17X22X12MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007240","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3193.75","73","","4170.85","4170.85","4170.85","1 through 10","1944.69","4375","percent of total billed charges",""
"MESH SURGICAL 17X22X12MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007240","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1944.69","44.45","","649.55","649.55","649.55","1 through 10","1944.69","4375","percent of total billed charges",""
"MESH SURGICAL 17X22X12MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007240","CDM","C1889","HCPCS","0278","RC","","","","both","","","4375.00","3281.25","WELLPOINT [1015]","HB CH WELLPOINT","3408.56","77.91","","8998.38","2542.37","8998.38","20","1944.69","4375","percent of total billed charges",""
"MESH SURGICAL 17X22X12MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007240","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2594.38","59.3","","1891.61","1609.14","3664.18","25","2187.5","3432.19","percent of total billed charges",""
"MESH SURGICAL 17X22X12MM SPINE SYN OBLONG THORACULUMBAR HEIGHT TITANIUM","SUP-ITM-10007240","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4375.00","3281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3432.19","78.45","","1470.68","1310.06","2481.69","19","2187.5","3432.19","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","AETNA [1001]","HB CH AETNA HMO / PPO","2041.70","58.3","","554.95","91.85","1421.75","94","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2556.50","73","","2490.03","2490.03","2490.03","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2041.70","58.3","","750.00","750.00","750.00","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.09","53","","1192.50","120.84","4149.90","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2976.74","85","","750.00","75.00","750.00","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3502.05","100","","657.00","121.50","1971.00","14","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3502.05","100","","75.00","75.00","75.00","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3502.05","100","","366.00","144.00","1971.00","45","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2556.50","73","","667.50","667.50","667.50","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1556.66","44.45","","123.77","123.77","123.77","1 through 10","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3502.05","2626.54","WELLPOINT [1015]","HB CH WELLPOINT","2728.45","77.91","","483.51","229.32","1316.08","96","1556.66","3502.05","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.05","2626.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","2076.72","59.3","","439.50","225.34","1872.27","197","1751.03","2747.36","percent of total billed charges",""
"MESH SURGICAL 2.4MM 2.7 12 HOLE BONE PLATE VA LCP STAINLESS LOCKING","SUP-ITM-10097071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3502.05","2626.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.36","78.45","","385.32","55.36","1815.62","58","1751.03","2747.36","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","8848.00","6636.00","AETNA [1001]","HB CH AETNA HMO / PPO","5158.38","58.3","","585.96","347.85","5016.82","1 through 10","3932.94","8848","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","8848.00","6636.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7520.80","85","","1295.16","1295.16","1295.16","1 through 10","3932.94","8848","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","8848.00","6636.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8848.00","100","","2700.00","1008.69","2700.00","1 through 10","3932.94","8848","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","8848.00","6636.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8848.00","100","","2520.00","797.10","5898.60","1 through 10","3932.94","8848","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","8848.00","6636.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3932.94","44.45","","1953.42","1953.42","1953.42","1 through 10","3932.94","8848","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","both","","","8848.00","6636.00","WELLPOINT [1015]","HB CH WELLPOINT","6893.48","77.91","","1490.36","627.80","7327.37","1 through 10","3932.94","8848","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8848.00","6636.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5246.86","59.3","","536.35","188.54","1772.63","17","4424","6941.26","percent of total billed charges",""
"MESH SURGICAL 20X30CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320424","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","8848.00","6636.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6941.26","78.45","","562.30","246.20","3344.28","1 through 10","4424","6941.26","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2123.65","1592.74","AETNA [1001]","HB CH AETNA HMO / PPO","1238.09","58.3","","585.96","347.85","5016.82","1 through 10","943.96","2123.65","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2123.65","1592.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1805.10","85","","1295.16","1295.16","1295.16","1 through 10","943.96","2123.65","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2123.65","1592.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2123.65","100","","2700.00","1008.69","2700.00","1 through 10","943.96","2123.65","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2123.65","1592.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2123.65","100","","2520.00","797.10","5898.60","1 through 10","943.96","2123.65","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2123.65","1592.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","943.96","44.45","","1953.42","1953.42","1953.42","1 through 10","943.96","2123.65","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","both","","","2123.65","1592.74","WELLPOINT [1015]","HB CH WELLPOINT","1654.54","77.91","","1490.36","627.80","7327.37","1 through 10","943.96","2123.65","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2123.65","1592.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","1259.32","59.3","","536.35","188.54","1772.63","17","1061.83","1666","percent of total billed charges",""
"MESH SURGICAL 30CMXVICRYL KNITTED POLYGLACTIN 910 IMPLANTABLE BX/3EA","SUP-ITM-10001472","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2123.65","1592.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1666.00","78.45","","562.30","246.20","3344.28","1 through 10","1061.83","1666","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","18050.00","13537.50","AETNA [1001]","HB CH AETNA HMO / PPO","10523.15","58.3","","585.96","347.85","5016.82","1 through 10","8023.23","18050","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","18050.00","13537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","15342.50","85","","1295.16","1295.16","1295.16","1 through 10","8023.23","18050","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","18050.00","13537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","18050.00","100","","2700.00","1008.69","2700.00","1 through 10","8023.23","18050","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","18050.00","13537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","18050.00","100","","2520.00","797.10","5898.60","1 through 10","8023.23","18050","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","18050.00","13537.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8023.23","44.45","","1953.42","1953.42","1953.42","1 through 10","8023.23","18050","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","both","","","18050.00","13537.50","WELLPOINT [1015]","HB CH WELLPOINT","14062.76","77.91","","1490.36","627.80","7327.37","1 through 10","8023.23","18050","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","18050.00","13537.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","10703.65","59.3","","536.35","188.54","1772.63","17","9025","14160.23","percent of total billed charges",""
"MESH SURGICAL 30X40CM PREPERITONEAL KNIT WEB SYNECOR RECTANGLE","SUP-ITM-10320524","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","18050.00","13537.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","14160.23","78.45","","562.30","246.20","3344.28","1 through 10","9025","14160.23","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","712.79","534.59","AETNA [1001]","HB CH AETNA HMO / PPO","415.56","58.3","","585.96","347.85","5016.82","1 through 10","316.84","712.79","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","712.79","534.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","605.87","85","","1295.16","1295.16","1295.16","1 through 10","316.84","712.79","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","712.79","534.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","712.79","100","","2700.00","1008.69","2700.00","1 through 10","316.84","712.79","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","712.79","534.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","712.79","100","","2520.00","797.10","5898.60","1 through 10","316.84","712.79","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","712.79","534.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.84","44.45","","1953.42","1953.42","1953.42","1 through 10","316.84","712.79","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","both","","","712.79","534.59","WELLPOINT [1015]","HB CH WELLPOINT","555.33","77.91","","1490.36","627.80","7327.37","1 through 10","316.84","712.79","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","712.79","534.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","422.68","59.3","","536.35","188.54","1772.63","17","356.4","559.18","percent of total billed charges",""
"MESH SURGICAL 6.0 XIN HERNIA PROLENE POLYPROPYLENE FLAT BX/6EA","SUP-ITM-10007916","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","712.79","534.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","559.18","78.45","","562.30","246.20","3344.28","1 through 10","356.4","559.18","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","AETNA [1001]","HB CH AETNA HMO / PPO","2774.26","58.3","","585.96","347.85","5016.82","1 through 10","2115.2","4758.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4044.81","85","","1295.16","1295.16","1295.16","1 through 10","2115.2","4758.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4758.60","100","","2700.00","1008.69","2700.00","1 through 10","2115.2","4758.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4758.60","100","","2520.00","797.10","5898.60","1 through 10","2115.2","4758.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2115.20","44.45","","1953.42","1953.42","1953.42","1 through 10","2115.2","4758.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","both","","","4758.60","3568.95","WELLPOINT [1015]","HB CH WELLPOINT","3707.43","77.91","","1490.36","627.80","7327.37","1 through 10","2115.2","4758.6","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","2821.85","59.3","","536.35","188.54","1772.63","17","2379.3","3733.12","percent of total billed charges",""
"MESH SURGICAL 7X10CM PHASIX ST RESORBABLE RECTANGLE CS/1EA","SUP-ITM-10159304","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4758.60","3568.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3733.12","78.45","","562.30","246.20","3344.28","1 through 10","2379.3","3733.12","percent of total billed charges",""
"MESH SURGICAL POSITIONING Y SHAPED FLAT SUTURING SURFACE MULTI DIRECTIONAL VAGINAL UPSYLON COLPASSIST IMPLANTABLE SACRAL COLPOPE","SUP-ITM-10118315","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2674.59","2005.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2098.22","78.45","","555.84","555.84","555.84","1 through 10","1337.3","2098.22","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","289.84","217.38","AETNA [1001]","HB CH AETNA HMO / PPO","168.98","58.3","","585.96","347.85","5016.82","1 through 10","128.83","289.84","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","289.84","217.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","246.36","85","","1295.16","1295.16","1295.16","1 through 10","128.83","289.84","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","289.84","217.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","289.84","100","","2700.00","1008.69","2700.00","1 through 10","128.83","289.84","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","289.84","217.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","289.84","100","","2520.00","797.10","5898.60","1 through 10","128.83","289.84","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","289.84","217.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.83","44.45","","1953.42","1953.42","1953.42","1 through 10","128.83","289.84","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","both","","","289.84","217.38","WELLPOINT [1015]","HB CH WELLPOINT","225.81","77.91","","1490.36","627.80","7327.37","1 through 10","128.83","289.84","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","289.84","217.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","171.88","59.3","","536.35","188.54","1772.63","17","144.92","227.38","percent of total billed charges",""
"MESH SYNTHETIC 3.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENE ULTRAPRO BX/3EA","SUP-ITM-10016608","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","289.84","217.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","227.38","78.45","","562.30","246.20","3344.28","1 through 10","144.92","227.38","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","AETNA [1001]","HB CH AETNA HMO / PPO","233.72","58.3","","585.96","347.85","5016.82","1 through 10","178.2","400.89","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","340.76","85","","1295.16","1295.16","1295.16","1 through 10","178.2","400.89","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","400.89","100","","2700.00","1008.69","2700.00","1 through 10","178.2","400.89","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","400.89","100","","2520.00","797.10","5898.60","1 through 10","178.2","400.89","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","178.20","44.45","","1953.42","1953.42","1953.42","1 through 10","178.2","400.89","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","both","","","400.89","300.67","WELLPOINT [1015]","HB CH WELLPOINT","312.33","77.91","","1490.36","627.80","7327.37","1 through 10","178.2","400.89","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","237.73","59.3","","536.35","188.54","1772.63","17","200.45","314.5","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/3EA","SUP-ITM-10002648","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","400.89","300.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.50","78.45","","562.30","246.20","3344.28","1 through 10","200.45","314.5","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","739.14","554.35","AETNA [1001]","HB CH AETNA HMO / PPO","430.92","58.3","","585.96","347.85","5016.82","1 through 10","328.55","739.14","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","739.14","554.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","628.27","85","","1295.16","1295.16","1295.16","1 through 10","328.55","739.14","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","739.14","554.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","739.14","100","","2700.00","1008.69","2700.00","1 through 10","328.55","739.14","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","739.14","554.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","739.14","100","","2520.00","797.10","5898.60","1 through 10","328.55","739.14","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","739.14","554.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","328.55","44.45","","1953.42","1953.42","1953.42","1 through 10","328.55","739.14","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","both","","","739.14","554.35","WELLPOINT [1015]","HB CH WELLPOINT","575.86","77.91","","1490.36","627.80","7327.37","1 through 10","328.55","739.14","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","739.14","554.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","438.31","59.3","","536.35","188.54","1772.63","17","369.57","579.86","percent of total billed charges",""
"MESH SYNTHETIC 30CMXABDOMINAL PARTIALLY ABSORBABLE SQUARE POLYPROPYLENE ULTRAPRO BX/1EA","SUP-ITM-10016609","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","739.14","554.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","579.86","78.45","","562.30","246.20","3344.28","1 through 10","369.57","579.86","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","both","","","1307.40","980.55","AETNA [1001]","HB CH AETNA HMO / PPO","762.21","58.3","","585.96","347.85","5016.82","1 through 10","581.14","1307.4","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","both","","","1307.40","980.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1111.29","85","","1295.16","1295.16","1295.16","1 through 10","581.14","1307.4","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","both","","","1307.40","980.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1307.40","100","","2700.00","1008.69","2700.00","1 through 10","581.14","1307.4","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","both","","","1307.40","980.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1307.40","100","","2520.00","797.10","5898.60","1 through 10","581.14","1307.4","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","both","","","1307.40","980.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","581.14","44.45","","1953.42","1953.42","1953.42","1 through 10","581.14","1307.4","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","both","","","1307.40","980.55","WELLPOINT [1015]","HB CH WELLPOINT","1018.60","77.91","","1490.36","627.80","7327.37","1 through 10","581.14","1307.4","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1307.40","980.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","775.29","59.3","","536.35","188.54","1772.63","17","653.7","1025.66","percent of total billed charges",""
"MESH SYNTHETIC 4.0X6.0IN ABDOMINAL PARTIALLY ABSORBABLE OVAL POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10031422","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1307.40","980.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1025.66","78.45","","562.30","246.20","3344.28","1 through 10","653.7","1025.66","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","AETNA [1001]","HB CH AETNA HMO / PPO","112.76","58.3","","585.96","347.85","5016.82","1 through 10","85.98","193.42","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","164.41","85","","1295.16","1295.16","1295.16","1 through 10","85.98","193.42","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","193.42","100","","2700.00","1008.69","2700.00","1 through 10","85.98","193.42","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","193.42","100","","2520.00","797.10","5898.60","1 through 10","85.98","193.42","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","85.98","44.45","","1953.42","1953.42","1953.42","1 through 10","85.98","193.42","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","both","","","193.42","145.06","WELLPOINT [1015]","HB CH WELLPOINT","150.69","77.91","","1490.36","627.80","7327.37","1 through 10","85.98","193.42","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","193.42","145.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","114.70","59.3","","536.35","188.54","1772.63","17","96.71","151.74","percent of total billed charges",""
"MESH SYNTHETIC 6.0 XIN ABDOMINAL NON ABSORBABLE SQUARE POLYPROPYLENE BX/6EA","SUP-ITM-10002679","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","193.42","145.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","151.74","78.45","","562.30","246.20","3344.28","1 through 10","96.71","151.74","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2234.46","1675.84","AETNA [1001]","HB CH AETNA HMO / PPO","1302.69","58.3","","585.96","347.85","5016.82","1 through 10","993.22","2234.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2234.46","1675.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1899.29","85","","1295.16","1295.16","1295.16","1 through 10","993.22","2234.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2234.46","1675.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2234.46","100","","2700.00","1008.69","2700.00","1 through 10","993.22","2234.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2234.46","1675.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2234.46","100","","2520.00","797.10","5898.60","1 through 10","993.22","2234.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2234.46","1675.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","993.22","44.45","","1953.42","1953.42","1953.42","1 through 10","993.22","2234.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","both","","","2234.46","1675.84","WELLPOINT [1015]","HB CH WELLPOINT","1740.87","77.91","","1490.36","627.80","7327.37","1 through 10","993.22","2234.46","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2234.46","1675.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","1325.03","59.3","","536.35","188.54","1772.63","17","1117.23","1752.93","percent of total billed charges",""
"MESH SYNTHETIC 6.0X8.0IN ABDOMINAL PARTIALLY ABSORBABLE RECTANGLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/1EA","SUP-ITM-10013733","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2234.46","1675.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1752.93","78.45","","562.30","246.20","3344.28","1 through 10","1117.23","1752.93","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.43","542.57","AETNA [1001]","HB CH AETNA HMO / PPO","421.76","58.3","","585.96","347.85","5016.82","1 through 10","321.56","723.43","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.43","542.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","614.92","85","","1295.16","1295.16","1295.16","1 through 10","321.56","723.43","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.43","542.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","723.43","100","","2700.00","1008.69","2700.00","1 through 10","321.56","723.43","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.43","542.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","723.43","100","","2520.00","797.10","5898.60","1 through 10","321.56","723.43","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.43","542.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.56","44.45","","1953.42","1953.42","1953.42","1 through 10","321.56","723.43","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.43","542.57","WELLPOINT [1015]","HB CH WELLPOINT","563.62","77.91","","1490.36","627.80","7327.37","1 through 10","321.56","723.43","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","723.43","542.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","428.99","59.3","","536.35","188.54","1772.63","17","361.72","567.53","percent of total billed charges",""
"MESH SYSTEM 3.0IN MD HERNIA REPAIR ULTRAPRO PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/3EA","SUP-ITM-10065919","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","723.43","542.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.53","78.45","","562.30","246.20","3344.28","1 through 10","361.72","567.53","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","both","","","737.47","553.10","AETNA [1001]","HB CH AETNA HMO / PPO","429.95","58.3","","585.96","347.85","5016.82","1 through 10","327.81","737.47","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","both","","","737.47","553.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","626.85","85","","1295.16","1295.16","1295.16","1 through 10","327.81","737.47","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","both","","","737.47","553.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","737.47","100","","2700.00","1008.69","2700.00","1 through 10","327.81","737.47","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","both","","","737.47","553.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","737.47","100","","2520.00","797.10","5898.60","1 through 10","327.81","737.47","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","both","","","737.47","553.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","327.81","44.45","","1953.42","1953.42","1953.42","1 through 10","327.81","737.47","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","both","","","737.47","553.10","WELLPOINT [1015]","HB CH WELLPOINT","574.56","77.91","","1490.36","627.80","7327.37","1 through 10","327.81","737.47","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","737.47","553.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","437.32","59.3","","536.35","188.54","1772.63","17","368.74","578.55","percent of total billed charges",""
"MESH SYSTEM 4.0IN LG HERNIA REPAIR ULTRAPRO PROLENE PARTIALLY ABSORBABLE ONLAY UNDERLAY CONNECTOR BX/3EA","SUP-ITM-10020125","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","737.47","553.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","578.55","78.45","","562.30","246.20","3344.28","1 through 10","368.74","578.55","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","AETNA [1001]","HB CH AETNA HMO / PPO","651.21","58.3","","585.96","347.85","5016.82","1 through 10","496.51","1117","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","949.45","85","","1295.16","1295.16","1295.16","1 through 10","496.51","1117","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1117.00","100","","2700.00","1008.69","2700.00","1 through 10","496.51","1117","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1117.00","100","","2520.00","797.10","5898.60","1 through 10","496.51","1117","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.51","44.45","","1953.42","1953.42","1953.42","1 through 10","496.51","1117","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","both","","","1117.00","837.75","WELLPOINT [1015]","HB CH WELLPOINT","870.25","77.91","","1490.36","627.80","7327.37","1 through 10","496.51","1117","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1117.00","837.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.38","59.3","","536.35","188.54","1772.63","17","558.5","876.29","percent of total billed charges",""
"Mesh T1","PX-27000119","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1117.00","837.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","876.29","78.45","","562.30","246.20","3344.28","1 through 10","558.5","876.29","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","AETNA [1001]","HB CH AETNA HMO / PPO","1970.67","58.3","","585.96","347.85","5016.82","1 through 10","1502.51","3380.22","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2873.19","85","","1295.16","1295.16","1295.16","1 through 10","1502.51","3380.22","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3380.22","100","","2700.00","1008.69","2700.00","1 through 10","1502.51","3380.22","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3380.22","100","","2520.00","797.10","5898.60","1 through 10","1502.51","3380.22","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1502.51","44.45","","1953.42","1953.42","1953.42","1 through 10","1502.51","3380.22","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","both","","","3380.22","2535.16","WELLPOINT [1015]","HB CH WELLPOINT","2633.53","77.91","","1490.36","627.80","7327.37","1 through 10","1502.51","3380.22","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3380.22","2535.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","2004.47","59.3","","536.35","188.54","1772.63","17","1690.11","2651.78","percent of total billed charges",""
"Mesh T2","PX-27000120","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","3380.22","2535.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2651.78","78.45","","562.30","246.20","3344.28","1 through 10","1690.11","2651.78","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","AETNA [1001]","HB CH AETNA HMO / PPO","2465.45","58.3","","585.96","347.85","5016.82","1 through 10","1879.75","4228.9","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3594.57","85","","1295.16","1295.16","1295.16","1 through 10","1879.75","4228.9","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4228.90","100","","2700.00","1008.69","2700.00","1 through 10","1879.75","4228.9","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4228.90","100","","2520.00","797.10","5898.60","1 through 10","1879.75","4228.9","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1879.75","44.45","","1953.42","1953.42","1953.42","1 through 10","1879.75","4228.9","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","both","","","4228.90","3171.67","WELLPOINT [1015]","HB CH WELLPOINT","3294.74","77.91","","1490.36","627.80","7327.37","1 through 10","1879.75","4228.9","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4228.90","3171.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","2507.74","59.3","","536.35","188.54","1772.63","17","2114.45","3317.57","percent of total billed charges",""
"Mesh T3","PX-27000121","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4228.90","3171.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3317.57","78.45","","562.30","246.20","3344.28","1 through 10","2114.45","3317.57","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.42","542.56","AETNA [1001]","HB CH AETNA HMO / PPO","421.75","58.3","","585.96","347.85","5016.82","1 through 10","321.56","723.42","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.42","542.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","614.91","85","","1295.16","1295.16","1295.16","1 through 10","321.56","723.42","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.42","542.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","723.42","100","","2700.00","1008.69","2700.00","1 through 10","321.56","723.42","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.42","542.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","723.42","100","","2520.00","797.10","5898.60","1 through 10","321.56","723.42","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.42","542.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.56","44.45","","1953.42","1953.42","1953.42","1 through 10","321.56","723.42","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","both","","","723.42","542.56","WELLPOINT [1015]","HB CH WELLPOINT","563.62","77.91","","1490.36","627.80","7327.37","1 through 10","321.56","723.42","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","723.42","542.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","428.99","59.3","","536.35","188.54","1772.63","17","361.71","567.52","percent of total billed charges",""
"MESH ULTRAPRO 4IN LG PROLENE ONLAY UNDERLAY CONNECTOR PARTIALLY ABSORBABLE BX/6EA","SUP-ITM-10024543","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","723.42","542.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.52","78.45","","562.30","246.20","3344.28","1 through 10","361.71","567.52","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","143.00","107.25","AETNA [1001]","HB CH AETNA HMO / PPO","83.37","58.3","","78.81","76.14","78.81","1 through 10","16.6","104.39","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","both","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","63.56","44.45","","62.41","62.41","62.41","1 through 10","16.6","104.39","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.45","81.45","244.35","1 through 10","17.47","112.18","percent of total billed charges",""
"Metanephrines","PX-30000572","CDM","83835","CPT","0301","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.86","63.33","106.86","16","17.47","112.18","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","AETNA [1001]","HB CH AETNA HMO / PPO","1390.46","58.3","","554.95","91.85","1421.75","94","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","2490.03","2490.03","2490.03","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.46","58.3","","750.00","750.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1264.05","53","","1192.50","120.84","4149.90","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2027.25","85","","750.00","75.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2385.00","100","","657.00","121.50","1971.00","14","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2385.00","100","","75.00","75.00","75.00","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2385.00","100","","366.00","144.00","1971.00","45","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","667.50","667.50","667.50","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","123.77","123.77","123.77","1 through 10","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","WELLPOINT [1015]","HB CH WELLPOINT","1858.15","77.91","","483.51","229.32","1316.08","96","1060.13","2385","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.31","59.3","","439.50","225.34","1872.27","197","1192.5","1871.03","percent of total billed charges",""
"METATARSAL PLATE 3.5MM OPENING WEDGE TITANIUM LOW PROFILE RIGHT","SUP-ITM-10027996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","385.32","55.36","1815.62","58","1192.5","1871.03","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","AETNA [1001]","HB CH AETNA HMO / PPO","475.73","58.3","","554.95","91.85","1421.75","94","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","595.68","73","","2490.03","2490.03","2490.03","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","475.73","58.3","","750.00","750.00","750.00","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","432.48","53","","1192.50","120.84","4149.90","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","693.60","85","","750.00","75.00","750.00","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","816.00","100","","657.00","121.50","1971.00","14","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","816.00","100","","75.00","75.00","75.00","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","816.00","100","","366.00","144.00","1971.00","45","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","595.68","73","","667.50","667.50","667.50","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","362.71","44.45","","123.77","123.77","123.77","1 through 10","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","both","","","816.00","612.00","WELLPOINT [1015]","HB CH WELLPOINT","635.75","77.91","","483.51","229.32","1316.08","96","362.71","816","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","816.00","612.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","483.89","59.3","","439.50","225.34","1872.27","197","408","640.15","percent of total billed charges",""
"METATARSAL PLATE SM 5 HOLE TIMAX","SUP-ITM-10051782","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","816.00","612.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","640.15","78.45","","385.32","55.36","1815.62","58","408","640.15","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","AETNA [1001]","HB CH AETNA HMO / PPO","1565.36","58.3","","554.95","91.85","1421.75","94","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","2490.03","2490.03","2490.03","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1565.36","58.3","","750.00","750.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1423.05","53","","1192.50","120.84","4149.90","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2282.25","85","","750.00","75.00","750.00","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2685.00","100","","657.00","121.50","1971.00","14","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2685.00","100","","75.00","75.00","75.00","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2685.00","100","","366.00","144.00","1971.00","45","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1960.05","73","","667.50","667.50","667.50","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1193.48","44.45","","123.77","123.77","123.77","1 through 10","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","483.51","229.32","1316.08","96","1193.48","2685","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","439.50","225.34","1872.27","197","1342.5","2106.38","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED LEFT","SUP-ITM-10116021","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2685.00","2013.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2106.38","78.45","","385.32","55.36","1815.62","58","1342.5","2106.38","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","554.95","91.85","1421.75","94","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2490.03","2490.03","2490.03","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","750.00","750.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","1192.50","120.84","4149.90","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","750.00","75.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","657.00","121.50","1971.00","14","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","75.00","75.00","75.00","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","366.00","144.00","1971.00","45","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","667.50","667.50","667.50","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","123.77","123.77","123.77","1 through 10","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","483.51","229.32","1316.08","96","1066.8","2400","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","439.50","225.34","1872.27","197","1200","1882.8","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE 1.5MM SHORT BONE TITANIUM LOW PROFILE CONTOURED RIGHT AR-8944CR-S","SUP-ITM-10116020","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","385.32","55.36","1815.62","58","1200","1882.8","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","AETNA [1001]","HB CH AETNA HMO / PPO","2186.83","58.3","","554.95","91.85","1421.75","94","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2738.23","73","","2490.03","2490.03","2490.03","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.83","58.3","","750.00","750.00","750.00","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1988.03","53","","1192.50","120.84","4149.90","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3188.35","85","","750.00","75.00","750.00","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3751.00","100","","657.00","121.50","1971.00","14","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3751.00","100","","75.00","75.00","75.00","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3751.00","100","","366.00","144.00","1971.00","45","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2738.23","73","","667.50","667.50","667.50","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1667.32","44.45","","123.77","123.77","123.77","1 through 10","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","both","","","3751.00","2813.25","WELLPOINT [1015]","HB CH WELLPOINT","2922.40","77.91","","483.51","229.32","1316.08","96","1667.32","3751","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.00","2813.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2224.34","59.3","","439.50","225.34","1872.27","197","1875.5","2942.66","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE RT 5DEG LONG","SUP-ITM-10194748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3751.00","2813.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2942.66","78.45","","385.32","55.36","1815.62","58","1875.5","2942.66","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","AETNA [1001]","HB CH AETNA HMO / PPO","780.04","58.3","","554.95","91.85","1421.75","94","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","976.72","73","","2490.03","2490.03","2490.03","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","780.04","58.3","","750.00","750.00","750.00","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","709.12","53","","1192.50","120.84","4149.90","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1137.27","85","","750.00","75.00","750.00","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1337.97","100","","657.00","121.50","1971.00","14","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1337.97","100","","75.00","75.00","75.00","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1337.97","100","","366.00","144.00","1971.00","45","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","976.72","73","","667.50","667.50","667.50","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","594.73","44.45","","123.77","123.77","123.77","1 through 10","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","both","","","1337.97","1003.48","WELLPOINT [1015]","HB CH WELLPOINT","1042.41","77.91","","483.51","229.32","1316.08","96","594.73","1337.97","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.97","1003.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","793.42","59.3","","439.50","225.34","1872.27","197","668.99","1049.64","percent of total billed charges",""
"METATARSOPHALANGEAL PLATE SM FUSION A.L.P.S.","SUP-ITM-10117382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1337.97","1003.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1049.64","78.45","","385.32","55.36","1815.62","58","668.99","1049.64","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","554.95","91.85","1421.75","94","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","2490.03","2490.03","2490.03","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","248.36","58.3","","750.00","750.00","750.00","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","225.78","53","","1192.50","120.84","4149.90","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","362.10","85","","750.00","75.00","750.00","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","426.00","100","","657.00","121.50","1971.00","14","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","426.00","100","","75.00","75.00","75.00","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.00","100","","366.00","144.00","1971.00","45","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","667.50","667.50","667.50","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.36","44.45","","123.77","123.77","123.77","1 through 10","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","both","","","426.00","319.50","WELLPOINT [1015]","HB CH WELLPOINT","331.90","77.91","","483.51","229.32","1316.08","96","189.36","426","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","439.50","225.34","1872.27","197","213","334.2","percent of total billed charges",""
"METATARSOPHALANGEAL POST WRIST MINI HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017511","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","385.32","55.36","1815.62","58","213","334.2","percent of total billed charges",""
"Methylene Blue Injection Non-Sentinel","PX-76002682","CDM","38999","CPT","0761","RC","","","","outpatient","","","520.00","390.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","255.16","49.07","","12132.25","11259.00","12132.25","1 through 10","255.16","970.06","percent of total billed charges",""
"Methylene Blue Injection Non-Sentinel","PX-76002682","CDM","38999","CPT","0761","RC","","","","outpatient","","","520.00","390.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","260.52","50.1","","10684.50","310.07","10684.50","1 through 10","255.16","970.06","percent of total billed charges",""
"Methylprednisolone 40 Mg Inj","PX-63601023","CDM","J1030","HCPCS","0636","RC","","","","both","","","23.81","17.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","23.81","100","","14.70","14.70","14.70","1 through 10","8.33","23.81","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.14","78.11","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","9.6","83.94","percent of total billed charges",""
"Mgh Antb Protozoa Nes","PX-30002182","CDM","86753","CPT","0301","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","47.38","47.38","47.38","1 through 10","9.6","83.94","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Mgh Anti Glomerular Bsmnt Mem83520","PX-30002031","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Mgh Hydroxychloroquine","PX-30002116","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","18.62","121.6","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Mgh Mannose Binding Protein","PX-30002060","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","both","","","99.00","74.25","AETNA [1001]","HB CH AETNA HMO / PPO","57.72","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Mgh Methotrexate","PX-30001533","CDM","80299","CPT","0301","RC","","","","outpatient","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.67","78.45","","165.29","165.29","165.29","1 through 10","14.12","86.37","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","both","","","136.00","102.00","AETNA [1001]","HB CH AETNA HMO / PPO","79.29","58.3","","121.91","121.91","121.91","1 through 10","18.27","99.28","percent of total billed charges",""
"Mgh Methotrexate 80299","PX-30001570","CDM","80299","CPT","0301","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","165.29","165.29","165.29","1 through 10","14.12","106.69","percent of total billed charges",""
"Mgh Total Iodine","PX-30002110","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","18.62","121.6","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","49","5.66","37.91","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.45","44.45","","34.60","34.60","34.60","1 through 10","5.66","37.91","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","both","","","46.00","34.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","20.45","44.45","","20.50","20.50","20.50","1 through 10","5.66","37.91","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","26.37","45","5.57","36.09","percent of total billed charges",""
"Microalbumin Qn Urine","PX-30000283","CDM","82043","CPT","0301","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","20.50","34.60","28","5.57","36.09","percent of total billed charges",""
"Microbiology Unlstd Proc","PX-30001367","CDM","87999","CPT","0306","RC","","","","both","","","131.00","98.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","83.05","63.4","","84.20","84.20","84.20","1 through 10","56.2","131","percent of total billed charges",""
"Microbiology Unlstd Proc","PX-30001432","CDM","87999","CPT","0306","RC","","","","both","","","4640.00","3480.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2941.76","63.4","","84.20","84.20","84.20","1 through 10","1990.56","4640","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0300","RC","","","","inpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.01","70.6","","89.18","89.18","89.18","1 through 10","66.64","84.01","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","both","","","119.00","89.25","AETNA [1001]","HB CH AETNA HMO / PPO","69.38","58.3","","65.77","65.77","65.77","1 through 10","14.26","86.87","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","119.00","89.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.57","59.3","","67.98","58.00","67.98","1 through 10","15.01","93.36","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","119.00","89.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","85.69","85.69","85.69","1 through 10","15.01","93.36","percent of total billed charges",""
"Microsomal Antibody","PX-30000856","CDM","86376","CPT","0302","RC","","","","outpatient","","","119.00","89.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.36","78.45","","52.85","52.85","89.18","1 through 10","15.01","93.36","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","AETNA [1001]","HB CH AETNA HMO / PPO","868.31","58.3","","554.95","91.85","1421.75","94","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1087.25","73","","2490.03","2490.03","2490.03","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","868.31","58.3","","750.00","750.00","750.00","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","789.37","53","","1192.50","120.84","4149.90","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1265.97","85","","750.00","75.00","750.00","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1489.38","100","","657.00","121.50","1971.00","14","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1489.38","100","","75.00","75.00","75.00","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1489.38","100","","366.00","144.00","1971.00","45","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1087.25","73","","667.50","667.50","667.50","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","662.03","44.45","","123.77","123.77","123.77","1 through 10","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","both","","","1489.38","1117.03","WELLPOINT [1015]","HB CH WELLPOINT","1160.38","77.91","","483.51","229.32","1316.08","96","662.03","1489.38","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1489.38","1117.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","883.20","59.3","","439.50","225.34","1872.27","197","744.69","1168.42","percent of total billed charges",""
"MIDFOOT PLATE LG FUSION","SUP-ITM-10100649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1489.38","1117.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1168.42","78.45","","385.32","55.36","1815.62","58","744.69","1168.42","percent of total billed charges",""
"Migraine And Other Headaches,MAJOR","054","DRG","","","","","","","","inpatient","","","21665.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21206.77","","Standard inlier is a Case rate ($21,206.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,900, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,010.21) for the length of stay and the standard reimbursement.","20242.82","20242.82","20242.82","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MAJOR","054","DRG","","","","","","","","inpatient","","","21665.23","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8671.70","","Case rate ($9,588.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,018.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9585.70","9585.70","9585.70","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","26243.70","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","13993.89","","Standard inlier is a Case rate ($13,993.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,013, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,986.37) for the length of stay and the standard reimbursement.","13993.88","13993.88","13993.88","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","26243.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7514.29","","Fee schedule rate ($7,514.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6335.67","6335.67","6335.67","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MINOR","054","DRG","","","","","","","","inpatient","","","26243.70","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4391.25","","Case rate ($4,855.29). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,285.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4854.10","4854.10","4854.10","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","30168.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17038.10","","Standard inlier is a Case rate ($17,038.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,418.49) for the length of stay and the standard reimbursement.","17038.09","17038.09","17038.09","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","30168.44","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8788.0374","","Fee schedule rate ($15,037.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8788.0374","11154.58","11154.58","1 through 10","4391.25","24811.76","case rate",""
"Migraine And Other Headaches,MODERATE","054","DRG","","","","","","","","inpatient","","","30168.44","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6038.55","","Case rate ($6,676.65). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,106.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6675.01","6675.01","6675.01","1 through 10","4391.25","24811.76","case rate",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","AETNA [1001]","HB CH AETNA HMO / PPO","393.53","58.3","","554.95","91.85","1421.75","94","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","2490.03","2490.03","2490.03","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","393.53","58.3","","750.00","750.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","357.75","53","","1192.50","120.84","4149.90","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","573.75","85","","750.00","75.00","750.00","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","675.00","100","","657.00","121.50","1971.00","14","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","675.00","100","","75.00","75.00","75.00","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","675.00","100","","366.00","144.00","1971.00","45","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","492.75","73","","667.50","667.50","667.50","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","300.04","44.45","","123.77","123.77","123.77","1 through 10","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","both","","","675.00","506.25","WELLPOINT [1015]","HB CH WELLPOINT","525.89","77.91","","483.51","229.32","1316.08","96","300.04","675","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","400.28","59.3","","439.50","225.34","1872.27","197","337.5","529.54","percent of total billed charges",""
"MINI BIO ANCHOR AR-1322BNF BX/5EA","SUP-ITM-10016032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","675.00","506.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","529.54","78.45","","385.32","55.36","1815.62","58","337.5","529.54","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.00","263.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","186.03","53","","262.35","194.30","262.35","1 through 10","156.02","351","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","both","","","351.00","263.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","351.00","100","","173.25","165.00","173.25","1 through 10","156.02","351","percent of total billed charges",""
"MINNI EV2 .035 135CM BX/5EA","SUP-ITM-10328981","CDM","C1887","HCPCS","0272","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","275.36","78.45","","513.75","29.41","761.11","1 through 10","175.5","275.36","percent of total billed charges",""
"Minor Bladder Procedures Without Cc/McC","664","MS-DRG","","","","","","","","inpatient","","","56587.38","42440.53","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10277.91","","Case rate ($9,978.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,994.25, add-ons for qualifying new technology services are included. If operating cost exceeds $55,517.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,300.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $8,899.18 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,655.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.12. The transfer capital threshold is the transfer adjustment factor * $740.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","10347.96","10347.96","10347.96","1 through 10","9778.98","10900.15","other","Inpatient DRG"
"Minor Bladder Procedures Without Cc/McC","664","MS-DRG","","","","","","","","inpatient","","","56587.38","42440.53","MEDICARE [2001]","HB BWF MEDICARE","10900.15","","Case rate ($10,900.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,994.25, add-ons for qualifying new technology services are included. If operating cost exceeds $55,517.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,300.90, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $9,820.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,655.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $740.12. The transfer capital threshold is the transfer adjustment factor * $740.12. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10988.11","10988.11","10988.11","1 through 10","9778.98","10900.15","other","Inpatient DRG"
"Minor Skin Disorders With McC","606","MS-DRG","","","","","","","","inpatient","","","28346.23","21259.67","MEDICARE [2001]","HB BWF MEDICARE","14271.96","","Case rate ($14,271.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,294.68, add-ons for qualifying new technology services are included. If operating cost exceeds $59,818.41 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,630.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $12,862.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,955.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,069.77. The transfer capital threshold is the transfer adjustment factor * $1,069.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16155.16","16155.16","16263.14","1 through 10","13986.52","15533","other","Inpatient Replacement Plans DRG"
"Minor Skin Disorders Without McC","607","MS-DRG","","","","","","","","inpatient","","","26667.72","20000.79","MEDICARE [2001]","HB BWF MEDICARE","8684.89","","Case rate ($8,684.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,698.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,222.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,201.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,704.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,359.25 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $640.79. The transfer capital threshold is the transfer adjustment factor * $640.79. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8786.37","8786.37","8844.31","1 through 10","8511.19","8945.44","other","Inpatient Replacement Plans DRG"
"Minor Small And Large Bowel Procedures With Cc","345","MS-DRG","","","","","","","","inpatient","","","16026.95","12020.21","MEDICARE [2001]","HB BWF MEDICARE","14193.72","","Case rate ($14,193.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,216.30, add-ons for qualifying new technology services are included. If operating cost exceeds $59,740.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,624.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,790.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,877.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,063.76. The transfer capital threshold is the transfer adjustment factor * $1,063.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7652.59","7652.59","7652.59","1 through 10","13909.85","14721.7543","other","Inpatient Replacement Plans DRG"
"Minor Small And Large Bowel Procedures With McC","344","MS-DRG","","","","","","","","inpatient","","","39387.44","29540.58","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","24120.28","","Case rate ($24,120.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,159.04, add-ons for qualifying new technology services are included. If operating cost exceeds $69,682.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,386.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $21,955.11 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,819.80 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,825.94. The transfer capital threshold is the transfer adjustment factor * $1,825.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","24410.27","24410.27","24410.27","1 through 10","23637.87","26512.44","other","Inpatient Replacement Plans DRG"
"Minor Small And Large Bowel Procedures With McC","344","MS-DRG","","","","","","","","inpatient","","","39387.44","29540.58","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","23637.87","","Case rate ($24,120.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,159.04, add-ons for qualifying new technology services are included. If operating cost exceeds $69,682.77 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,386.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.9. The base transfer operating payment is the transfer adjustment factor * $21,955.11 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,819.80 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,825.94. The transfer capital threshold is the transfer adjustment factor * $1,825.94. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","24297.02","24297.02","24297.02","1 through 10","23637.87","26512.44","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Age >17 Without McC","641","TRIS-DRG","","","","","","","","inpatient","","","10955.69","","TRICARE [160005]","HB BWF TRICARE","5037.31","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($6,958.80). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $3,163.09, and the first day is paid a rate of $6,326.18. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $3,163.09, and the first day is paid a rate of $6,326.18. The transfer payment is capped at $6,368.44. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $50,780.24 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.20000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,970.57), capped at $6,368.44. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $3,163.09, and the first day is paid a rate of $6,326.18. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $3,163.09, and the first day is paid a rate of $6,326.18. The transfer payment is capped at $6,368.44. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $50,780.24 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.20000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","5691.50","5691.50","5691.50","1 through 10","5037.31","5037.31","other","Inpatient DRGs"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","35141.25","26355.94","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13015.83","","Case rate ($12,636.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,656.78, add-ons for qualifying new technology services are included. If operating cost exceeds $58,180.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,505.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,353.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,317.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.22. The transfer capital threshold is the transfer adjustment factor * $944.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","12692.49","12692.49","12692.49","1 through 10","12384","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","35141.25","26355.94","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","12636.73","","Case rate ($12,636.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,656.78, add-ons for qualifying new technology services are included. If operating cost exceeds $58,180.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,505.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,353.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,317.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.22. The transfer capital threshold is the transfer adjustment factor * $944.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12156.63","12156.63","12156.63","1 through 10","12384","13709.93","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","35141.25","26355.94","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","12636.73","","Case rate ($12,636.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,656.78, add-ons for qualifying new technology services are included. If operating cost exceeds $58,180.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,505.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,353.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,317.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.22. The transfer capital threshold is the transfer adjustment factor * $944.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","5208.59","5208.59","5208.59","1 through 10","12384","13709.93","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","35141.25","26355.94","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12384.00","","Case rate ($12,636.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,656.78, add-ons for qualifying new technology services are included. If operating cost exceeds $58,180.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,505.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,353.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,317.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.22. The transfer capital threshold is the transfer adjustment factor * $944.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12088.08","12088.08","12147.35","1 through 10","12384","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","35141.25","26355.94","MEDICARE [2001]","HB BWF MEDICARE","12636.73","","Case rate ($12,636.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,656.78, add-ons for qualifying new technology services are included. If operating cost exceeds $58,180.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,505.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,353.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,317.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.22. The transfer capital threshold is the transfer adjustment factor * $944.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13367.05","0.03","13456.11","49","12384","13709.93","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC","640","MS-DRG","","","","","","","","inpatient","","","35141.25","26355.94","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","12384.00","","Case rate ($12,636.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,656.78, add-ons for qualifying new technology services are included. If operating cost exceeds $58,180.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,505.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $11,353.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,317.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $944.22. The transfer capital threshold is the transfer adjustment factor * $944.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12054.69","12054.69","12054.69","1 through 10","12384","13709.93","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7729.62","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7598.37","7598.37","7598.37","1 through 10","7354.4","7729.62","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7504.49","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7892.64","7892.64","7892.64","1 through 10","7354.4","7729.62","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7354.40","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7227.84","7227.84","7227.84","1 through 10","7354.4","7729.62","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","HUMANA [1012]","HB BWF MEDICARE","7504.49","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21270.48","21270.48","21270.48","1 through 10","7354.4","7729.62","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","MEDICARE [2001]","HB BWF MEDICARE","7504.49","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7968.60","0.03","8020.98","39","7354.4","7729.62","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","7504.49","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7215.32","7215.32","7215.32","1 through 10","7354.4","7729.62","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","MOLINA [1014]","HB BWF MEDICARE","7504.49","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11295.48","11295.48","11295.48","1 through 10","7354.4","7729.62","other","Inpatient Replacement Plans DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7354.40","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7209.52","7205.32","12088.09","1 through 10","7354.4","7729.62","other","Inpatient DRG"
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC","641","MS-DRG","","","","","","","","inpatient","","","21964.77","16473.58","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7354.40","","Case rate ($7,504.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,516.17, add-ons for qualifying new technology services are included. If operating cost exceeds $53,039.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,110.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $6,615.09 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,176.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $550.16. The transfer capital threshold is the transfer adjustment factor * $550.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7245.58","7213.98","8173.91","1 through 10","7354.4","7729.62","other","Inpatient DRG"
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","AETNA [1001]","HB CH AETNA HMO / PPO","123.60","58.3","","113.36","113.36","113.36","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","both","","","212.00","159.00","WELLPOINT [1015]","HB CH WELLPOINT","165.17","77.91","","162.25","162.25","162.25","1 through 10","24.94","201.61","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.72","59.3","","362.16","120.72","362.16","1 through 10","63.83","166.31","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","122.32","57.7","","124.22","124.22","124.22","1 through 10","63.83","166.31","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","128.26","60.5","","136.58","136.58","136.58","1 through 10","63.83","166.31","percent of total billed charges",""
"Mitochondrial Antibody Each","PX-30003772","CDM","86381","CPT","0302","RC","","","","outpatient","","","212.00","159.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","166.31","78.45","","158.37","93.85","158.37","1 through 10","63.83","166.31","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Endo Service Initial 15 Mins >5yrs","PX-37000034","CDM","G0500","HCPCS","0370","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","25.37","25.37","38","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","54","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","18.02","53","","34.98","34.98","52.47","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","28.90","85","","21.44","21.44","21.44","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","34.00","100","","20.81","20.81","20.81","12","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","34.00","100","","27.55","27.55","27.55","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","both","","","34.00","25.50","WELLPOINT [1015]","HB CH WELLPOINT","26.49","77.91","","25.99","25.99","58.99","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.34","19.34","57","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Each Addl 15 Mins","PX-37000028","CDM","99153","CPT","0370","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","25.37","25.37","36","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","AETNA [1001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","11","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","19.82","58.3","","18.71","18.71","18.71","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","18.02","53","","17.49","17.49","17.49","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","28.90","85","","22.32","22.32","22.32","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","34.00","100","","21.67","21.67","21.67","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","34.00","100","","28.69","28.69","28.69","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","both","","","34.00","25.50","WELLPOINT [1015]","HB CH WELLPOINT","26.49","77.91","","25.99","25.99","58.99","1 through 10","15.11","34","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","34.00","25.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.16","59.3","","19.34","19.32","19.34","1 through 10","17","26.67","percent of total billed charges",""
"Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs","PX-37000027","CDM","99152","CPT","0370","RC","","","","outpatient","","","34.00","25.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","26.67","78.45","","25.37","25.37","38.37","1 through 10","17","26.67","percent of total billed charges",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","75663.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","103655.89","","Standard inlier is a Case rate ($103,655.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $110,641, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($14,713.52) for the length of stay and the standard reimbursement.","98944.25","98944.25","98944.25","1 through 10","14753.66","222741.55","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,EXTREME","951","DRG","","","","","","","","inpatient","","","75663.50","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","1938.74","105439.36","105439.36","1 through 10","14753.66","222741.55","percent of total billed charges",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","57291.44","","MASSHEALTH [3001]","HB BWF MEDICAID","24721.94","","Case rate ($27,334.36). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $69,764.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27327.65","27327.65","27327.65","1 through 10","14753.66","222741.55","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MAJOR","951","DRG","","","","","","","","inpatient","","","57291.44","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","24721.94","","Case rate ($27,334.36). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $69,764.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27327.65","27327.65","27327.65","1 through 10","14753.66","222741.55","case rate",""
"Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","951","DRG","","","","","","","","inpatient","","","26767.87","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","14753.66","","Case rate ($16,312.70). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,742.70, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4713.51","4713.51","4713.51","1 through 10","14753.66","222741.55","case rate",""
"Moderately Extensive O.R. Procedures For Other Complications Of Treatment,MINOR","793","DRG","","","","","","","","inpatient","","","40607.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25609.82","","Standard inlier is a Case rate ($25,609.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,107, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,635.21) for the length of stay and the standard reimbursement.","25609.82","25609.82","25609.82","1 through 10","9255.29","50337.44","case rate",""
"Molecular Path Procedure Level 4","PX-31000005","CDM","81403","CPT","0310","RC","","","","outpatient","","","1294.00","970.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1015.14","78.45","","562.39","562.39","562.39","1 through 10","575.18","1015.14","percent of total billed charges",""
"Molecular Path Procedure Level 8","PX-31000009","CDM","81407","CPT","0310","RC","","","","both","","","1739.00","1304.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","921.67","53","","1792.46","1792.46","1792.46","1 through 10","746.03","4493.69","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","both","","","104.00","78.00","AETNA [1001]","HB CH AETNA HMO / PPO","60.63","58.3","","57.27","57.27","57.27","1 through 10","26.24","157.97","percent of total billed charges",""
"Mononuclear Cell Antigen Qn","PX-30000850","CDM","86356","CPT","0302","RC","","","","outpatient","","","104.00","78.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","81.59","78.45","","77.65","77.65","77.65","1 through 10","11.33","100.56","percent of total billed charges",""
"Morcellator T1","PX-27000122","CDM","C1782","HCPCS","0272","RC","","","","outpatient","","","1181.25","885.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","700.48","59.3","","1002.06","1002.06","1002.06","1 through 10","525.07","926.69","percent of total billed charges",""
"Morpho Analysis Insitu Hybrid Man","PX-31000055","CDM","88368","CPT","0310","RC","","","","both","","","878.00","658.50","WELLPOINT [1015]","HB CH WELLPOINT","684.05","77.91","","2380.61","2380.61","2380.61","1 through 10","405.83","1456.11","percent of total billed charges",""
"Morpho Analysis Insitu Hybrid Man","PX-31000055","CDM","88368","CPT","0310","RC","","","","outpatient","","","878.00","658.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","688.79","78.45","","656.56","656.56","656.56","1 through 10","324.26","926.86","percent of total billed charges",""
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","4875.00","3656.25","HUMANA [1012]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1002.40","1002.40","1002.40","1 through 10","385.88","4875","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","4875.00","3656.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1015.16","1 through 10","385.88","4875","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","both","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","414.64","414.64","414.64","1 through 10","385.88","4875","other","OPPS APC"
"Mra Abdomen W&W/O Cont","PX-61000123","CDM","C8902","HCPCS","0618","RC","","","","outpatient","","","4875.00","3656.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1732.58","35.54","","1650.94","1650.94","1650.94","1 through 10","385.88","1881.54","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","956.16","956.16","956.16","1 through 10","292.92","4051","other","Multiple Radiology"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3443.35","85","","773.62","773.62","773.62","1 through 10","292.92","4051","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","both","","","4051.00","3038.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4051.00","100","","909.89","909.89","909.89","1 through 10","292.92","4051","percent of total billed charges",""
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1459.45","","Case rate ($1,459.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1459.45","1221.26","1459.45","1 through 10","385.88","2025.5","other","Multiple Imaging"
"Mra Abdomen W/WO Contrast Material","PX-61000127","CDM","74185","CPT","0610","RC","","","","outpatient","","","4051.00","3038.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1459.45","","Case rate ($1,459.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1221.26","1221.26","1459.45","1 through 10","385.88","2025.5","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","225.91","2985.7","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","282.47","282.47","1 through 10","225.91","2985.7","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","641.60","287.06","1015.16","1 through 10","225.91","2985.7","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","573.02","573.02","573.02","1 through 10","225.91","2985.7","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","626.21","626.21","626.21","1 through 10","225.91","2985.7","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","both","","","4090.00","3067.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","281.32","286.32","1 through 10","225.91","2985.7","other","OPPS APC"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2254.96","2254.96","2254.96","1 through 10","230.56","2045","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","2045","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","292.00","697.91","1 through 10","230.56","2045","other","Multiple Imaging"
"Mra Head W/O Cont","PX-61000081","CDM","70544","CPT","0615","RC","","","","outpatient","","","4090.00","3067.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","262.84","262.84","525.68","1 through 10","230.56","2045","other","Multiple Radiology"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","6176.00","4632.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.19","937.19","937.19","1 through 10","385.88","4508.48","other","OPPS APC"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","both","","","6176.00","4632.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4508.48","73","","580.72","580.72","580.72","1 through 10","385.88","4508.48","percent of total billed charges",""
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","977.44","977.44","1 through 10","385.88","3088","other","Multiple Imaging"
"Mra Neck W&W/O Cont","PX-61000086","CDM","70549","CPT","0615","RC","","","","outpatient","","","6176.00","4632.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","3088","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","both","","","4263.00","3197.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","265.02","","Case rate ($265.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","690.56","670.29","690.56","1 through 10","265.02","3111.99","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2350.22","2350.22","2350.22","1 through 10","385.88","2131.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","584.04","584.04","1 through 10","385.88","2131.5","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","488.72","977.44","1 through 10","385.88","2131.5","other","Multiple Imaging"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","422.54","422.54","422.54","1 through 10","385.88","2131.5","other","Multiple Radiology"
"Mra Neck W/Cont","PX-61000085","CDM","70548","CPT","0615","RC","","","","outpatient","","","4263.00","3197.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","461.13","461.13","461.13","1 through 10","385.88","2131.5","other","Multiple Radiology"
"Mra Pelvis W&W/O Contrast","PX-61000109","CDM","C8920","HCPCS","0618","RC","","","","outpatient","","","4974.00","3730.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1767.76","35.54","","1684.73","1684.73","1684.73","1 through 10","385.88","2487","percent of total billed charges",""
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","5434.00","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","413.01","417.32","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","ELDER SERVICES [1037]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","411.34","411.34","411.34","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","958.55","464.99","968.56","1 through 10","385.88","4079.24","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","HUMANA [1012]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","419.02","419.02","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","195","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","414.54","414.34","418.63","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","720.87","720.87","720.87","1 through 10","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","847.84","823.26","847.84","14","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","2594.43","890.85","2594.43","1 through 10","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","926.54","926.54","926.54","38","385.88","4079.24","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","MOLINA [1014]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","841.43","832.74","841.43","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","414.14","417.13","1 through 10","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","both","","","5588.00","4191.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","415.63","420.63","60","385.88","4079.24","other","OPPS APC"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3081.08","3081.08","3081.08","1 through 10","385.88","2794","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","488.72","1168.07","59","385.88","2794","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","584.03","1168.07","95","385.88","2794","other","Multiple Imaging"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","30","385.88","2794","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","443.76","922.26","1 through 10","385.88","2794","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","2794","other","Multiple Radiology"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3081.08","3081.08","3081.08","1 through 10","385.88","2794","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Abdomen W&W/O Cont","PX-61000067","CDM","74183","CPT","0614","RC","","","","outpatient","","","5588.00","4191.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1985.98","35.54","","1892.66","1892.66","2475.73","19","385.88","2794","percent of total billed charges",""
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","14","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","both","","","3532.00","2649.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","281.32","281.32","1 through 10","230.56","2578.36","other","OPPS APC"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","1766","other","Multiple Imaging"
"MRI Abdomen W/O Cont","PX-61000065","CDM","74181","CPT","0614","RC","","","","outpatient","","","3532.00","2649.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","1766","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","998.92","17","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","417.32","998.92","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","ELDER SERVICES [1037]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","1099.76","1099.76","1099.76","1 through 10","385.88","4006.24","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","959.77","1099.76","1 through 10","385.88","4006.24","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","HUMANA [1012]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","225","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","415.63","418.83","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","648.20","648.20","648.20","1 through 10","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","762.38","762.38","1535.44","15","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","801.05","801.05","801.05","1 through 10","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","833.14","808.68","833.14","46","385.88","4006.24","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4006.24","73","","3025.51","3025.51","3025.51","1 through 10","385.88","4006.24","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","TRICARE [160005]","HB BWF TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","964.40","1 through 10","385.88","4006.24","other","Tricare OPPS"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","414.14","998.92","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","424.11","424.11","424.11","1 through 10","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1950.44","35.54","","1858.53","1858.53","2395.86","1 through 10","385.88","4006.24","percent of total billed charges",""
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","both","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","413.01","994.86","64","385.88","4006.24","other","OPPS APC"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3025.51","3025.51","3025.51","1 through 10","385.88","2744","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","60","385.88","2744","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","128","385.88","2744","other","Multiple Imaging"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","845.08","879.81","41","385.88","2744","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","2766.75","14","385.88","2744","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","2744","other","Multiple Radiology"
"MRI Brain W&W/O Cont","PX-61000018","CDM","70553","CPT","0611","RC","","","","outpatient","","","5488.00","4116.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1950.44","35.54","","1858.53","1562.51","2431.08","15","385.88","2744","percent of total billed charges",""
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","both","","","4620.00","3465.00","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","848.22","424.11","1015.16","1 through 10","385.88","3372.6","other","OPPS APC"
"MRI Brain W/Cont","PX-61000017","CDM","70552","CPT","0611","RC","","","","outpatient","","","4620.00","3465.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","2310","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","631.33","1 through 10","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","225.91","3075.49","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","3075.49","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","113","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","284.32","284.52","1 through 10","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","389.26","389.26","389.26","1 through 10","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","457.83","457.83","457.83","1 through 10","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","481.05","481.05","481.05","1 through 10","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","500.32","500.32","500.32","11","225.91","3075.49","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","MOLINA [1014]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","630.27","281.32","630.27","1 through 10","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","both","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","265.40","286.32","30","225.91","3075.49","other","OPPS APC"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","697.91","23","230.56","2106.5","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","697.91","44","230.56","2106.5","other","Multiple Imaging"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","13","230.56","2106.5","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","657.10","1 through 10","230.56","2106.5","other","Multiple Radiology"
"MRI Brain W/O Cont","PX-61000016","CDM","70551","CPT","0611","RC","","","","outpatient","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1497.30","35.54","","1426.99","1426.99","1866.59","1 through 10","230.56","2106.5","percent of total billed charges",""
"MRI Brain W/O Cont|REDUCED SERVICES","PX-61000016","CDM","70551","CPT","0611","RC","","","52","both","","","4213.00","3159.75","MEDICARE [2001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","295.64","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","24","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","418.83","418.83","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","TRICARE [160005]","HB BWF TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","385.88","6110.48","other","Tricare OPPS"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","411.34","420.63","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","","both","","","7843.00","5882.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","418.63","424.11","1 through 10","385.88","6110.48","other","OPPS APC"
"MRI Breast Bilat W&W/O Cont|REDUCED SERVICES","PX-61000124","CDM","C8908","HCPCS","0614","RC","","","52","both","","","7843.00","5882.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","212.06","212.06","212.06","1 through 10","402.91","436.84","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","AETNA [1001]","HB CH AETNA HMO / PPO","2743.02","58.3","","2594.03","2594.03","2594.03","1 through 10","230.56","3665.67","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","230.56","3665.67","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","230.56","3665.67","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","657.10","578.71","657.10","1 through 10","230.56","3665.67","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","267.44","287.06","1 through 10","230.56","3665.67","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.52","281.52","281.52","1 through 10","230.56","3665.67","other","OPPS APC"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","both","","","4705.00","3528.75","WELLPOINT [1015]","HB CH WELLPOINT","3665.67","77.91","","3603.27","3603.27","3603.27","1 through 10","230.56","3665.67","percent of total billed charges",""
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","2352.5","other","Multiple Imaging"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","697.91","11","230.56","2352.5","other","Multiple Imaging"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","2352.5","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont","PX-61000076","CDM","77047","CPT","0614","RC","","","","outpatient","","","4705.00","3528.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","631.73","551.04","631.73","1 through 10","230.56","2352.5","other","Multiple Radiology"
"MRI Breast Bilat W/O Cont|REDUCED SERVICES","PX-61000076","CDM","77047","CPT","0614","RC","","","52","both","","","4705.00","3528.75","MEDICARE [2001]","HB BWF MEDICARE","287.03","","APC Price ($287.03). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","143.53","143.53","143.53","1 through 10","272.7","1476.43","other","OPPS APC"
"MRI Breast Unilat W/O Cont","PX-61000079","CDM","77046","CPT","0614","RC","","","","both","","","4688.00","3516.00","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","230.56","3652.42","other","OPPS APC"
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","outpatient","","","2013.00","1509.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","3226.45","other","Multiple Radiology"
"MRI Breast W/Out&With Contrast W/Cad Unilateral","PX-61000158","CDM","77048","CPT","0610","RC","","","","outpatient","","","2013.00","1509.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","3226.45","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","AETNA [1001]","HB CH AETNA HMO / PPO","1167.75","58.3","","4418.63","4418.63","4418.63","1 through 10","271.02","1902.85","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","929.97","968.56","1 through 10","271.02","1902.85","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","both","","","2003.00","1502.25","WELLPOINT [1015]","HB CH WELLPOINT","1560.54","77.91","","6137.77","6137.77","6137.77","1 through 10","271.02","1902.85","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1381.26","","Case rate ($1,381.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1381.26","1155.83","1381.26","36","385.88","4377.06","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","1381.26","","Case rate ($1,381.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1381.26","1155.83","1381.26","1 through 10","385.88","4377.06","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1381.26","","Case rate ($1,381.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1381.26","1155.83","1381.26","53","385.88","4377.06","other","Multiple Imaging"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","4399.05","24","385.88","4377.06","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","922.25","922.25","1 through 10","385.88","4377.06","other","Multiple Radiology"
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","628.54","31.38","","3499.06","3499.06","3499.06","1 through 10","385.88","4377.06","percent of total billed charges",""
"MRI Breast Without&With Contrast W/Cad Bilateral","PX-61000159","CDM","77049","CPT","0610","RC","","","","outpatient","","","2003.00","1502.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.87","35.54","","2714.30","2714.30","3550.49","1 through 10","385.88","4377.06","percent of total billed charges",""
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","998.92","998.92","1 through 10","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","419.73","1015.16","16","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","767.01","767.01","767.01","1 through 10","385.88","3949.3","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","838.21","838.21","1130.16","1 through 10","385.88","3949.3","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","MOLINA [1014]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2014.08","1015.16","2014.08","1 through 10","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","both","","","5410.00","4057.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","411.34","994.86","1 through 10","385.88","3949.3","other","OPPS APC"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","584.04","1168.07","1 through 10","385.88","2705","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","584.04","1168.07","11","385.88","2705","other","Multiple Imaging"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","439.90","439.90","879.81","1 through 10","385.88","2705","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","461.13","461.13","922.25","1 through 10","385.88","2705","other","Multiple Radiology"
"MRI C-Spine W&W/O Cont","PX-61000030","CDM","72156","CPT","0612","RC","","","","outpatient","","","5410.00","4057.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1922.71","35.54","","2396.91","1832.41","2396.91","1 through 10","385.88","2705","percent of total billed charges",""
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","both","","","4662.00","3496.50","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","3403.26","other","OPPS APC"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","both","","","4662.00","3496.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","995.06","995.06","995.06","1 through 10","385.88","3403.26","other","OPPS APC"
"MRI C-Spine W/Cont","PX-61000025","CDM","72142","CPT","0612","RC","","","","outpatient","","","4662.00","3496.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","1168.07","1168.07","1 through 10","385.88","2331","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","631.33","1 through 10","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","282.47","282.47","1 through 10","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","328.55","328.55","328.55","1 through 10","225.91","2737.5","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","555.65","578.71","1 through 10","225.91","2737.5","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","866.19","84","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","284.52","631.77","1 through 10","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","372.58","372.58","372.58","1 through 10","225.91","2737.5","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","438.21","438.21","438.21","1 through 10","225.91","2737.5","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","478.88","464.82","478.88","16","225.91","2737.5","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","282.47","282.47","1 through 10","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","263.16","633.77","30","225.91","2737.5","other","OPPS APC"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","27","230.56","1875","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","348.96","697.91","49","230.56","1875","other","Multiple Imaging"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","262.84","525.68","16","230.56","1875","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","495.94","578.71","1 through 10","230.56","1875","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","275.52","275.52","275.52","1 through 10","230.56","1875","other","Multiple Radiology"
"MRI C-Spine W/O Cont","PX-61000024","CDM","72141","CPT","0612","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1332.75","35.54","","1269.90","1269.90","1661.12","1 through 10","230.56","1875","percent of total billed charges",""
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","4788.07","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1434.75","1434.75","1434.75","1 through 10","385.88","4788.07","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","both","","","6559.00","4919.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.33","415.63","420.63","1 through 10","385.88","4788.07","other","OPPS APC"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","1168.07","1168.07","1 through 10","385.88","3279.5","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","1 through 10","385.88","3279.5","other","Multiple Imaging"
"MRI Chest W&W/O Cont","PX-61000037","CDM","71552","CPT","0614","RC","","","","outpatient","","","6559.00","4919.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","1 through 10","385.88","3279.5","other","Multiple Radiology"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","4735.00","3551.25","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","1 through 10","225.91","3456.55","other","OPPS APC"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","both","","","4735.00","3551.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1056.51","1056.51","1056.51","1 through 10","225.91","3456.55","other","Multiple Imaging"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","4735.00","3551.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","2367.5","other","Multiple Imaging"
"MRI Chest W/O Cont","PX-61000035","CDM","71550","CPT","0614","RC","","","","outpatient","","","4735.00","3551.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","2367.5","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","998.92","417.32","998.92","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","968.56","968.56","1 through 10","385.88","3893.09","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1863.38","24","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","650.18","650.18","650.18","1 through 10","385.88","3893.09","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","835.68","835.68","835.68","1 through 10","385.88","3893.09","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","TRICARE [160005]","HB BWF TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","402.90","402.90","402.90","1 through 10","385.88","3893.09","other","Tricare OPPS"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.63","415.63","415.63","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","424.11","424.11","424.11","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","both","","","5333.00","3999.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","415.64","415.63","994.86","1 through 10","385.88","3893.09","other","OPPS APC"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","584.04","1168.07","1 through 10","385.88","2666.5","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","584.04","1168.07","11","385.88","2666.5","other","Multiple Imaging"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","439.90","879.81","1 through 10","385.88","2666.5","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","461.13","461.13","461.13","1 through 10","385.88","2666.5","other","Multiple Radiology"
"MRI L-Spine W&W/O Cont","PX-61000032","CDM","72158","CPT","0612","RC","","","","outpatient","","","5333.00","3999.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1895.35","35.54","","3987.00","2362.74","3987.00","1 through 10","385.88","2666.5","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","11","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","282.47","282.47","1 through 10","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","ELDER SERVICES [1037]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","281.32","281.32","281.32","1 through 10","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","657.10","657.10","657.10","1 through 10","225.91","2717.79","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","555.65","578.71","1 through 10","225.91","2717.79","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","HUMANA [1012]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","283.04","264.23","283.62","1 through 10","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","287.06","239","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.52","284.32","936.58","1 through 10","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","373.57","373.57","373.57","1 through 10","225.91","2717.79","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","439.37","426.63","439.37","11","225.91","2717.79","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","480.15","480.15","480.15","38","225.91","2717.79","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","TRICARE [160005]","HB BWF TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","225.91","2717.79","other","Tricare OPPS"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","282.47","286.32","1 through 10","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1323.15","35.54","","1260.85","1260.85","1260.85","1 through 10","225.91","2717.79","percent of total billed charges",""
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","both","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","265.90","286.32","60","225.91","2717.79","other","OPPS APC"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2052.54","2052.54","2052.54","1 through 10","230.56","1861.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","348.96","697.91","43","230.56","1861.5","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","3620.00","3620.00","3620.00","1 through 10","230.56","1861.5","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","348.96","697.91","73","230.56","1861.5","other","Multiple Imaging"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","1314.20","35","230.56","1861.5","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","275.52","578.71","1 through 10","230.56","1861.5","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","1861.5","other","Multiple Radiology"
"MRI L-Spine W/O Cont","PX-61000028","CDM","72148","CPT","0612","RC","","","","outpatient","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1323.15","35.54","","1649.27","1260.85","3620.00","1 through 10","230.56","1861.5","percent of total billed charges",""
"MRI L-Spine W/O Cont|REDUCED SERVICES","PX-61000028","CDM","72148","CPT","0612","RC","","","52","both","","","3723.00","2792.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","140.66","140.66","140.66","1 through 10","272.7","1168.28","other","OPPS APC"
"MRI Lwr Ext Joint W&W/O Cont","PX-61000064","CDM","73723","CPT","0614","RC","","","","both","","","5207.00","3905.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","415.63","420.63","1 through 10","385.88","3801.11","other","OPPS APC"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","both","","","4049.00","3036.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","2955.77","other","Multiple Radiology"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","both","","","4049.00","3036.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","286.32","281.32","286.32","12","225.91","2955.77","other","OPPS APC"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","4049.00","3036.75","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2232.28","2232.28","2232.28","1 through 10","230.56","2024.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Lwr Ext Joint W/O Cont","PX-61000062","CDM","73721","CPT","0614","RC","","","","outpatient","","","4049.00","3036.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","2024.5","other","Multiple Radiology"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","4543.00","3407.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","424.11","1 through 10","385.88","3316.39","other","OPPS APC"
"MRI Lwr Ext W&W/O Cont","PX-61000061","CDM","73720","CPT","0614","RC","","","","both","","","4543.00","3407.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","416.13","420.63","1 through 10","385.88","3316.39","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4119.00","3089.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","555.65","578.71","1 through 10","225.91","3006.87","other","Multiple Radiology"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","both","","","4119.00","3089.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","591.08","286.32","591.08","1 through 10","225.91","3006.87","other","OPPS APC"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4119.00","3089.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","2059.5","other","Multiple Radiology"
"MRI Lwr Ext W/O Cont","PX-61000055","CDM","73718","CPT","0614","RC","","","","outpatient","","","4119.00","3089.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1463.89","35.54","","1394.94","1394.94","1394.94","1 through 10","230.56","2059.5","percent of total billed charges",""
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","417.32","417.32","417.32","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","417.32","417.32","417.32","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","968.56","968.56","1 through 10","385.88","3149.95","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1015.16","22","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.83","418.83","418.83","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","729.71","729.71","729.71","1 through 10","385.88","3149.95","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","937.91","910.37","937.91","1 through 10","385.88","3149.95","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","both","","","4315.00","3236.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","418.63","999.86","1 through 10","385.88","3149.95","other","OPPS APC"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","584.04","1168.07","1 through 10","385.88","2157.5","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","636.17","1168.07","1 through 10","385.88","2157.5","other","Multiple Imaging"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","2157.5","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","929.97","922.25","929.97","1 through 10","385.88","2157.5","other","Multiple Radiology"
"MRI Orbit/Face/Neck W&W/O Cont","PX-61000015","CDM","70543","CPT","0611","RC","","","","outpatient","","","4315.00","3236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1533.55","35.54","","1461.47","1461.47","1461.47","1 through 10","385.88","2157.5","percent of total billed charges",""
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4119.00","3089.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","263.16","263.16","263.16","1 through 10","225.91","3006.87","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","both","","","4119.00","3089.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","282.47","282.47","282.47","1 through 10","225.91","3006.87","other","OPPS APC"
"MRI Orbit/Face/Neck W/O Cont","PX-61000009","CDM","70540","CPT","0611","RC","","","","outpatient","","","4119.00","3089.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","2059.5","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","937.19","417.32","5486.00","1 through 10","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","998.92","417.32","998.92","1 through 10","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","968.56","484.28","968.56","1 through 10","385.88","4118.66","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","HUMANA [1012]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.02","419.02","419.02","1 through 10","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1015.16","424.11","1015.16","106","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","994.86","418.63","994.86","1 through 10","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","716.95","716.95","716.95","1 through 10","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","843.23","843.23","843.23","1 through 10","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","921.50","921.50","921.50","17","385.88","4118.66","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","TRICARE [160005]","HB BWF TRICARE","402.91","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","964.40","964.40","964.40","1 through 10","385.88","4118.66","other","Tricare OPPS"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.43","415.63","999.86","1 through 10","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","both","","","5642.00","4231.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","994.86","415.63","998.86","17","385.88","4118.66","other","OPPS APC"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","3110.56","3110.56","3110.56","1 through 10","385.88","2821","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","37","385.88","2821","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","1168.07","977.44","1168.07","50","385.88","2821","other","Multiple Imaging"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","14","385.88","2821","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","922.25","887.52","1844.50","1 through 10","385.88","2821","other","Multiple Radiology"
"MRI Pelvis W&W/O Cont","PX-61000040","CDM","72197","CPT","0614","RC","","","","outpatient","","","5642.00","4231.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2005.17","35.54","","1910.77","1910.77","1964.77","1 through 10","385.88","2821","percent of total billed charges",""
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.33","631.33","631.33","1 through 10","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","287.06","287.06","1215.72","12","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","577.92","577.92","577.92","1 through 10","225.91","3066.73","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","631.56","613.02","631.56","1 through 10","225.91","3066.73","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","both","","","4201.00","3150.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","281.32","263.16","281.32","1 through 10","225.91","3066.73","other","OPPS APC"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","584.01","697.91","1 through 10","230.56","2100.5","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","348.96","697.91","1 through 10","230.56","2100.5","other","Multiple Imaging"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","2100.5","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","275.52","551.04","1 through 10","230.56","2100.5","other","Multiple Radiology"
"MRI Pelvis W/O Cont","PX-61000038","CDM","72195","CPT","0614","RC","","","","outpatient","","","4201.00","3150.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1493.04","35.54","","1861.13","1861.13","1861.13","1 through 10","230.56","2100.5","percent of total billed charges",""
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","HUMANA [1012]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.17","418.17","418.17","1 through 10","385.88","3627.37","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","MEDICARE [2001]","HB BWF MEDICARE","424.11","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","424.11","424.11","1272.33","11","385.88","3627.37","other","OPPS APC"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","both","","","4969.00","3726.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","426.52","","Case rate ($426.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","840.71","816.02","840.71","1 through 10","385.88","3627.37","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","584.04","584.04","1 through 10","385.88","2484.5","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.04","488.72","1168.07","1 through 10","385.88","2484.5","other","Multiple Imaging"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","879.81","879.81","879.81","1 through 10","385.88","2484.5","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","461.13","461.13","461.13","1 through 10","385.88","2484.5","other","Multiple Radiology"
"MRI T-Spine W&W/O Cont","PX-61000031","CDM","72157","CPT","0612","RC","","","","outpatient","","","4969.00","3726.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.98","35.54","","2201.46","2201.46","2201.46","1 through 10","385.88","2484.5","percent of total billed charges",""
"MRI T-Spine W/Cont","PX-61000027","CDM","72147","CPT","0612","RC","","","","outpatient","","","3845.00","2883.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1168.07","","Case rate ($1,168.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","977.44","977.44","977.44","1 through 10","385.88","1922.5","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","282.47","282.47","282.47","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.33","282.47","633.17","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","328.55","328.55","328.55","1 through 10","225.91","2735.31","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","HUMANA [1012]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","637.57","637.57","637.57","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","MEDICARE [2001]","HB BWF MEDICARE","287.06","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","641.60","287.06","1215.72","24","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","437.05","424.38","437.05","1 through 10","225.91","2735.31","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.91","","Case rate ($225.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","477.62","477.62","477.62","1 through 10","225.91","2735.31","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","TRICARE [160005]","HB BWF TRICARE","272.70","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","272.71","272.71","272.71","1 through 10","225.91","2735.31","other","Tricare OPPS"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.12","284.12","284.12","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","both","","","3747.00","2810.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","628.77","281.32","628.77","1 through 10","225.91","2735.31","other","OPPS APC"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","2066.15","2066.15","2066.15","1 through 10","230.56","1873.5","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","292.01","3644.00","1 through 10","230.56","1873.5","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","292.01","697.91","1 through 10","230.56","1873.5","other","Multiple Imaging"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","262.84","262.84","262.84","1 through 10","230.56","1873.5","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","551.04","551.04","551.04","1 through 10","230.56","1873.5","other","Multiple Radiology"
"MRI T-Spine W/O Cont","PX-61000026","CDM","72146","CPT","0612","RC","","","","outpatient","","","3747.00","2810.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1331.68","35.54","","1660.21","1269.21","1660.21","1 through 10","230.56","1873.5","percent of total billed charges",""
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","584.01","584.01","584.01","1 through 10","230.56","1830","other","Multiple Imaging"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","697.91","","Case rate ($697.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","697.91","697.91","697.91","1 through 10","230.56","1830","other","Multiple Imaging"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","525.68","525.68","525.68","1 through 10","230.56","1830","other","Multiple Radiology"
"MRI Tmj Unilat or Bilat","PX-61000122","CDM","70336","CPT","0610","RC","","","","outpatient","","","3660.00","2745.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1300.76","35.54","","1239.60","1239.60","1239.60","1 through 10","230.56","1830","percent of total billed charges",""
"MRI Upr Ext Joint W&W/O","PX-61000052","CDM","73223","CPT","0614","RC","","","","outpatient","","","3736.00","2802.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","385.88","","Case rate ($385.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","845.08","845.08","845.08","1 through 10","385.88","2022.39","other","Multiple Radiology"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","3058.00","2293.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","2232.34","other","Multiple Radiology"
"MRI Upr Ext Joint W/O Cont","PX-61000050","CDM","73221","CPT","0614","RC","","","","both","","","3058.00","2293.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","281.32","","APC Price ($287.06). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.32","266.40","286.32","12","225.91","2232.34","other","OPPS APC"
"MRI Upr Ext W&W/O Cont","PX-61000049","CDM","73220","CPT","0614","RC","","","","both","","","5650.00","4237.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","415.63","","APC Price ($424.11). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","420.63","420.63","420.63","1 through 10","385.88","4124.5","other","OPPS APC"
"MRI Upr Ext W/O Cont","PX-61000043","CDM","73218","CPT","0614","RC","","","","both","","","4272.00","3204.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","230.56","","Case rate ($230.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","578.71","578.71","578.71","1 through 10","225.91","3118.56","other","Multiple Radiology"
"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","427","MS-DRG","","","","","","","","inpatient","","","82518.34","61888.75","MEDICARE [2001]","HB BWF MEDICARE","73158.90","","Case rate ($73,158.90). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $66,912.59, add-ons for qualifying new technology services are included. If operating cost exceeds $112,436.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $7,664.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $67,716.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $66,573.35 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $5,103.26. The transfer capital threshold is the transfer adjustment factor * $5,103.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","70876.60","70876.60","70876.60","1 through 10","65468.18","73158.9","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","447","MS-DRG","","","","","","","","inpatient","","","74249.01","55686.76","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","60622.64","","Case rate ($61,859.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $61,960.12, add-ons for qualifying new technology services are included. If operating cost exceeds $107,483.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $7,284.40, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $56,796.99 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $61,620.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,723.62. The transfer capital threshold is the transfer adjustment factor * $4,723.62. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","60060.22","60060.22","60060.22","1 through 10","60622.64","66302.7783","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","62631.69","46973.77","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","39386.27","","Case rate ($39,386.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,449.92, add-ons for qualifying new technology services are included. If operating cost exceeds $84,973.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,558.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,048.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $39,110.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.08. The transfer capital threshold is the transfer adjustment factor * $2,998.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","36866.27","36866.27","36866.27","1 through 10","38598.54","40567.86","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","62631.69","46973.77","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","38598.54","","Case rate ($39,386.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,449.92, add-ons for qualifying new technology services are included. If operating cost exceeds $84,973.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,558.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,048.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $39,110.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.08. The transfer capital threshold is the transfer adjustment factor * $2,998.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","36692.70","36692.70","36692.70","1 through 10","38598.54","40567.86","other","Inpatient DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","62631.69","46973.77","MEDICARE [2001]","HB BWF MEDICARE","39386.27","","Case rate ($39,386.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,449.92, add-ons for qualifying new technology services are included. If operating cost exceeds $84,973.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,558.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,048.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $39,110.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.08. The transfer capital threshold is the transfer adjustment factor * $2,998.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","40581.48","39588.47","40855.30","15","38598.54","40567.86","other","Inpatient Replacement Plans DRG"
"Multiple Level Spinal Fusion Except Cervical Without McC","448","MS-DRG","","","","","","","","inpatient","","","62631.69","46973.77","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","38598.54","","Case rate ($39,386.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,449.92, add-ons for qualifying new technology services are included. If operating cost exceeds $84,973.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,558.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $36,048.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $39,110.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,998.08. The transfer capital threshold is the transfer adjustment factor * $2,998.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","36659.18","36659.18","36692.70","1 through 10","38598.54","40567.86","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia With Cc","059","MS-DRG","","","","","","","","inpatient","","","46702.78","35027.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11529.48","","Case rate ($11,764.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,783.40, add-ons for qualifying new technology services are included. If operating cost exceeds $57,307.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,438.04, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $10,548.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,444.17 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $877.27. The transfer capital threshold is the transfer adjustment factor * $877.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11190.65","11190.65","11190.65","1 through 10","11529.48","12117.72","other","Inpatient DRG"
"Multiple Sclerosis And Cerebellar Ataxia With McC","058","MS-DRG","","","","","","","","inpatient","","","37553.73","28165.30","MEDICARE [2001]","HB BWF MEDICARE","17584.31","","Case rate ($17,584.31). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,105.06, add-ons for qualifying new technology services are included. If operating cost exceeds $61,628.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,769.33, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $16,036.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,765.82 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,208.55. The transfer capital threshold is the transfer adjustment factor * $1,208.55. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18482.04","18482.04","18482.04","1 through 10","15757.82","17584.31","other","Inpatient DRG"
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MAJOR","043","DRG","","","","","","","","inpatient","","","46702.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14105.4156","","Fee schedule rate ($34,173.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14105.4156","34173.10","34173.10","1 through 10","8114.72","147635.6","case rate",""
"Multiple Sclerosis, Other Demyelinating Disease And Inflammatory Neuropathies,MODERATE","043","DRG","","","","","","","","inpatient","","","41214.07","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14105.4156","","Fee schedule rate ($18,525.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14105.4156","18525.82","18525.82","1 through 10","8114.72","147635.6","case rate",""
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0740","RC","","","","both","","","2562.00","1921.50","MEDICARE [2001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","1 through 10","598.61","2738","other","OPPS APC"
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0740","RC","","","","outpatient","","","2562.00","1921.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1519.27","59.3","","1459.73","1424.85","1459.73","1 through 10","1069.88","3447.02","percent of total billed charges",""
"Multiple Sleep Latency","PX-74000004","CDM","95805","CPT","0740","RC","","","","outpatient","","","2562.00","1921.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2009.89","78.45","","1915.08","1915.08","1915.08","1 through 10","1069.88","3447.02","percent of total billed charges",""
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0740","RC","","","","both","","","2562.00","1921.50","MEDICARE [2001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","630.12","630.12","1 through 10","598.61","2738","other","OPPS APC"
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0740","RC","","","","outpatient","","","2562.00","1921.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1519.27","59.3","","1459.73","1424.85","1459.73","1 through 10","1069.88","3447.02","percent of total billed charges",""
"Multiple Sleep Latency Ltd","PX-74000005","CDM","95805","CPT","0740","RC","","","","outpatient","","","2562.00","1921.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2009.89","78.45","","1915.08","1915.08","1915.08","1 through 10","1069.88","3447.02","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","126.65","126.65","126.65","1 through 10","12.79","111.69","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","87.31","87.31","87.32","1 through 10","13.45","120.03","percent of total billed charges",""
"Mumps Antibody","PX-30000973","CDM","86735","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","114.55","61.75","114.55","1 through 10","13.45","120.03","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","both","","","157.00","117.75","WELLPOINT [1015]","HB CH WELLPOINT","122.32","77.91","","273.50","273.50","273.50","1 through 10","18.03","149.31","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","157.00","117.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","90.59","57.7","","92.26","92.26","92.26","1 through 10","46.11","123.17","percent of total billed charges",""
"Muscle-Specific Kinase Antibody","PX-30003823","CDM","86366","CPT","0302","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","117.63","117.63","117.63","1 through 10","46.11","123.17","percent of total billed charges",""
"Mycoplasma Antibody","PX-30000975","CDM","86738","CPT","0302","RC","","","","outpatient","","","94.00","70.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.74","78.45","","69.96","69.96","69.96","1 through 10","10.76","73.74","percent of total billed charges",""
"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","827","MS-DRG","","","","","","","","inpatient","","","33047.51","24785.63","MEDICARE [2001]","HB BWF MEDICARE","23654.11","","Case rate ($23,654.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,654.22, add-ons for qualifying new technology services are included. If operating cost exceeds $67,177.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,194.70, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $21,680.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,314.98 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,633.93. The transfer capital threshold is the transfer adjustment factor * $1,633.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","21187.14","23654.11","other","Inpatient DRG"
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","413.34","413.34","413.34","1 through 10","333.38","750","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","413.34","413.34","413.34","1 through 10","333.38","750","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","574.16","574.16","574.16","1 through 10","333.38","750","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","427.19","427.19","427.19","1 through 10","375","588.38","percent of total billed charges",""
"Myocardial Strain Imaging Quan Assmt","PX-48000441","CDM","93356","CPT","0483","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","560.46","332.13","560.46","1 through 10","375","588.38","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","82.78","80.09","82.78","1 through 10","12.66","109.5","percent of total billed charges",""
"Myoglobin","PX-30000581","CDM","83874","CPT","0301","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","112.24","66.52","112.24","1 through 10","13.32","117.68","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","AETNA [1001]","HB CH AETNA HMO / PPO","3537.32","58.3","","554.95","91.85","1421.75","94","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","2490.03","2490.03","2490.03","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3537.32","58.3","","750.00","750.00","750.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3215.74","53","","1192.50","120.84","4149.90","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5157.32","85","","750.00","75.00","750.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6067.44","100","","657.00","121.50","1971.00","14","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6067.44","100","","75.00","75.00","75.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6067.44","100","","366.00","144.00","1971.00","45","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","667.50","667.50","667.50","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","123.77","123.77","123.77","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","WELLPOINT [1015]","HB CH WELLPOINT","4727.14","77.91","","483.51","229.32","1316.08","96","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","3597.99","59.3","","439.50","225.34","1872.27","197","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 11X200MM T2 TITANIUM ARTHRODESIS LEFT","SUP-ITM-10033506","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","385.32","55.36","1815.62","58","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","AETNA [1001]","HB CH AETNA HMO / PPO","3537.32","58.3","","554.95","91.85","1421.75","94","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","2490.03","2490.03","2490.03","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3537.32","58.3","","750.00","750.00","750.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3215.74","53","","1192.50","120.84","4149.90","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5157.32","85","","750.00","75.00","750.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6067.44","100","","657.00","121.50","1971.00","14","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6067.44","100","","75.00","75.00","75.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6067.44","100","","366.00","144.00","1971.00","45","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","667.50","667.50","667.50","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","123.77","123.77","123.77","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","WELLPOINT [1015]","HB CH WELLPOINT","4727.14","77.91","","483.51","229.32","1316.08","96","2696.98","6067.44","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","3597.99","59.3","","439.50","225.34","1872.27","197","3033.72","4759.91","percent of total billed charges",""
"NAIL ANKLE 12X300MM T2 LEFT","SUP-ITM-10033510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","385.32","55.36","1815.62","58","3033.72","4759.91","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","578.31","433.73","AETNA [1001]","HB CH AETNA HMO / PPO","337.15","58.3","","1830.28","315.58","1830.28","1 through 10","257.06","578.31","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","578.31","433.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","422.17","73","","4170.85","4170.85","4170.85","1 through 10","257.06","578.31","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","578.31","433.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","257.06","44.45","","649.55","649.55","649.55","1 through 10","257.06","578.31","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","both","","","578.31","433.73","WELLPOINT [1015]","HB CH WELLPOINT","450.56","77.91","","8998.38","2542.37","8998.38","20","257.06","578.31","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","578.31","433.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","342.94","59.3","","1891.61","1609.14","3664.18","25","289.16","453.68","percent of total billed charges",""
"NAIL BONE 1.5MMX300 FEMORAL TI ELASTIC","SUP-ITM-10040837","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","578.31","433.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","453.68","78.45","","1470.68","1310.06","2481.69","19","289.16","453.68","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","AETNA [1001]","HB CH AETNA HMO / PPO","2673.56","58.3","","554.95","91.85","1421.75","94","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","2490.03","2490.03","2490.03","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2673.56","58.3","","750.00","750.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2430.51","53","","1192.50","120.84","4149.90","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3897.98","85","","750.00","75.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4585.86","100","","657.00","121.50","1971.00","14","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4585.86","100","","75.00","75.00","75.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4585.86","100","","366.00","144.00","1971.00","45","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","667.50","667.50","667.50","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2038.41","44.45","","123.77","123.77","123.77","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","WELLPOINT [1015]","HB CH WELLPOINT","3572.84","77.91","","483.51","229.32","1316.08","96","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2719.41","59.3","","439.50","225.34","1872.27","197","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 10CMX15 PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3597.61","78.45","","385.32","55.36","1815.62","58","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","AETNA [1001]","HB CH AETNA HMO / PPO","2673.56","58.3","","554.95","91.85","1421.75","94","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","2490.03","2490.03","2490.03","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2673.56","58.3","","750.00","750.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2430.51","53","","1192.50","120.84","4149.90","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3897.98","85","","750.00","75.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4585.86","100","","657.00","121.50","1971.00","14","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4585.86","100","","75.00","75.00","75.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4585.86","100","","366.00","144.00","1971.00","45","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","667.50","667.50","667.50","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2038.41","44.45","","123.77","123.77","123.77","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","WELLPOINT [1015]","HB CH WELLPOINT","3572.84","77.91","","483.51","229.32","1316.08","96","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2719.41","59.3","","439.50","225.34","1872.27","197","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 10CMX18 ANKLE INTRAMEDULLARY PHOENIX TI","SUP-ITM-10072719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3597.61","78.45","","385.32","55.36","1815.62","58","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","AETNA [1001]","HB CH AETNA HMO / PPO","3527.15","58.3","","554.95","91.85","1421.75","94","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4416.50","73","","2490.03","2490.03","2490.03","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3527.15","58.3","","750.00","750.00","750.00","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3206.50","53","","1192.50","120.84","4149.90","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5142.50","85","","750.00","75.00","750.00","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6050.00","100","","657.00","121.50","1971.00","14","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6050.00","100","","75.00","75.00","75.00","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6050.00","100","","366.00","144.00","1971.00","45","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4416.50","73","","667.50","667.50","667.50","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2689.23","44.45","","123.77","123.77","123.77","1 through 10","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","both","","","6050.00","4537.50","WELLPOINT [1015]","HB CH WELLPOINT","4713.56","77.91","","483.51","229.32","1316.08","96","2689.23","6050","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6050.00","4537.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3587.65","59.3","","439.50","225.34","1872.27","197","3025","4746.23","percent of total billed charges",""
"NAIL BONE 10X150MM PHANTOM TTC LT","SUP-ITM-10285960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6050.00","4537.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4746.23","78.45","","385.32","55.36","1815.62","58","3025","4746.23","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","AETNA [1001]","HB CH AETNA HMO / PPO","7374.95","58.3","","554.95","91.85","1421.75","94","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","9234.50","73","","2490.03","2490.03","2490.03","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7374.95","58.3","","750.00","750.00","750.00","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6704.50","53","","1192.50","120.84","4149.90","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10752.50","85","","750.00","75.00","750.00","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12650.00","100","","657.00","121.50","1971.00","14","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","12650.00","100","","75.00","75.00","75.00","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","12650.00","100","","366.00","144.00","1971.00","45","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","9234.50","73","","667.50","667.50","667.50","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5622.93","44.45","","123.77","123.77","123.77","1 through 10","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","both","","","12650.00","9487.50","WELLPOINT [1015]","HB CH WELLPOINT","9855.62","77.91","","483.51","229.32","1316.08","96","5622.93","12650","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12650.00","9487.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","7501.45","59.3","","439.50","225.34","1872.27","197","6325","9923.93","percent of total billed charges",""
"NAIL BONE 10X175MM PHANTOM ACTIVCORE","SUP-ITM-10285947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","12650.00","9487.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9923.93","78.45","","385.32","55.36","1815.62","58","6325","9923.93","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","AETNA [1001]","HB CH AETNA HMO / PPO","4195.61","58.3","","554.95","91.85","1421.75","94","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","2490.03","2490.03","2490.03","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4195.61","58.3","","750.00","750.00","750.00","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3814.19","53","","1192.50","120.84","4149.90","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6117.09","85","","750.00","75.00","750.00","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7196.58","100","","657.00","121.50","1971.00","14","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7196.58","100","","75.00","75.00","75.00","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7196.58","100","","366.00","144.00","1971.00","45","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5253.50","73","","667.50","667.50","667.50","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3198.88","44.45","","123.77","123.77","123.77","1 through 10","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","both","","","7196.58","5397.43","WELLPOINT [1015]","HB CH WELLPOINT","5606.86","77.91","","483.51","229.32","1316.08","96","3198.88","7196.58","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","4267.57","59.3","","439.50","225.34","1872.27","197","3598.29","5645.72","percent of total billed charges",""
"NAIL BONE 10X380MM LONG 125DEG GAMMA3 TITANIUM LEFT","SUP-ITM-10088673","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7196.58","5397.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5645.72","78.45","","385.32","55.36","1815.62","58","3598.29","5645.72","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","AETNA [1001]","HB CH AETNA HMO / PPO","2673.56","58.3","","554.95","91.85","1421.75","94","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","2490.03","2490.03","2490.03","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2673.56","58.3","","750.00","750.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2430.51","53","","1192.50","120.84","4149.90","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3897.98","85","","750.00","75.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4585.86","100","","657.00","121.50","1971.00","14","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4585.86","100","","75.00","75.00","75.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4585.86","100","","366.00","144.00","1971.00","45","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","667.50","667.50","667.50","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2038.41","44.45","","123.77","123.77","123.77","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","WELLPOINT [1015]","HB CH WELLPOINT","3572.84","77.91","","483.51","229.32","1316.08","96","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2719.41","59.3","","439.50","225.34","1872.27","197","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 11X210MM ANKLE INTRAMEDULLARY PHOENIX TITANIUM","SUP-ITM-10072726","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3597.61","78.45","","385.32","55.36","1815.62","58","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","AETNA [1001]","HB CH AETNA HMO / PPO","1899.05","58.3","","554.95","91.85","1421.75","94","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2377.88","73","","2490.03","2490.03","2490.03","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1899.05","58.3","","750.00","750.00","750.00","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1726.41","53","","1192.50","120.84","4149.90","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2768.76","85","","750.00","75.00","750.00","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3257.37","100","","657.00","121.50","1971.00","14","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3257.37","100","","75.00","75.00","75.00","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3257.37","100","","366.00","144.00","1971.00","45","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2377.88","73","","667.50","667.50","667.50","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1447.90","44.45","","123.77","123.77","123.77","1 through 10","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","both","","","3257.37","2443.03","WELLPOINT [1015]","HB CH WELLPOINT","2537.82","77.91","","483.51","229.32","1316.08","96","1447.9","3257.37","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3257.37","2443.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","1931.62","59.3","","439.50","225.34","1872.27","197","1628.69","2555.41","percent of total billed charges",""
"NAIL BONE 11X235MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMAL","SUP-ITM-10025089","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3257.37","2443.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2555.41","78.45","","385.32","55.36","1815.62","58","1628.69","2555.41","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","AETNA [1001]","HB CH AETNA HMO / PPO","2082.06","58.3","","554.95","91.85","1421.75","94","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2607.03","73","","2490.03","2490.03","2490.03","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2082.06","58.3","","750.00","750.00","750.00","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1892.78","53","","1192.50","120.84","4149.90","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3035.59","85","","750.00","75.00","750.00","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3571.28","100","","657.00","121.50","1971.00","14","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3571.28","100","","75.00","75.00","75.00","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3571.28","100","","366.00","144.00","1971.00","45","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2607.03","73","","667.50","667.50","667.50","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1587.43","44.45","","123.77","123.77","123.77","1 through 10","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","both","","","3571.28","2678.46","WELLPOINT [1015]","HB CH WELLPOINT","2782.38","77.91","","483.51","229.32","1316.08","96","1587.43","3571.28","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3571.28","2678.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","2117.77","59.3","","439.50","225.34","1872.27","197","1785.64","2801.67","percent of total billed charges",""
"NAIL BONE 11X340MM 130DEG TROCHANTERIC FIXATION TITANIUM CANNULATED PROXIMALIMAL RIGHT","SUP-ITM-10009654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3571.28","2678.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2801.67","78.45","","385.32","55.36","1815.62","58","1785.64","2801.67","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","AETNA [1001]","HB CH AETNA HMO / PPO","2363.65","58.3","","554.95","91.85","1421.75","94","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","2490.03","2490.03","2490.03","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.65","58.3","","750.00","750.00","750.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.77","53","","1192.50","120.84","4149.90","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3446.14","85","","750.00","75.00","750.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4054.28","100","","657.00","121.50","1971.00","14","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4054.28","100","","75.00","75.00","75.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4054.28","100","","366.00","144.00","1971.00","45","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","667.50","667.50","667.50","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","123.77","123.77","123.77","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","WELLPOINT [1015]","HB CH WELLPOINT","3158.69","77.91","","483.51","229.32","1316.08","96","1802.13","4054.28","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.19","59.3","","439.50","225.34","1872.27","197","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 11X380MM 130DEG LONG FEMORAL TFN ADVANCED TI CANNULATED LEFT","SUP-ITM-10164062","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","385.32","55.36","1815.62","58","2027.14","3180.58","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","AETNA [1001]","HB CH AETNA HMO / PPO","3537.32","58.3","","554.95","91.85","1421.75","94","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","2490.03","2490.03","2490.03","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3537.32","58.3","","750.00","750.00","750.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3215.74","53","","1192.50","120.84","4149.90","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5157.32","85","","750.00","75.00","750.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6067.44","100","","657.00","121.50","1971.00","14","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6067.44","100","","75.00","75.00","75.00","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6067.44","100","","366.00","144.00","1971.00","45","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4429.23","73","","667.50","667.50","667.50","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2696.98","44.45","","123.77","123.77","123.77","1 through 10","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","both","","","6067.44","4550.58","WELLPOINT [1015]","HB CH WELLPOINT","4727.14","77.91","","483.51","229.32","1316.08","96","2696.98","6067.44","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","3597.99","59.3","","439.50","225.34","1872.27","197","3033.72","4759.91","percent of total billed charges",""
"NAIL BONE 12MMX200 T2 TITANIUM ARTHRODESIS LT ANKLE","SUP-ITM-10033509","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6067.44","4550.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4759.91","78.45","","385.32","55.36","1815.62","58","3033.72","4759.91","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","AETNA [1001]","HB CH AETNA HMO / PPO","2673.56","58.3","","554.95","91.85","1421.75","94","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","2490.03","2490.03","2490.03","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2673.56","58.3","","750.00","750.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2430.51","53","","1192.50","120.84","4149.90","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3897.98","85","","750.00","75.00","750.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4585.86","100","","657.00","121.50","1971.00","14","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4585.86","100","","75.00","75.00","75.00","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4585.86","100","","366.00","144.00","1971.00","45","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3347.68","73","","667.50","667.50","667.50","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2038.41","44.45","","123.77","123.77","123.77","1 through 10","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","both","","","4585.86","3439.39","WELLPOINT [1015]","HB CH WELLPOINT","3572.84","77.91","","483.51","229.32","1316.08","96","2038.41","4585.86","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","2719.41","59.3","","439.50","225.34","1872.27","197","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 12X150MM PHOENIX TITANIUM INTRAMEDULLARY ANKLE","SUP-ITM-10072730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4585.86","3439.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3597.61","78.45","","385.32","55.36","1815.62","58","2292.93","3597.61","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","AETNA [1001]","HB CH AETNA HMO / PPO","2178.24","58.3","","554.95","91.85","1421.75","94","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2727.47","73","","2490.03","2490.03","2490.03","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.24","58.3","","750.00","750.00","750.00","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.22","53","","1192.50","120.84","4149.90","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3175.82","85","","750.00","75.00","750.00","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3736.26","100","","657.00","121.50","1971.00","14","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3736.26","100","","75.00","75.00","75.00","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3736.26","100","","366.00","144.00","1971.00","45","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2727.47","73","","667.50","667.50","667.50","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1660.77","44.45","","123.77","123.77","123.77","1 through 10","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","both","","","3736.26","2802.19","WELLPOINT [1015]","HB CH WELLPOINT","2910.92","77.91","","483.51","229.32","1316.08","96","1660.77","3736.26","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2215.60","59.3","","439.50","225.34","1872.27","197","1868.13","2931.1","percent of total billed charges",""
"NAIL BONE 130 DEG 10X235MMLATEX FREE TI TFN-ADVANCED CANNULATED 1 LEFT SHORT","SUP-ITM-10164128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3736.26","2802.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2931.10","78.45","","385.32","55.36","1815.62","58","1868.13","2931.1","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","AETNA [1001]","HB CH AETNA HMO / PPO","1894.80","58.3","","554.95","91.85","1421.75","94","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2372.56","73","","2490.03","2490.03","2490.03","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1894.80","58.3","","750.00","750.00","750.00","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1722.54","53","","1192.50","120.84","4149.90","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2762.57","85","","750.00","75.00","750.00","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3250.08","100","","657.00","121.50","1971.00","14","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3250.08","100","","75.00","75.00","75.00","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3250.08","100","","366.00","144.00","1971.00","45","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2372.56","73","","667.50","667.50","667.50","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1444.66","44.45","","123.77","123.77","123.77","1 through 10","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3250.08","2437.56","WELLPOINT [1015]","HB CH WELLPOINT","2532.14","77.91","","483.51","229.32","1316.08","96","1444.66","3250.08","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3250.08","2437.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1927.30","59.3","","439.50","225.34","1872.27","197","1625.04","2549.69","percent of total billed charges",""
"NAIL BONE 170X11MM SHORT 130DEG FEMORAL TFN ADVANCED CANNULATED TI NECK RIGHT","SUP-ITM-10164075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3250.08","2437.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2549.69","78.45","","385.32","55.36","1815.62","58","1625.04","2549.69","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","AETNA [1001]","HB CH AETNA HMO / PPO","1906.41","58.3","","554.95","91.85","1421.75","94","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2387.10","73","","2490.03","2490.03","2490.03","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1906.41","58.3","","750.00","750.00","750.00","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1733.10","53","","1192.50","120.84","4149.90","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2779.50","85","","750.00","75.00","750.00","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3270.00","100","","657.00","121.50","1971.00","14","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3270.00","100","","75.00","75.00","75.00","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3270.00","100","","366.00","144.00","1971.00","45","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2387.10","73","","667.50","667.50","667.50","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1453.52","44.45","","123.77","123.77","123.77","1 through 10","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","both","","","3270.00","2452.50","WELLPOINT [1015]","HB CH WELLPOINT","2547.66","77.91","","483.51","229.32","1316.08","96","1453.52","3270","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3270.00","2452.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1939.11","59.3","","439.50","225.34","1872.27","197","1635","2565.32","percent of total billed charges",""
"NAIL BONE 4.5MM DIAX46CM HUMERAL TIBIAL INTRAMEDULLARY ENDER","SUP-ITM-10062518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3270.00","2452.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2565.32","78.45","","385.32","55.36","1815.62","58","1635","2565.32","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","AETNA [1001]","HB CH AETNA HMO / PPO","2166.27","58.3","","554.95","91.85","1421.75","94","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2712.48","73","","2490.03","2490.03","2490.03","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2166.27","58.3","","750.00","750.00","750.00","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1969.34","53","","1192.50","120.84","4149.90","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3158.37","85","","750.00","75.00","750.00","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3715.73","100","","657.00","121.50","1971.00","14","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3715.73","100","","75.00","75.00","75.00","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3715.73","100","","366.00","144.00","1971.00","45","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2712.48","73","","667.50","667.50","667.50","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.64","44.45","","123.77","123.77","123.77","1 through 10","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","both","","","3715.73","2786.80","WELLPOINT [1015]","HB CH WELLPOINT","2894.93","77.91","","483.51","229.32","1316.08","96","1651.64","3715.73","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3715.73","2786.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","2203.43","59.3","","439.50","225.34","1872.27","197","1857.87","2914.99","percent of total billed charges",""
"NAIL BONE 8.5X255MM HUMERAL CANNULATED TITANIUM MULTILOC LEFT","SUP-ITM-10125471","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3715.73","2786.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2914.99","78.45","","385.32","55.36","1815.62","58","1857.87","2914.99","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","AETNA [1001]","HB CH AETNA HMO / PPO","3492.17","58.3","","554.95","91.85","1421.75","94","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4372.70","73","","2490.03","2490.03","2490.03","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3492.17","58.3","","750.00","750.00","750.00","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3174.70","53","","1192.50","120.84","4149.90","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5091.50","85","","750.00","75.00","750.00","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5990.00","100","","657.00","121.50","1971.00","14","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5990.00","100","","75.00","75.00","75.00","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5990.00","100","","366.00","144.00","1971.00","45","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4372.70","73","","667.50","667.50","667.50","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2662.56","44.45","","123.77","123.77","123.77","1 through 10","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","both","","","5990.00","4492.50","WELLPOINT [1015]","HB CH WELLPOINT","4666.81","77.91","","483.51","229.32","1316.08","96","2662.56","5990","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5990.00","4492.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3552.07","59.3","","439.50","225.34","1872.27","197","2995","4699.16","percent of total billed charges",""
"NAIL BONE 8X135MM SALVATION","SUP-ITM-10239197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5990.00","4492.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4699.16","78.45","","385.32","55.36","1815.62","58","2995","4699.16","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","AETNA [1001]","HB CH AETNA HMO / PPO","2363.65","58.3","","554.95","91.85","1421.75","94","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","2490.03","2490.03","2490.03","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.65","58.3","","750.00","750.00","750.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.77","53","","1192.50","120.84","4149.90","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3446.14","85","","750.00","75.00","750.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4054.28","100","","657.00","121.50","1971.00","14","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4054.28","100","","75.00","75.00","75.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4054.28","100","","366.00","144.00","1971.00","45","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","667.50","667.50","667.50","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","123.77","123.77","123.77","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","WELLPOINT [1015]","HB CH WELLPOINT","3158.69","77.91","","483.51","229.32","1316.08","96","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.19","59.3","","439.50","225.34","1872.27","197","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMORAL 11X320MM LONG 130DEG TFN ADVANCED NECK RT","SUP-ITM-10164069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","385.32","55.36","1815.62","58","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","AETNA [1001]","HB CH AETNA HMO / PPO","2363.65","58.3","","554.95","91.85","1421.75","94","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","2490.03","2490.03","2490.03","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.65","58.3","","750.00","750.00","750.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.77","53","","1192.50","120.84","4149.90","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3446.14","85","","750.00","75.00","750.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4054.28","100","","657.00","121.50","1971.00","14","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4054.28","100","","75.00","75.00","75.00","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4054.28","100","","366.00","144.00","1971.00","45","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.62","73","","667.50","667.50","667.50","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.13","44.45","","123.77","123.77","123.77","1 through 10","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.28","3040.71","WELLPOINT [1015]","HB CH WELLPOINT","3158.69","77.91","","483.51","229.32","1316.08","96","1802.13","4054.28","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.19","59.3","","439.50","225.34","1872.27","197","2027.14","3180.58","percent of total billed charges",""
"NAIL FEMORAL 11X360MM 130DEG PROSTHESIS TI CANNULATED TFNA RIGHT","SUP-ITM-10164065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.28","3040.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.58","78.45","","385.32","55.36","1815.62","58","2027.14","3180.58","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","AETNA [1001]","HB CH AETNA HMO / PPO","2143.29","58.3","","554.95","91.85","1421.75","94","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2683.71","73","","2490.03","2490.03","2490.03","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2143.29","58.3","","750.00","750.00","750.00","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1948.45","53","","1192.50","120.84","4149.90","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3124.87","85","","750.00","75.00","750.00","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3676.32","100","","657.00","121.50","1971.00","14","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3676.32","100","","75.00","75.00","75.00","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3676.32","100","","366.00","144.00","1971.00","45","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2683.71","73","","667.50","667.50","667.50","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1634.12","44.45","","123.77","123.77","123.77","1 through 10","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","both","","","3676.32","2757.24","WELLPOINT [1015]","HB CH WELLPOINT","2864.22","77.91","","483.51","229.32","1316.08","96","1634.12","3676.32","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3676.32","2757.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","2180.06","59.3","","439.50","225.34","1872.27","197","1838.16","2884.07","percent of total billed charges",""
"NAIL HUMERAL 9X220MM NAIL-EX TITANIUM CANNULATED","SUP-ITM-10036603","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3676.32","2757.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2884.07","78.45","","385.32","55.36","1815.62","58","1838.16","2884.07","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","AETNA [1001]","HB CH AETNA HMO / PPO","2112.23","58.3","","554.95","91.85","1421.75","94","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2644.81","73","","2490.03","2490.03","2490.03","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.23","58.3","","750.00","750.00","750.00","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.21","53","","1192.50","120.84","4149.90","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3079.58","85","","750.00","75.00","750.00","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3623.03","100","","657.00","121.50","1971.00","14","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3623.03","100","","75.00","75.00","75.00","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3623.03","100","","366.00","144.00","1971.00","45","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2644.81","73","","667.50","667.50","667.50","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1610.44","44.45","","123.77","123.77","123.77","1 through 10","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","both","","","3623.03","2717.27","WELLPOINT [1015]","HB CH WELLPOINT","2822.70","77.91","","483.51","229.32","1316.08","96","1610.44","3623.03","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3623.03","2717.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","2148.46","59.3","","439.50","225.34","1872.27","197","1811.52","2842.27","percent of total billed charges",""
"NAIL HUMERUS 7MMX24CM TITANIUM","SUP-ITM-10065091","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3623.03","2717.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2842.27","78.45","","385.32","55.36","1815.62","58","1811.52","2842.27","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","AETNA [1001]","HB CH AETNA HMO / PPO","2642.16","58.3","","554.95","91.85","1421.75","94","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3308.36","73","","2490.03","2490.03","2490.03","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2642.16","58.3","","750.00","750.00","750.00","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2401.96","53","","1192.50","120.84","4149.90","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3852.20","85","","750.00","75.00","750.00","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4532.00","100","","657.00","121.50","1971.00","14","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4532.00","100","","75.00","75.00","75.00","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4532.00","100","","366.00","144.00","1971.00","45","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3308.36","73","","667.50","667.50","667.50","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2014.47","44.45","","123.77","123.77","123.77","1 through 10","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","both","","","4532.00","3399.00","WELLPOINT [1015]","HB CH WELLPOINT","3530.88","77.91","","483.51","229.32","1316.08","96","2014.47","4532","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4532.00","3399.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2687.48","59.3","","439.50","225.34","1872.27","197","2266","3555.35","percent of total billed charges",""
"NAIL IM 3.5MM 50MM","SUP-ITM-10334844","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4532.00","3399.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3555.35","78.45","","385.32","55.36","1815.62","58","2266","3555.35","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","AETNA [1001]","HB CH AETNA HMO / PPO","2675.19","58.3","","554.95","91.85","1421.75","94","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3349.72","73","","2490.03","2490.03","2490.03","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2675.19","58.3","","750.00","750.00","750.00","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2431.99","53","","1192.50","120.84","4149.90","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3900.36","85","","750.00","75.00","750.00","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4588.66","100","","657.00","121.50","1971.00","14","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4588.66","100","","75.00","75.00","75.00","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4588.66","100","","366.00","144.00","1971.00","45","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3349.72","73","","667.50","667.50","667.50","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2039.66","44.45","","123.77","123.77","123.77","1 through 10","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","both","","","4588.66","3441.49","WELLPOINT [1015]","HB CH WELLPOINT","3575.03","77.91","","483.51","229.32","1316.08","96","2039.66","4588.66","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4588.66","3441.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","2721.08","59.3","","439.50","225.34","1872.27","197","2294.33","3599.8","percent of total billed charges",""
"NAIL IM 4.0MM 55MM","SUP-ITM-10334863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4588.66","3441.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3599.80","78.45","","385.32","55.36","1815.62","58","2294.33","3599.8","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","AETNA [1001]","HB CH AETNA HMO / PPO","11077.00","58.3","","554.95","91.85","1421.75","94","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","13870.00","73","","2490.03","2490.03","2490.03","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","11077.00","58.3","","750.00","750.00","750.00","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","10070.00","53","","1192.50","120.84","4149.90","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","16150.00","85","","750.00","75.00","750.00","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","19000.00","100","","657.00","121.50","1971.00","14","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","19000.00","100","","75.00","75.00","75.00","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19000.00","100","","366.00","144.00","1971.00","45","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","13870.00","73","","667.50","667.50","667.50","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8445.50","44.45","","123.77","123.77","123.77","1 through 10","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","both","","","19000.00","14250.00","WELLPOINT [1015]","HB CH WELLPOINT","14802.90","77.91","","483.51","229.32","1316.08","96","8445.5","19000","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19000.00","14250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","11267.00","59.3","","439.50","225.34","1872.27","197","9500","14905.5","percent of total billed charges",""
"NAIL INTRAMEDULLARY 10MMX22CM DYNANAIL ANKLE ARTHRODESIS","SUP-ITM-10277000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19000.00","14250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","14905.50","78.45","","385.32","55.36","1815.62","58","9500","14905.5","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","AETNA [1001]","HB CH AETNA HMO / PPO","4410.15","58.3","","554.95","91.85","1421.75","94","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5522.14","73","","2490.03","2490.03","2490.03","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4410.15","58.3","","750.00","750.00","750.00","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4009.23","53","","1192.50","120.84","4149.90","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6429.89","85","","750.00","75.00","750.00","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7564.58","100","","657.00","121.50","1971.00","14","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7564.58","100","","75.00","75.00","75.00","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7564.58","100","","366.00","144.00","1971.00","45","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5522.14","73","","667.50","667.50","667.50","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3362.46","44.45","","123.77","123.77","123.77","1 through 10","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","both","","","7564.58","5673.43","WELLPOINT [1015]","HB CH WELLPOINT","5893.56","77.91","","483.51","229.32","1316.08","96","3362.46","7564.58","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7564.58","5673.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","4485.80","59.3","","439.50","225.34","1872.27","197","3782.29","5934.41","percent of total billed charges",""
"NAIL INTRAMEDULLARY 11X180MM HINDFOOT NON LOCKING CANNULATED","SUP-ITM-10080371","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7564.58","5673.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5934.41","78.45","","385.32","55.36","1815.62","58","3782.29","5934.41","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","AETNA [1001]","HB CH AETNA HMO / PPO","4840.11","58.3","","554.95","91.85","1421.75","94","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6060.52","73","","2490.03","2490.03","2490.03","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4840.11","58.3","","750.00","750.00","750.00","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4400.10","53","","1192.50","120.84","4149.90","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7056.77","85","","750.00","75.00","750.00","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8302.08","100","","657.00","121.50","1971.00","14","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8302.08","100","","75.00","75.00","75.00","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8302.08","100","","366.00","144.00","1971.00","45","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6060.52","73","","667.50","667.50","667.50","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3690.27","44.45","","123.77","123.77","123.77","1 through 10","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","both","","","8302.08","6226.56","WELLPOINT [1015]","HB CH WELLPOINT","6468.15","77.91","","483.51","229.32","1316.08","96","3690.27","8302.08","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8302.08","6226.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","4923.13","59.3","","439.50","225.34","1872.27","197","4151.04","6512.98","percent of total billed charges",""
"NAIL INTRAMEDULLARY 12X210MM FOOT PANTA","SUP-ITM-10079555","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8302.08","6226.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6512.98","78.45","","385.32","55.36","1815.62","58","4151.04","6512.98","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","AETNA [1001]","HB CH AETNA HMO / PPO","3166.98","58.3","","554.95","91.85","1421.75","94","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3965.52","73","","2490.03","2490.03","2490.03","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3166.98","58.3","","750.00","750.00","750.00","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2879.08","53","","1192.50","120.84","4149.90","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4617.39","85","","750.00","75.00","750.00","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5432.22","100","","657.00","121.50","1971.00","14","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5432.22","100","","75.00","75.00","75.00","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5432.22","100","","366.00","144.00","1971.00","45","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3965.52","73","","667.50","667.50","667.50","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2414.62","44.45","","123.77","123.77","123.77","1 through 10","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","both","","","5432.22","4074.16","WELLPOINT [1015]","HB CH WELLPOINT","4232.24","77.91","","483.51","229.32","1316.08","96","2414.62","5432.22","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5432.22","4074.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","3221.31","59.3","","439.50","225.34","1872.27","197","2716.11","4261.58","percent of total billed charges",""
"NAIL TIBIAL 10X345MM INTRAMEDULLARY STERILE","SUP-ITM-10232931","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5432.22","4074.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4261.58","78.45","","385.32","55.36","1815.62","58","2716.11","4261.58","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","554.95","91.85","1421.75","94","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","2490.03","2490.03","2490.03","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","750.00","750.00","750.00","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","1192.50","120.84","4149.90","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2844.65","85","","750.00","75.00","750.00","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3346.65","100","","657.00","121.50","1971.00","14","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3346.65","100","","75.00","75.00","75.00","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3346.65","100","","366.00","144.00","1971.00","45","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","667.50","667.50","667.50","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","123.77","123.77","123.77","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","483.51","229.32","1316.08","96","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","439.50","225.34","1872.27","197","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 10X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10036985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","385.32","55.36","1815.62","58","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","AETNA [1001]","HB CH AETNA HMO / PPO","1951.10","58.3","","554.95","91.85","1421.75","94","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","2490.03","2490.03","2490.03","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1951.10","58.3","","750.00","750.00","750.00","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1773.72","53","","1192.50","120.84","4149.90","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2844.65","85","","750.00","75.00","750.00","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3346.65","100","","657.00","121.50","1971.00","14","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3346.65","100","","75.00","75.00","75.00","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3346.65","100","","366.00","144.00","1971.00","45","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2443.05","73","","667.50","667.50","667.50","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1487.59","44.45","","123.77","123.77","123.77","1 through 10","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","both","","","3346.65","2509.99","WELLPOINT [1015]","HB CH WELLPOINT","2607.38","77.91","","483.51","229.32","1316.08","96","1487.59","3346.65","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1984.56","59.3","","439.50","225.34","1872.27","197","1673.33","2625.45","percent of total billed charges",""
"NAIL TIBIAL 12X360MM FX TITANIUM CANNULATED PROXIMALIMAL BEND","SUP-ITM-10037011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3346.65","2509.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2625.45","78.45","","385.32","55.36","1815.62","58","1673.33","2625.45","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0300","RC","","","","inpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","273.22","70.6","","289.07","289.07","289.07","1 through 10","216.72","273.22","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","387.00","290.25","AETNA [1001]","HB CH AETNA HMO / PPO","225.62","58.3","","213.19","40.40","213.19","13","38.47","282.51","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","both","","","387.00","290.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","282.51","73","","274.48","274.48","274.48","1 through 10","38.47","282.51","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","387.00","290.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","229.49","59.3","","220.34","220.34","376.00","1 through 10","35.01","303.6","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","289.07","289.07","289.07","1 through 10","35.01","303.6","percent of total billed charges",""
"Natriuretic Peptide","PX-30000583","CDM","83880","CPT","0301","RC","","","","outpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","289.07","171.31","289.07","1 through 10","35.01","303.6","percent of total billed charges",""
"Ndsc Dcmprn Spinal Cord 1 W/Lamot Ntrspc Lumbar","PX-76002397","CDM","62380","CPT","0761","RC","","","","both","","","4192.00","3144.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3563.20","85","","2025.48","2025.48","2025.48","1 through 10","1798.37","4192","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","AETNA [1001]","HB CH AETNA HMO / PPO","655.88","58.3","","554.95","91.85","1421.75","94","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","821.25","73","","2490.03","2490.03","2490.03","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","655.88","58.3","","750.00","750.00","750.00","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","596.25","53","","1192.50","120.84","4149.90","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","956.25","85","","750.00","75.00","750.00","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1125.00","100","","657.00","121.50","1971.00","14","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1125.00","100","","75.00","75.00","75.00","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1125.00","100","","366.00","144.00","1971.00","45","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","821.25","73","","667.50","667.50","667.50","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","500.06","44.45","","123.77","123.77","123.77","1 through 10","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","both","","","1125.00","843.75","WELLPOINT [1015]","HB CH WELLPOINT","876.49","77.91","","483.51","229.32","1316.08","96","500.06","1125","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","667.13","59.3","","439.50","225.34","1872.27","197","562.5","882.56","percent of total billed charges",""
"NEEDLE CURVED SYSTEM MENISCAL REPAIR FAST FIX 360","SUP-ITM-10094730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1125.00","843.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","882.56","78.45","","385.32","55.36","1815.62","58","562.5","882.56","percent of total billed charges",""
"NEEDLE PROCEDURE L 4.6IN 21GA OD CONCAVE SIDE OPENING SIDEKICK COAPTITE IMPLANT - DISCONTINUED PER SUPPLIER","SUP-ITM-10025146","CDM","L8606","HCPCS","0278","RC","","","","both","","","162.41","121.81","AETNA [1001]","HB CH AETNA HMO / PPO","94.69","58.3","","1786.05","1786.05","1786.05","1 through 10","86.08","778.64","percent of total billed charges",""
"NEEDLE PROCEDURE L 4.6IN 21GA OD CONCAVE SIDE OPENING SIDEKICK COAPTITE IMPLANT - DISCONTINUED PER SUPPLIER","SUP-ITM-10025146","CDM","L8606","HCPCS","0278","RC","","","","both","","","162.41","121.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.69","58.3","","3150.00","3150.00","3150.00","1 through 10","86.08","778.64","percent of total billed charges",""
"NEEDLE PROCEDURE L 4.6IN 21GA OD CONCAVE SIDE OPENING SIDEKICK COAPTITE IMPLANT - DISCONTINUED PER SUPPLIER","SUP-ITM-10025146","CDM","L8606","HCPCS","0278","RC","","","","both","","","162.41","121.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","86.08","53","","1669.50","1669.50","1669.50","1 through 10","86.08","778.64","percent of total billed charges",""
"NEEDLE PROCEDURE L 4.6IN 21GA OD CONCAVE SIDE OPENING SIDEKICK COAPTITE IMPLANT - DISCONTINUED PER SUPPLIER","SUP-ITM-10025146","CDM","L8606","HCPCS","0278","RC","","","","outpatient","","","162.41","121.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.31","59.3","","1845.90","1845.90","1845.90","1 through 10","72.19","127.41","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","AETNA [1001]","HB CH AETNA HMO / PPO","409.27","58.3","","554.95","91.85","1421.75","94","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","512.46","73","","2490.03","2490.03","2490.03","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.27","58.3","","750.00","750.00","750.00","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.06","53","","1192.50","120.84","4149.90","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","596.70","85","","750.00","75.00","750.00","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","702.00","100","","657.00","121.50","1971.00","14","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","702.00","100","","75.00","75.00","75.00","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","702.00","100","","366.00","144.00","1971.00","45","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.46","73","","667.50","667.50","667.50","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.04","44.45","","123.77","123.77","123.77","1 through 10","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","WELLPOINT [1015]","HB CH WELLPOINT","546.93","77.91","","483.51","229.32","1316.08","96","312.04","702","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.29","59.3","","439.50","225.34","1872.27","197","351","550.72","percent of total billed charges",""
"NEEDLE TAPERCUT 1.3MM 3 0 SIZE ANCHOR SUTURE XSUTURE ABSORBABLE ETHIBOND QUICKANCHOR PLUS V4","SUP-ITM-10011767","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","550.72","78.45","","385.32","55.36","1815.62","58","351","550.72","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","73.32","75.98","1 through 10","13.33","100.74","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","235.56","235.56","235.56","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30000584","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30001465","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","73.32","75.98","1 through 10","13.33","100.74","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30001465","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","235.56","235.56","235.56","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephelometry Ea Analyte","PX-30001465","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","11.72","108.26","percent of total billed charges",""
"Nephritis And Nephrosis,MAJOR","462","DRG","","","","","","","","inpatient","","","48933.98","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27339.13","","Standard inlier is a Case rate ($27,339.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,694, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,880.90) for the length of stay and the standard reimbursement.","26096.79","26096.79","26096.79","1 through 10","8295.86","36490.53","case rate",""
"Nervous System Malignancy,MAJOR","041","DRG","","","","","","","","inpatient","","","259861.71","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12316.99","","Case rate ($13,618.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,048.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","43427.42","43427.42","43427.42","1 through 10","11653.82","54540.73","case rate",""
"NET RETRIEVAL 3X5.5CM RESCUENET FOREIGN BODY BX/5EA","SUP-ITM-10210617","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","262.65","196.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","206.05","78.45","","119.66","119.66","119.66","1 through 10","131.33","206.05","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1808.00","1356.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","905.81","50.1","","1114.58","1114.58","1114.58","1 through 10","723.2","1418.38","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1808.00","1356.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1043.22","57.7","","1660.00","1060.07","1758.00","1 through 10","723.2","1418.38","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1808.00","1356.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1093.84","60.5","","1274.55","1274.55","1274.55","1 through 10","723.2","1418.38","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1808.00","1356.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.66","44.45","","789.34","789.34","789.34","1 through 10","723.2","1418.38","percent of total billed charges",""
"Neurofilament Light Chain Digital Ia Plasma Quan","PX-30003813","CDM","0361U","CPT","0300","RC","","","","outpatient","","","1808.00","1356.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.38","78.45","","1351.55","800.94","1351.56","1 through 10","723.2","1418.38","percent of total billed charges",""
"Neurological Eye Disorders","123","MS-DRG","","","","","","","","inpatient","","","31917.50","23938.12","MEDICARE [2001]","HB BWF MEDICARE","8395.35","","Case rate ($8,395.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,704.31, add-ons for qualifying new technology services are included. If operating cost exceeds $53,228.04 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,125.36, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,491.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,365.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.58. The transfer capital threshold is the transfer adjustment factor * $564.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8237.76","8237.76","8237.76","1 through 10","7538.48","8395.35","other","Inpatient DRG"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","both","","","5343.00","4007.25","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","5081.19","other","OPPS APC"
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5343.00","4007.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2621.81","49.07","","2115.00","2115.00","2115.00","1 through 10","567.68","4191.58","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5343.00","4007.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2676.84","50.1","","331.25","331.25","331.25","1 through 10","567.68","4191.58","percent of total billed charges",""
"Neurolysis Ganglion Impar","PX-76002828","CDM","64999","CPT","0761","RC","","","","outpatient","","","5343.00","4007.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4191.58","78.45","","282.15","282.15","282.15","1 through 10","567.68","4191.58","percent of total billed charges",""
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","both","","","4905.00","3678.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1468.33","","Case rate ($1,468.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","3656.14","3656.14","3656.14","1 through 10","1468.33","3821.49","other","Multiple Surgery"
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","both","","","4905.00","3678.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","2433.76","","APC Price ($2,483.43). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2280.15","2073.06","2280.55","1 through 10","1468.33","3821.49","other","OPPS APC"
"Neuroplasty &/Transpos Median Nrv Carpal Tunne","PX-76002373","CDM","64721","CPT","0761","RC","","","","outpatient","","","4905.00","3678.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1468.33","","Case rate ($1,468.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","3450.58","3450.58","3450.58","1 through 10","1468.33","4472.66","other","Multiple Surgery"
"Neuroplasty &/Transpos Median Nrv Carpal Tunne|BILATERAL PROCEDURE","PX-76002373","CDM","64721","CPT","0761","RC","","","50","outpatient","","","4905.00","3678.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2798.54","","Case rate ($2,798.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3962.73","3962.73","3962.73","1 through 10","2798.54","8319.15","other","ASC "
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","28253.29","21189.97","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","175.89","","Case rate ($175.89) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","10264.73","10264.73","10264.73","1 through 10","175.89","9513.218","other","Inpatient Psych"
"Neuroses Except Depressive","882","MS-DRG","","","","","","","","inpatient","","","28253.29","21189.97","MEDICARE [2001]","HB BWF MEDICARE","175.89","","Case rate ($175.89) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","9752.28","6543.29","25597.49","1 through 10","175.89","9513.218","other","Inpatient Psych"
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","both","","","975.00","731.25","WELLPOINT [1015]","HB CH WELLPOINT","759.62","77.91","","2948.77","2948.77","2948.77","1 through 10","516.75","975","percent of total billed charges",""
"NEUROSTIMULATOR EXTERNAL 43X15X51MM VERIFY ENS POLYCARBONATE ABS BLEND PLASTIC RESIN","SUP-ITM-10152713","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","975.00","731.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","578.18","59.3","","4673.98","4673.98","4673.98","1 through 10","433.39","764.89","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT - DISCONTINUED PER SUPPLIER","SUP-ITM-10209119","CDM","C1820","HCPCS","0278","RC","","","","both","","","35100.00","26325.00","WELLPOINT [1015]","HB CH WELLPOINT","27346.41","77.91","","17681.62","17681.62","17681.62","1 through 10","18603","35100","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT - DISCONTINUED PER SUPPLIER","SUP-ITM-10209119","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","35100.00","26325.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","20814.30","59.3","","74853.32","74853.32","74853.32","1 through 10","15601.95","27535.95","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT 16 CHANNEL","SUP-ITM-10211136","CDM","C1820","HCPCS","0278","RC","","","","both","","","36900.00","27675.00","WELLPOINT [1015]","HB CH WELLPOINT","28748.79","77.91","","17681.62","17681.62","17681.62","1 through 10","19557","36900","percent of total billed charges",""
"NEUROSTIMULATOR IPG PROCLAIM DRG 4 PORT 16 CHANNEL","SUP-ITM-10211136","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","36900.00","27675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","21881.70","59.3","","74853.32","74853.32","74853.32","1 through 10","16402.05","28948.05","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","78.52","78.52","78.52","1 through 10","17.44","108.26","percent of total billed charges",""
"Neutralization Viral","PX-30000858","CDM","86382","CPT","0302","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","103.02","103.02","1 through 10","17.44","108.26","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","AETNA [1001]","HB CH AETNA HMO / PPO","299.08","58.3","","282.93","282.93","658.29","18","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","369.87","72.1","","376.25","376.25","376.25","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","325.24","63.4","","330.84","330.84","1161.00","14","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.03","44.45","","227.34","227.34","528.95","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","UNITED HEALTHCARE ALTERNATE [1020]","HB CH HPHC ALLIANCE PPO PREFERRED B","325.24","63.4","","769.74","769.74","769.74","1 through 10","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","both","","","513.00","384.75","WELLPOINT [1015]","HB CH WELLPOINT","399.68","77.91","","914.40","393.01","2075.40","28","139.78","487.86","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","304.21","59.3","","680.35","292.41","3444.57","50","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","296.00","57.7","","700.08","300.90","2020.14","80","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","310.37","60.5","","376.25","315.87","1121.79","25","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","304.21","59.3","","664.09","664.09","664.09","1 through 10","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bacteral Vaginosis Rna Vaginal-Fluid Alg","PX-31001145","CDM","81513","CPT","0310","RC","","","","outpatient","","","513.00","384.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","402.45","78.45","","383.63","227.34","892.58","20","187.76","402.45","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","both","","","2097.00","1572.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","1329.50","63.4","","965.88","965.88","965.88","1 through 10","408.44","1994.25","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1029.00","49.07","","2097.00","2097.00","2097.00","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1050.60","50.1","","646.01","646.01","646.01","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1243.52","59.3","","2097.00","2097.00","2097.00","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2","PX-30003660","CDM","0202U","CPT","0300","RC","","","","outpatient","","","2097.00","1572.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","1268.69","60.5","","1675.50","1675.50","1675.50","1 through 10","767.5","1645.1","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","298.00","223.50","AETNA [1001]","HB CH AETNA HMO / PPO","173.73","58.3","","164.43","164.43","164.43","1 through 10","70.75","383.33","percent of total billed charges",""
"Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr","PX-30003536","CDM","81596","CPT","0300","RC","","","","both","","","298.00","223.50","WELLPOINT [1015]","HB CH WELLPOINT","232.17","77.91","","228.40","228.40","228.40","1 through 10","70.75","383.33","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","AETNA [1001]","HB CH AETNA HMO / PPO","278.67","58.3","","271.03","271.03","271.03","1 through 10","103.06","454.58","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","167.30","35","","139.78","139.78","139.78","1 through 10","103.06","454.58","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","303.05","63.4","","478.00","183.53","504.95","1 through 10","103.06","454.58","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","348.94","73","","140.98","140.98","140.98","1 through 10","103.06","454.58","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","TRICARE [160005]","HB BWF TRICARE","454.10","95","","163.28","163.28","163.28","1 through 10","103.06","454.58","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","both","","","478.00","358.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","167.30","35","","139.78","139.78","139.78","1 through 10","103.06","454.58","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","234.55","49.07","","221.08","221.08","221.08","52","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","239.48","50.1","","221.08","221.08","221.08","62","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.45","59.3","","280.11","280.11","280.11","1 through 10","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","275.81","57.7","","459.30","440.76","1322.28","47","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","289.19","60.5","","478.00","478.00","1434.00","16","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","289.19","60.5","","482.12","482.12","482.12","1 through 10","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","374.99","78.45","","367.49","367.49","367.49","1 through 10","174.95","374.99","percent of total billed charges",""
"Nfct Ds Rna 4 Targets Upper Respiratory Specimen","PX-30003718","CDM","0241U","CPT","0300","RC","","","","outpatient","","","478.00","358.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","374.99","78.45","","367.49","217.78","367.49","1 through 10","174.95","374.99","percent of total billed charges",""
"Nitric Oxide Expired Gas Determin","PX-92000001","CDM","95012","CPT","0460","RC","","","","both","","","110.00","82.50","WELLPOINT [1015]","HB CH WELLPOINT","85.70","77.91","","84.27","84.27","84.27","1 through 10","45.68","124.95","percent of total billed charges",""
"Nitric Oxide Expired Gas Determin","PX-92000001","CDM","95012","CPT","0460","RC","","","","outpatient","","","110.00","82.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.23","59.3","","62.70","62.70","62.70","1 through 10","48.9","188.77","percent of total billed charges",""
"Nitric Oxide Expired Gas Determin","PX-92000001","CDM","95012","CPT","0460","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.30","78.45","","82.26","82.26","82.26","1 through 10","48.9","188.77","percent of total billed charges",""
"Nitric Oxide Expired Gas Determin","PX-92000001","CDM","95012","CPT","0460","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.90","44.45","","48.75","48.75","48.75","1 through 10","48.9","188.77","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","both","","","110.00","82.50","WELLPOINT [1015]","HB CH WELLPOINT","85.70","77.91","","84.27","84.27","84.27","1 through 10","45.68","124.95","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","110.00","82.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.23","59.3","","62.70","62.70","62.70","1 through 10","48.9","188.77","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.30","78.45","","82.26","82.26","82.26","1 through 10","48.9","188.77","percent of total billed charges",""
"Nitric Oxide Test","PX-46000082","CDM","95012","CPT","0460","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.90","44.45","","48.75","48.75","48.75","1 through 10","48.9","188.77","percent of total billed charges",""
"Njx Aa&/Strd Tfrml Epi Cervical/Thoracic 1 Level","PX-76001520","CDM","64479","CPT","0761","RC","","","","both","","","2252.00","1689.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1904.45","1904.45","1904.45","1 through 10","764.84","1643.96","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Cervical/Thoracic 1 Level","PX-76001520","CDM","64479","CPT","0761","RC","","","","both","","","2252.00","1689.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1036.13","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1039.30","982.82","1044.03","1 through 10","764.84","1643.96","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","1760.00","1320.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","3372.95","3372.95","3372.95","1 through 10","764.84","1627.62","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","both","","","1760.00","1320.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1036.13","","APC Price ($1,057.27). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1043.63","1043.13","1561.70","13","764.84","1627.62","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level","PX-76001526","CDM","64483","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","764.84","","Case rate ($764.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1820.32","1820.32","1820.32","1 through 10","764.84","1873.9","other","Multiple Surgery"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level|MULTIPLE PROCEDURES","PX-76001526","CDM","64483","CPT","0761","RC","","","51","both","","","1760.00","1320.00","MEDICARE [2001]","HB BWF MEDICARE","930.14","","APC Price ($930.14). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1057.27","1057.27","1057.27","1 through 10","755.04","958.04","other","OPPS APC"
"Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl","PX-76001529","CDM","64484","CPT","0761","RC","","","","outpatient","","","313.00","234.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.61","59.3","","282.56","282.56","282.56","1 through 10","87.19","245.55","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","847.08","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.16","846.26","847.16","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","AETNA [1001]","HB CH AETNA HMO / PPO","1051.73","58.3","","994.52","994.52","994.52","1 through 10","598.81","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1550.92","1550.92","1 through 10","598.81","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","30","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1781.55","1773.29","1887.36","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","812.97","742.69","813.87","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","both","","","1804.00","1353.00","WELLSENSE [1003]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2427.75","2427.75","2427.75","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","988.81","968.26","988.81","1 through 10","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","969.63","969.63","990.18","13","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1069.77","59.3","","1027.84","1027.84","1027.84","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1353.31","1407.20","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-76002390","CDM","62321","CPT","0761","RC","","","","outpatient","","","1804.00","1353.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1415.24","78.45","","1348.47","1348.47","1348.47","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","847.08","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.16","846.26","847.16","1 through 10","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB CH AETNA HMO / PPO","325.31","58.3","","994.52","994.52","994.52","1 through 10","248.03","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1550.92","1550.92","1 through 10","248.03","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","30","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1781.55","1773.29","1887.36","1 through 10","248.03","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","812.97","742.69","813.87","1 through 10","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","both","","","558.00","418.50","WELLSENSE [1003]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2427.75","2427.75","2427.75","1 through 10","248.03","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","330.89","59.3","","1027.84","1027.84","1027.84","1 through 10","277.49","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1353.31","1407.20","1 through 10","277.49","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn","PX-98301325","CDM","62321","CPT","0983","RC","","","","outpatient","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","437.75","78.45","","1348.47","1348.47","1348.47","1 through 10","277.49","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","847.08","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.16","847.06","851.76","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","AETNA [1001]","HB CH AETNA HMO / PPO","1068.64","58.3","","1010.39","1010.39","1010.39","1 through 10","598.81","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","742.69","809.25","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.25","742.69","811.54","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","FALLON HEALTH [1008]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.30","104.30","104.30","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","744.96","744.96","744.96","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1491.04","1550.92","1 through 10","598.81","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1338.09","73","","1300.86","1300.86","1300.86","1 through 10","598.81","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","HUMANA [1012]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","744.20","744.20","744.20","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","245","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","739.67","805.96","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1865.70","1820.59","1983.17","14","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","6051.36","1827.18","6051.36","1 through 10","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","1984.57","1826.52","6296.02","37","598.81","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1338.09","73","","1165.27","1165.27","1165.27","1 through 10","598.81","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","598.81","1627.62","other","Tricare OPPS"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.96","807.96","807.96","1 through 10","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","both","","","1833.00","1374.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","805.96","739.68","813.87","77","598.81","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","968.26","968.26","988.81","27","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","684.77","","Case rate ($684.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","990.18","969.63","990.18","40","598.81","1873.9","other","ASC "
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1086.97","59.3","","1044.25","1044.25","1044.25","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","2706.62","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1550.92","1479.06","1760.50","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","1437.99","78.45","","1370.00","1370.00","1370.00","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-76002392","CDM","62323","CPT","0761","RC","","","","outpatient","","","1833.00","1374.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1437.99","78.45","","811.88","811.88","1370.00","1 through 10","598.81","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","847.08","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","847.16","847.06","851.76","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","AETNA [1001]","HB CH AETNA HMO / PPO","300.83","58.3","","1010.39","1010.39","1010.39","1 through 10","229.36","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","809.25","742.69","809.25","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","809.25","742.69","811.54","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","FALLON HEALTH [1008]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.30","104.30","104.30","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","744.96","744.96","744.96","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","1550.92","1491.04","1550.92","1 through 10","229.36","1627.62","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","376.68","73","","1300.86","1300.86","1300.86","1 through 10","229.36","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","HUMANA [1012]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","744.20","744.20","744.20","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","754.77","822.41","245","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","805.96","739.67","805.96","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1865.70","1820.59","1983.17","14","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,130). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","6051.36","1827.18","6051.36","1 through 10","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","1984.57","1826.52","6296.02","37","229.36","1627.62","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","376.68","73","","1165.27","1165.27","1165.27","1 through 10","229.36","1627.62","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","781.29","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","822.41","822.41","822.41","1 through 10","229.36","1627.62","other","Tricare OPPS"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","807.96","807.96","807.96","1 through 10","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","both","","","516.00","387.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","805.96","739.68","813.87","77","229.36","1627.62","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","305.99","59.3","","1044.25","1044.25","1044.25","1 through 10","256.61","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1407.20","1407.20","2706.62","1 through 10","256.61","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1550.92","1479.06","1760.50","1 through 10","256.61","1873.9","other","Multiple Surgery"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","404.80","78.45","","1370.00","1370.00","1370.00","1 through 10","256.61","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn","PX-98301327","CDM","62323","CPT","0983","RC","","","","outpatient","","","516.00","387.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","404.80","78.45","","811.88","811.88","1370.00","1 through 10","256.61","1873.9","percent of total billed charges",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA","PX-76002392","CDM","62323","CPT","0761","RC","","","74","both","","","1833.00","1374.75","MEDICARE [2001]","HB BWF MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","805.88","1630.56","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn|DISCONTINUED OUT-PATIENT HOSPITAL/AMBULATORY SURGERY CENTER (ASC) PROCEDURE AFTER ADMINISTRATION OF ANESTHESIA","PX-98301327","CDM","62323","CPT","0983","RC","","","74","both","","","516.00","387.00","MEDICARE [2001]","HB BWF MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","805.88","1630.56","other","OPPS APC"
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn","PX-76002391","CDM","62322","CPT","0761","RC","","","","both","","","2252.00","1689.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","598.81","1643.96","per diem",""
"Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn","PX-98301326","CDM","62322","CPT","0983","RC","","","","both","","","439.00","329.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","232.67","1627.62","per diem",""
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2239.00","1679.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","469.56","469.56","1 through 10","453.34","1634.47","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2239.00","1679.25","MEDICARE [2001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1634.47","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","both","","","2239.00","1679.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.66","469.57","472.66","1 through 10","453.34","1634.47","other","OPPS APC"
"NM Bone 3 Phase","PX-34000045","CDM","78315","CPT","0341","RC","","","","outpatient","","","2239.00","1679.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1327.73","59.3","","1275.72","1275.72","1275.72","1 through 10","626.57","1756.5","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","442.95","469.56","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","MEDICARE [2001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","450.15","1431.60","28","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","453.34","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","477.20","477.20","477.20","1 through 10","453.34","1329.12","other","Tricare OPPS"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","both","","","1608.00","1206.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.66","469.56","472.66","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","1608.00","1206.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","953.54","59.3","","916.50","916.50","916.50","1 through 10","626.57","1261.48","percent of total billed charges",""
"NM Bone Wb","PX-34000044","CDM","78306","CPT","0341","RC","","","","outpatient","","","1608.00","1206.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1261.48","78.45","","1202.40","1202.40","1202.40","1 through 10","626.57","1261.48","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","469.56","406.32","469.56","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","MEDICARE [2001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","23","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","470.86","470.86","470.86","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","470.46","469.56","470.46","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","both","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","467.65","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","467.66","467.66","470.66","1 through 10","453.34","1388.46","other","OPPS APC"
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1127.89","59.3","","1083.51","1083.51","1083.51","1 through 10","626.57","1492.12","percent of total billed charges",""
"NM Gastric Emptying","PX-34000029","CDM","78264","CPT","0341","RC","","","","outpatient","","","1902.00","1426.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1492.12","78.45","","1849.00","1421.51","1849.00","1 through 10","626.57","1492.12","percent of total billed charges",""
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","2755.00","2066.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","639.23","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","607.27","2011.15","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","2755.00","2066.25","MEDICARE [2001]","HB BWF MEDICARE","639.23","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","639.23","639.23","1 through 10","607.27","2011.15","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","both","","","2755.00","2066.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","639.23","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","629.65","629.65","629.65","1 through 10","607.27","2011.15","other","OPPS APC"
"NM Hepatobiliary System Img W/Drug","PX-34000023","CDM","78227","CPT","0341","RC","","","","outpatient","","","2755.00","2066.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1633.72","59.3","","1569.89","1569.89","1569.89","1 through 10","807.41","2161.3","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1524.98","1525.53","14","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1519.33","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1525.53","1525.53","1525.53","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","FALLON HEALTH [1008]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4651.02","4651.02","4651.02","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","MEDICARE [2001]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","171","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1522.33","1519.33","1522.53","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1519.33","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.13","498.78","1525.53","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","both","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1519.33","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.34","1519.33","1524.98","35","1472.82","4622.47","other","OPPS APC"
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","outpatient","","","4213.00","3159.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2498.31","59.3","","2400.84","2400.84","13153.23","1 through 10","2106.5","3721.34","percent of total billed charges",""
"NM Hrt Muscle Image Spect Sing","PX-34000049","CDM","78451","CPT","0341","RC","","","","outpatient","","","4213.00","3159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3305.10","78.45","","3149.77","3149.77","3149.78","1 through 10","2106.5","3721.34","percent of total billed charges",""
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1502.00","1126.50","MEDICARE [2001]","HB BWF MEDICARE","639.23","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney Scan W/Flow & Function","PX-34000104","CDM","78707","CPT","0341","RC","","","","both","","","1502.00","1126.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","626.44","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","580.92","580.92","580.92","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","MEDICARE [2001]","HB BWF MEDICARE","639.23","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","639.23","589.92","639.23","16","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","626.44","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","629.25","629.25","629.25","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","both","","","1876.00","1407.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","626.44","","APC Price ($639.23). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","631.45","631.45","631.45","1 through 10","607.27","1712.76","other","OPPS APC"
"NM Kidney W/Pharmacological Interv","PX-34000105","CDM","78708","CPT","0341","RC","","","","outpatient","","","1876.00","1407.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1112.47","59.3","","1068.86","1068.86","1068.86","1 through 10","807.41","1471.72","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.53","1524.98","1525.53","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1519.33","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1525.53","1525.53","1525.53","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","FALLON HEALTH [1008]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1525.33","1525.33","1525.33","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","MEDICARE [2001]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","104","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1550.34","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1522.53","1521.98","1522.53","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1519.33","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1522.13","1522.13","1522.13","1 through 10","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","both","","","4185.00","3138.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1519.33","","APC Price ($1,550.34). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1519.74","1519.33","1524.34","25","1472.82","4622.47","other","OPPS APC"
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","4185.00","3138.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2481.71","59.3","","2384.43","2384.43","2384.43","1 through 10","2092.5","3721.34","percent of total billed charges",""
"NM Myocardial Spect Multiple Studie","PX-34000050","CDM","78452","CPT","0341","RC","","","","outpatient","","","4185.00","3138.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3283.13","78.45","","1853.84","1853.84","3128.25","1 through 10","2092.5","3721.34","percent of total billed charges",""
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","both","","","1512.00","1134.00","MEDICARE [2001]","HB BWF MEDICARE","477.20","","APC Price ($477.20). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.20","477.20","477.20","1 through 10","453.34","1329.12","other","OPPS APC"
"NM Thyroid Scan W/Uptake Sgl/Multi","PX-34000134","CDM","78014","CPT","0341","RC","","","","outpatient","","","1512.00","1134.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","896.62","59.3","","861.42","861.42","861.42","1 through 10","626.57","1186.16","percent of total billed charges",""
"Non Endoscopic GI Tube Removal Under Sedation","PX-75000449","CDM","43999","CPT","0750","RC","","","","both","","","1307.00","980.25","WELLPOINT [1015]","HB CH WELLPOINT","1018.28","77.91","","2383.28","2383.28","2383.28","1 through 10","560.7","1242.96","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5034.00","3775.50","AETNA [1001]","HB CH AETNA HMO / PPO","2934.82","58.3","","2731.24","2731.24","2731.24","1 through 10","789.41","4787.33","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5034.00","3775.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","814.34","","APC Price ($830.96). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","817.66","817.66","817.66","1 through 10","789.41","4787.33","other","OPPS APC"
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5034.00","3775.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2668.02","53","","2553.01","2553.01","2553.01","1 through 10","789.41","4787.33","percent of total billed charges",""
"Non Esrd Acute Hemodialysis OP","PX-82000035","CDM","90935","CPT","0829","RC","","","","both","","","5034.00","3775.50","WELLPOINT [1015]","HB CH WELLPOINT","3921.99","77.91","","3793.87","3793.87","3793.87","1 through 10","789.41","4787.33","percent of total billed charges",""
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","098","MS-DRG","","","","","","","","inpatient","","","49961.49","37471.12","MEDICARE [2001]","HB BWF MEDICARE","23489.68","","Case rate ($23,489.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,503.89, add-ons for qualifying new technology services are included. If operating cost exceeds $67,027.62 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,183.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $21,528.05 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,164.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,622.40. The transfer capital threshold is the transfer adjustment factor * $1,622.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21821.52","21821.52","21821.52","1 through 10","21040.06","23557.15","other","Inpatient DRG"
"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC","097","MS-DRG","","","","","","","","inpatient","","","80144.03","60108.02","MEDICARE [2001]","HB BWF MEDICARE","36774.29","","Case rate ($36,774.29). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $33,648.97, add-ons for qualifying new technology services are included. If operating cost exceeds $79,172.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,114.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.7. The base transfer operating payment is the transfer adjustment factor * $33,881.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $33,309.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,553.40. The transfer capital threshold is the transfer adjustment factor * $2,553.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35894.51","35894.51","35894.51","1 through 10","32922.87","36774.29","other","Inpatient DRG"
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MAJOR","050","DRG","","","","","","","","inpatient","","","40537.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","45710.56","","Standard inlier is a Case rate ($45,710.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $55,303, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,488.42) for the length of stay and the standard reimbursement.","45710.55","45710.55","45710.55","1 through 10","12476.92","70356.41","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MODERATE","050","DRG","","","","","","","","inpatient","","","26278.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26829.22","","Standard inlier is a Case rate ($26,829.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,486, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,808.51) for the length of stay and the standard reimbursement.","26829.21","26829.21","26829.21","1 through 10","12476.92","70356.41","case rate",""
"Non-Bacterial Infections Of Nervous System Except Viral Meningitis,MODERATE","050","DRG","","","","","","","","inpatient","","","26278.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28819.93","","Standard inlier is a Case rate ($28,819.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,171, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,090.87) for the length of stay and the standard reimbursement.","27509.93","27509.93","27509.93","1 through 10","12476.92","70356.41","case rate",""
"Non-Elective Or Complex Hip Joint Replacement,MINOR","323","DRG","","","","","","","","inpatient","","","42073.60","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","40158.02","","Standard inlier is a Case rate ($40,158.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $52,844, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,700.59) for the length of stay and the standard reimbursement.","38341.61","38341.61","38341.61","1 through 10","15978.27","48438.76","case rate",""
"Non-Elective Or Complex Knee Joint Replacement,MINOR","325","DRG","","","","","","","","inpatient","","","30946.60","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","31498.46","","Case rate ($34,826.96). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $77,256.96, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $8,043.18 and the sum of the standard inlier and any outlier amount.","34818.41","34818.41","34818.41","1 through 10","31498.46","82356.95","case rate",""
"Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis,MODERATE","952","DRG","","","","","","","","inpatient","","","43038.21","","MASSHEALTH [3001]","HB BWF MEDICAID","12444.94","","Case rate ($13,760.02). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,190.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5563.78","5563.78","5563.78","1 through 10","12444.94","40379.16","case rate",""
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","46189.28","34641.96","MEDICARE [2001]","HB BWF MEDICARE","16919.52","","Case rate ($16,919.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,497.29, add-ons for qualifying new technology services are included. If operating cost exceeds $61,021.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,722.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $15,418.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,158.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.96. The transfer capital threshold is the transfer adjustment factor * $1,161.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17199.09","17199.09","17199.09","1 through 10","15163.19","16919.52","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","988","MS-DRG","","","","","","","","inpatient","","","46189.28","34641.96","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15163.19","","Case rate ($15,472.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,497.29, add-ons for qualifying new technology services are included. If operating cost exceeds $61,021.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,722.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,971.43 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,158.06 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,161.96. The transfer capital threshold is the transfer adjustment factor * $1,161.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15547.93","15547.93","15547.93","1 through 10","15163.19","16919.52","other","Inpatient DRG"
"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC","987","MS-DRG","","","","","","","","inpatient","","","69554.62","52165.96","MEDICARE [2001]","HB BWF MEDICARE","31906.12","","Case rate ($31,906.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $31,957.57, add-ons for qualifying new technology services are included. If operating cost exceeds $77,481.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,984.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,143.14 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $31,618.33 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,423.74. The transfer capital threshold is the transfer adjustment factor * $2,423.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35080.15","35080.15","35080.15","1 through 10","31268","34638.2003","other","Inpatient Replacement Plans DRG"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","AETNA [1001]","HB CH AETNA HMO / PPO","0.58","58.3","","0.57","0.57","199.02","51","0.21","31.67","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","0.73","73","","0.57","0.57","0.57","1 through 10","0.21","31.67","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","both","","","1.00","0.75","WELLPOINT [1015]","HB CH WELLPOINT","0.78","77.91","","0.79","0.79","2.79","33","0.21","31.67","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0343","RC","","","","outpatient","","","1.00","0.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.59","59.3","","316.44","0.57","462.94","1 through 10","0.19","21.5","percent of total billed charges",""
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10.30","","APC Price ($10). Final payment is multiplied by 103%.","10.29","6.18","10.29","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.81","9.81","9.81","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","FALLON HEALTH [1008]","HB BWF MEDICARE","10.00","","APC Price ($10).","3.00","3.00","5.88","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MEDICARE [2001]","HB BWF MEDICARE","10.00","","APC Price ($10).","10.00","6.00","10.00","198","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","10.00","","APC Price ($10).","0.99","0.98","1.00","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.80","5.88","9.80","1 through 10","9.5","10.3","other","OPPS APC"
"Non-Heu Tc-99m Add-on per Dose","PX-34300155","CDM","Q9969","HCPCS","0636","RC","","","","both","","","1.00","0.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9.80","","APC Price ($10). Final payment is multiplied by 98%.","9.80","5.88","9.80","48","9.5","10.3","other","OPPS APC"
"Non-Hypovolemic Sodium Disorders,EXTREME","426","DRG","","","","","","","","inpatient","","","50533.03","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","40796.63","","Standard inlier is a Case rate ($40,796.63). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $50,609, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,790.91) for the length of stay and the standard reimbursement.","38942.24","38942.24","38942.24","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,EXTREME","426","DRG","","","","","","","","inpatient","","","50533.03","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","17938.57","","Case rate ($19,834.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,264.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","38482.21","","MASSHEALTH [3001]","HB BWF MEDICAID","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9639.07","9639.07","10434.29","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","38482.21","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","41419.03","","Fee schedule rate ($41,419.03). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20492.99","20492.99","20492.99","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","38482.21","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10434.29","10434.29","10434.29","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MAJOR","426","DRG","","","","","","","","inpatient","","","38482.21","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10434.29","10434.29","10434.29","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14655.07","","Standard inlier is a Case rate ($14,655.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,998, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,080.34) for the length of stay and the standard reimbursement.","14655.06","14655.06","14655.06","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15742.47","","Standard inlier is a Case rate ($15,742.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,681, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,234.58) for the length of stay and the standard reimbursement.","15742.46","15742.46","15742.46","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","MASSHEALTH [3001]","HB BWF MEDICAID","5993.99","","Case rate ($6,627.39). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,057.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6625.77","6625.77","6625.77","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6950.87","","Fee schedule rate ($6,950.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6950.87","6950.87","6950.87","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","14815.45","","Fee schedule rate ($14,815.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14815.45","14815.45","14815.45","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5993.99","","Case rate ($6,627.39). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,057.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6625.76","695.29","6660.16","1 through 10","4074.82","41419.03","case rate",""
"Non-Hypovolemic Sodium Disorders,MODERATE","426","DRG","","","","","","","","inpatient","","","19215.81","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5993.99","","Case rate ($6,627.39). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,057.39, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6625.76","2614.56","6625.76","1 through 10","4074.82","41419.03","case rate",""
"Non-India Ink (Spot) Tattooing Lymph Node Area","PX-76002699","CDM","38999","CPT","0761","RC","","","","outpatient","","","766.00","574.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","375.88","49.07","","12132.25","11259.00","12132.25","1 through 10","375.88","970.06","percent of total billed charges",""
"Non-India Ink (Spot) Tattooing Lymph Node Area","PX-76002699","CDM","38999","CPT","0761","RC","","","","outpatient","","","766.00","574.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","383.77","50.1","","10684.50","310.07","10684.50","1 through 10","375.88","970.06","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","554.95","91.85","1421.75","94","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","105.12","73","","2490.03","2490.03","2490.03","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","83.95","58.3","","750.00","750.00","750.00","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.32","53","","1192.50","120.84","4149.90","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","122.40","85","","750.00","75.00","750.00","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","144.00","100","","657.00","121.50","1971.00","14","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","144.00","100","","75.00","75.00","75.00","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","144.00","100","","366.00","144.00","1971.00","45","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.12","73","","667.50","667.50","667.50","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.01","44.45","","123.77","123.77","123.77","1 through 10","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","WELLPOINT [1015]","HB CH WELLPOINT","112.19","77.91","","483.51","229.32","1316.08","96","64.01","144","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.00","108.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.39","59.3","","439.50","225.34","1872.27","197","72","112.97","percent of total billed charges",""
"NON-LOCKING SCREW 4.5 X 38MM TI","SUP-ITM-10327199","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","385.32","55.36","1815.62","58","72","112.97","percent of total billed charges",""
"Non-Malignant Breast Disorders With Cc/McC","600","MS-DRG","","","","","","","","inpatient","","","20843.33","15632.50","MEDICARE [2001]","HB BWF MEDICARE","9929.75","","Case rate ($9,929.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,945.37, add-ons for qualifying new technology services are included. If operating cost exceeds $55,469.10 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,297.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,854.13 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,606.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $736.37. The transfer capital threshold is the transfer adjustment factor * $736.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9698.94","9698.94","9698.94","1 through 10","9459.8174","10227.64","other","Inpatient Replacement Plans DRG"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","287.00","215.25","AETNA [1001]","HB CH AETNA HMO / PPO","167.32","58.3","","7.63","7.63","7.63","23","67.25","745.32","percent of total billed charges",""
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","287.00","215.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","236.71","","APC Price ($241.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","274.17","274.17","274.17","1 through 10","67.25","745.32","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","287.00","215.25","MEDICARE [2001]","HB BWF MEDICARE","241.54","","APC Price ($241.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","241.54","241.54","241.54","1 through 10","67.25","745.32","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","both","","","287.00","215.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","236.71","","APC Price ($241.54). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","236.71","236.71","236.71","1 through 10","67.25","745.32","other","OPPS APC"
"Nonpressurized Inhalation Treatment","PX-46000001","CDM","94640","CPT","0410","RC","","","","outpatient","","","287.00","215.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.19","59.3","","163.49","163.49","163.49","1 through 10","143.5","473.25","percent of total billed charges",""
"Nonspecific Cva And Precerebral Occlusion Without Infarction,MODERATE","046","DRG","","","","","","","","inpatient","","","46173.30","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","15522.6235","","Fee schedule rate ($18,083.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15522.6235","18083.40","18083.40","1 through 10","5032.12","28416.64","case rate",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","1 through 10","34.39","207.04","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","186.00","139.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.30","59.3","","106.07","106.07","207.06","1 through 10","26.86","164.21","percent of total billed charges",""
"Nuc Acid Stph Aureus Amplified","PX-30001337","CDM","87641","CPT","0306","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","139.15","139.15","1 through 10","26.86","164.21","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","17","34.39","219.73","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.79","44.45","","133.49","133.49","133.49","1 through 10","34.39","219.73","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","515.10","37","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","301.00","225.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","178.49","59.3","","167.60","167.60","167.60","1 through 10","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Candida","PX-30001268","CDM","87481","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","20","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","103.13","103.13","103.13","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","131.85","13","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001344","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","24","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","127.58","127.58","127.58","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","103.13","103.13","103.13","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","131.85","131.85","131.85","13","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Infectious","PX-30001428","CDM","87798","CPT","0306","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","172.98","102.51","172.98","24","26.86","181.22","percent of total billed charges",""
"Nucleic Acid Amp Multi Org","PX-30001347","CDM","87801","CPT","0306","RC","","","","outpatient","","","468.00","351.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","277.52","59.3","","266.63","266.63","266.63","1 through 10","53.71","367.15","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","222.00","166.50","AETNA [1001]","HB CH AETNA HMO / PPO","129.43","58.3","","122.47","122.47","122.47","1 through 10","36.52","207.04","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","both","","","222.00","166.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.68","44.45","","166.06","166.06","166.06","1 through 10","36.52","207.04","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","222.00","166.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","131.65","59.3","","126.58","126.58","126.58","1 through 10","26.86","174.16","percent of total billed charges",""
"Nucleic Acid Amp Probe Clostridium","PX-30001277","CDM","87493","CPT","0306","RC","","","","outpatient","","","222.00","166.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.16","78.45","","98.41","98.41","98.41","1 through 10","26.86","174.16","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","both","","","226.00","169.50","AETNA [1001]","HB CH AETNA HMO / PPO","131.76","58.3","","124.74","124.74","124.74","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","226.00","169.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.02","59.3","","128.92","128.92","257.84","1 through 10","26.86","177.3","percent of total billed charges",""
"Nucleic Acid Amp Probe Herpes Smpx","PX-30001300","CDM","87529","CPT","0306","RC","","","","outpatient","","","226.00","169.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","177.30","78.45","","169.14","169.14","169.14","1 through 10","26.86","177.3","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","301.00","225.75","AETNA [1001]","HB CH AETNA HMO / PPO","175.48","58.3","","166.13","166.13","166.13","1 through 10","34.39","219.73","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","both","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.79","44.45","","225.26","225.26","225.26","1 through 10","34.39","219.73","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","301.00","225.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","178.49","59.3","","171.70","171.70","171.70","15","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Amp Strep Group B","PX-30001341","CDM","87653","CPT","0306","RC","","","","outpatient","","","301.00","225.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","236.13","78.45","","225.26","133.49","225.26","1 through 10","26.86","236.13","percent of total billed charges",""
"Nucleic Acid Direct Chlamydia Trach","PX-30001274","CDM","87490","CPT","0306","RC","","","","both","","","233.00","174.75","AETNA [1001]","HB CH AETNA HMO / PPO","135.84","58.3","","128.71","128.71","128.71","59","22.3","170.09","percent of total billed charges",""
"Nucleic Acid Direct Chlamydia Trach","PX-30001274","CDM","87490","CPT","0306","RC","","","","both","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.57","44.45","","103.42","103.42","174.52","1 through 10","22.3","170.09","percent of total billed charges",""
"Nucleic Acid Direct Chlamydia Trach","PX-30001274","CDM","87490","CPT","0306","RC","","","","outpatient","","","233.00","174.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","138.17","59.3","","133.02","133.02","399.06","58","20.68","182.79","percent of total billed charges",""
"Nucleic Acid Direct Chlamydia Trach","PX-30001274","CDM","87490","CPT","0306","RC","","","","outpatient","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","182.79","78.45","","174.52","103.42","174.52","40","20.68","182.79","percent of total billed charges",""
"Nucleic Acid Direct Gc","PX-30001329","CDM","87590","CPT","0306","RC","","","","both","","","233.00","174.75","AETNA [1001]","HB CH AETNA HMO / PPO","135.84","58.3","","128.71","128.71","128.71","59","26.34","170.09","percent of total billed charges",""
"Nucleic Acid Direct Gc","PX-30001329","CDM","87590","CPT","0306","RC","","","","both","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","103.57","44.45","","103.42","103.42","174.52","1 through 10","26.34","170.09","percent of total billed charges",""
"Nucleic Acid Direct Gc","PX-30001329","CDM","87590","CPT","0306","RC","","","","outpatient","","","233.00","174.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","138.17","59.3","","133.02","133.02","399.06","58","20.68","182.79","percent of total billed charges",""
"Nucleic Acid Direct Gc","PX-30001329","CDM","87590","CPT","0306","RC","","","","outpatient","","","233.00","174.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","182.79","78.45","","174.52","103.42","174.52","40","20.68","182.79","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","175.20","175.20","175.20","1 through 10","41.98","252.76","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","435.12","435.12","435.12","1 through 10","44.17","270.03","percent of total billed charges",""
"Nucleic Acid Qn Cmv","PX-30001281","CDM","87497","CPT","0306","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","237.56","237.56","237.56","1 through 10","44.17","270.03","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","both","","","356.00","267.00","AETNA [1001]","HB CH AETNA HMO / PPO","207.55","58.3","","196.18","196.18","196.18","1 through 10","41.98","259.88","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","356.00","267.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","211.11","59.3","","202.76","202.76","202.76","1 through 10","44.17","279.28","percent of total billed charges",""
"Nucleic Acid Qn Hepatitis B","PX-30001292","CDM","87517","CPT","0306","RC","","","","outpatient","","","356.00","267.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","279.28","78.45","","157.64","157.64","157.64","1 through 10","44.17","279.28","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Nucleic Acid Qn Infect Agent","PX-30001405","CDM","87799","CPT","0306","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","501.00","375.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","297.09","59.3","","285.38","285.38","285.38","1 through 10","44.17","393.03","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hepatitis","PX-30001295","CDM","87522","CPT","0306","RC","","","","outpatient","","","501.00","375.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","393.03","78.45","","374.41","221.88","374.41","1 through 10","44.17","393.03","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","both","","","652.00","489.00","AETNA [1001]","HB CH AETNA HMO / PPO","380.12","58.3","","359.48","359.48","359.48","1 through 10","83.4","502.06","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","652.00","489.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.64","59.3","","371.52","371.52","371.52","1 through 10","57.95","511.49","percent of total billed charges",""
"Nucleic Acid Rev Trans Qn Hiv-1","PX-30001309","CDM","87536","CPT","0306","RC","","","","outpatient","","","652.00","489.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","487.42","487.42","487.42","1 through 10","57.95","511.49","percent of total billed charges",""
"Nucleic Acid Rev Trans/Amp Probe En","PX-30001282","CDM","87498","CPT","0306","RC","","","","outpatient","","","292.00","219.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.07","78.45","","129.39","129.39","129.39","1 through 10","26.86","229.07","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","both","","","221.00","165.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","117.13","53","","111.30","111.30","111.30","1 through 10","34.39","207.04","percent of total billed charges",""
"Nucleic Acid Staph a Amplified Prob","PX-30001336","CDM","87640","CPT","0306","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","97.95","165.29","1 through 10","26.86","173.37","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","AETNA [1001]","HB CH AETNA HMO / PPO","48.97","58.3","","554.95","91.85","1421.75","94","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","2490.03","2490.03","2490.03","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","48.97","58.3","","750.00","750.00","750.00","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.52","53","","1192.50","120.84","4149.90","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","71.40","85","","750.00","75.00","750.00","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","84.00","100","","657.00","121.50","1971.00","14","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","84.00","100","","75.00","75.00","75.00","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","84.00","100","","366.00","144.00","1971.00","45","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","61.32","73","","667.50","667.50","667.50","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.34","44.45","","123.77","123.77","123.77","1 through 10","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","both","","","84.00","63.00","WELLPOINT [1015]","HB CH WELLPOINT","65.44","77.91","","483.51","229.32","1316.08","96","37.34","84","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.81","59.3","","439.50","225.34","1872.27","197","42","65.9","percent of total billed charges",""
"NUT SURGICAL 10MM SALVATION","SUP-ITM-10192793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","84.00","63.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.90","78.45","","385.32","55.36","1815.62","58","42","65.9","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","195.62","195.62","195.62","1 through 10","34.1","147.2","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","both","","","118.00","88.50","WELLPOINT [1015]","HB CH WELLPOINT","91.93","77.91","","90.58","90.58","90.58","12","34.1","147.2","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","67.39","11","59","140.98","percent of total billed charges",""
"Nutrition Therapy Eval 15 Min","PX-94000018","CDM","97802","CPT","0942","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","52.40","52.40","353.65","1 through 10","59","140.98","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","195.62","65.21","260.82","1 through 10","28.81","127.59","percent of total billed charges",""
"Nutrition Therapy Re-Eval 15 Min","PX-94000019","CDM","97803","CPT","0942","RC","","","","both","","","118.00","88.50","WELLPOINT [1015]","HB CH WELLPOINT","91.93","77.91","","90.58","90.58","90.58","1 through 10","28.81","127.59","percent of total billed charges",""
"Nwh Kinevac 5 Mcg Vial (Rad)","PX-63600475","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","292.00","219.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.42","52.2","","74.55","74.55","74.55","1 through 10","146","292.34","percent of total billed charges",""
"Nwh Mayo Medical Labs 89591 Posa Posaconazole Serum","PX-30003029","CDM","80299","CPT","0301","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","121.91","121.91","121.91","1 through 10","18.27","188.34","percent of total billed charges",""
"Nwh Mayo Medical Labs 89591 Posa Posaconazole Serum","PX-30003029","CDM","80299","CPT","0301","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","165.29","165.29","165.29","1 through 10","14.12","202.4","percent of total billed charges",""
"Nwh Mml Amio Amiodarone Serum","PX-30002258","CDM","80299","CPT","0301","RC","","","","both","","","56.00","42.00","AETNA [1001]","HB CH AETNA HMO / PPO","32.65","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Mml Amio Amiodarone Serum","PX-30002258","CDM","80299","CPT","0301","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.93","78.45","","165.29","165.29","165.29","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Cital Citalopram Serum","PX-30002264","CDM","80299","CPT","0301","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","121.91","121.91","121.91","1 through 10","18.27","105.12","percent of total billed charges",""
"Nwh Mml Cital Citalopram Serum","PX-30002264","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","165.29","165.29","165.29","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Faaab","PX-30003052","CDM","80299","CPT","0300","RC","","","","both","","","1065.00","798.75","AETNA [1001]","HB CH AETNA HMO / PPO","620.90","58.3","","121.91","121.91","121.91","1 through 10","18.27","777.45","percent of total billed charges",""
"Nwh Mml Faaab","PX-30003052","CDM","80299","CPT","0300","RC","","","","outpatient","","","1065.00","798.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","835.49","78.45","","165.29","165.29","165.29","1 through 10","14.12","835.49","percent of total billed charges",""
"Nwh Mml Felba Felbamate (Felbatol) Serum","PX-30002257","CDM","80299","CPT","0301","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Mml Felba Felbamate (Felbatol) Serum","PX-30002257","CDM","80299","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","165.29","165.29","165.29","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Fluox Fluoxetine Serum","PX-30003293","CDM","80299","CPT","0301","RC","","","","both","","","141.00","105.75","AETNA [1001]","HB CH AETNA HMO / PPO","82.20","58.3","","121.91","121.91","121.91","1 through 10","18.27","102.93","percent of total billed charges",""
"Nwh Mml Fluox Fluoxetine Serum","PX-30003293","CDM","80299","CPT","0301","RC","","","","outpatient","","","141.00","105.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","110.61","78.45","","165.29","165.29","165.29","1 through 10","14.12","110.61","percent of total billed charges",""
"Nwh Mml Itcon Itraconazole Serum","PX-30002259","CDM","80299","CPT","0301","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Mml Itcon Itraconazole Serum","PX-30002259","CDM","80299","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","165.29","165.29","165.29","1 through 10","14.12","86.37","percent of total billed charges",""
"Nwh Mml Laco Lacosamide Serum","PX-30003007","CDM","80299","CPT","0301","RC","","","","both","","","192.00","144.00","AETNA [1001]","HB CH AETNA HMO / PPO","111.94","58.3","","121.91","121.91","121.91","1 through 10","18.27","140.16","percent of total billed charges",""
"Nwh Mml Laco Lacosamide Serum","PX-30003007","CDM","80299","CPT","0301","RC","","","","outpatient","","","192.00","144.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","150.62","78.45","","165.29","165.29","165.29","1 through 10","14.12","150.62","percent of total billed charges",""
"Nwh Mml Mst Drug of Abuse Tetrahydrocannabinol Gc-Ms Conf Urine","PX-30002982","CDM","80299","CPT","0301","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","121.91","121.91","121.91","1 through 10","18.27","167.9","percent of total billed charges",""
"Nwh Mml Mst Drug of Abuse Tetrahydrocannabinol Gc-Ms Conf Urine","PX-30002982","CDM","80299","CPT","0301","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","165.29","165.29","165.29","1 through 10","14.12","180.44","percent of total billed charges",""
"Nwh Mml Mtx Methotrexate Serum","PX-30002983","CDM","80299","CPT","0301","RC","","","","both","","","377.00","282.75","AETNA [1001]","HB CH AETNA HMO / PPO","219.79","58.3","","121.91","121.91","121.91","1 through 10","18.27","275.21","percent of total billed charges",""
"Nwh Mml Mtx Methotrexate Serum","PX-30002983","CDM","80299","CPT","0301","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.76","78.45","","165.29","165.29","165.29","1 through 10","14.12","295.76","percent of total billed charges",""
"Nwh Mml Paro Paroxetine Serum","PX-30002260","CDM","80299","CPT","0301","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","121.91","121.91","121.91","1 through 10","18.27","105.12","percent of total billed charges",""
"Nwh Mml Paro Paroxetine Serum","PX-30002260","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","165.29","165.29","165.29","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Venla Venlafaxine  Serum","PX-30002261","CDM","80299","CPT","0301","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","121.91","121.91","121.91","1 through 10","18.27","105.12","percent of total billed charges",""
"Nwh Mml Venla Venlafaxine  Serum","PX-30002261","CDM","80299","CPT","0301","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","165.29","165.29","165.29","1 through 10","14.12","112.97","percent of total billed charges",""
"Nwh Mml Vori Voriconazole Serum","PX-30002262","CDM","80299","CPT","0301","RC","","","","both","","","112.00","84.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Mml Vori Voriconazole Serum","PX-30002262","CDM","80299","CPT","0301","RC","","","","outpatient","","","112.00","84.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","165.29","165.29","165.29","1 through 10","14.12","87.86","percent of total billed charges",""
"Nwh Mml Wrf Warfarin Serum","PX-30002263","CDM","80299","CPT","0301","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","121.91","121.91","121.91","1 through 10","18.27","188.34","percent of total billed charges",""
"Nwh Mml Wrf Warfarin Serum","PX-30002263","CDM","80299","CPT","0301","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","165.29","165.29","165.29","1 through 10","14.12","202.4","percent of total billed charges",""
"Nwh P Mml Infxr Infliximab Quant W Reflex to Ab to Inliximab, Serum","PX-30003053","CDM","80299","CPT","0301","RC","","","","both","","","409.00","306.75","AETNA [1001]","HB CH AETNA HMO / PPO","238.45","58.3","","121.91","121.91","121.91","1 through 10","18.27","298.57","percent of total billed charges",""
"Nwh P Mml Infxr Infliximab Quant W Reflex to Ab to Inliximab, Serum","PX-30003053","CDM","80299","CPT","0301","RC","","","","outpatient","","","409.00","306.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.86","78.45","","165.29","165.29","165.29","1 through 10","14.12","320.86","percent of total billed charges",""
"Nwh Rufinamide, Serum","PX-30003644","CDM","80299","CPT","0301","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","121.91","121.91","121.91","1 through 10","18.27","98.98","percent of total billed charges",""
"Nwh Rufinamide, Serum","PX-30003644","CDM","80299","CPT","0301","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","165.29","165.29","165.29","1 through 10","14.12","86.37","percent of total billed charges",""
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","45103.67","33827.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","15526.18","","Case rate ($15,073.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,097.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,621.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,692.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,603.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,758.72 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,131.35. The transfer capital threshold is the transfer adjustment factor * $1,131.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","15219.02","15219.02","15219.02","1 through 10","14772.48","15792.733","other","Inpatient DRG"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","45103.67","33827.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","15073.96","","Case rate ($15,073.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,097.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,621.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,692.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,603.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,758.72 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,131.35. The transfer capital threshold is the transfer adjustment factor * $1,131.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14568.36","14568.36","14568.36","1 through 10","14772.48","15792.733","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity With Cc","620","MS-DRG","","","","","","","","inpatient","","","45103.67","33827.75","MEDICARE [2001]","HB BWF MEDICARE","15073.96","","Case rate ($15,073.96). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,097.97, add-ons for qualifying new technology services are included. If operating cost exceeds $60,621.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,692.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $13,603.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,758.72 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,131.35. The transfer capital threshold is the transfer adjustment factor * $1,131.35. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16023.80","16023.80","16023.80","1 through 10","14772.48","15792.733","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","36545.70","27409.27","MEDICARE [2001]","HB BWF MEDICARE","14227.79","","Case rate ($14,227.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,250.42, add-ons for qualifying new technology services are included. If operating cost exceeds $59,774.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,627.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,822.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,911.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,066.38. The transfer capital threshold is the transfer adjustment factor * $1,066.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14688.51","0.03","14786.52","1 through 10","13943.23","15483.73","other","Inpatient Replacement Plans DRG"
"O.R. Procedures For Obesity Without Cc/McC","621","MS-DRG","","","","","","","","inpatient","","","36545.70","27409.27","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13943.23","","Case rate ($14,227.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,250.42, add-ons for qualifying new technology services are included. If operating cost exceeds $59,774.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,627.16, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.2. The base transfer operating payment is the transfer adjustment factor * $12,822.16 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,911.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,066.38. The transfer capital threshold is the transfer adjustment factor * $1,066.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","395.00","395.00","395.00","1 through 10","13943.23","15483.73","other","Inpatient DRG"
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","AETNA [1001]","HB CH AETNA HMO / PPO","198.02","58.3","","554.95","91.85","1421.75","94","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","247.95","73","","2490.03","2490.03","2490.03","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.02","58.3","","750.00","750.00","750.00","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.02","53","","1192.50","120.84","4149.90","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","288.71","85","","750.00","75.00","750.00","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","339.66","100","","657.00","121.50","1971.00","14","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","339.66","100","","75.00","75.00","75.00","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","339.66","100","","366.00","144.00","1971.00","45","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","247.95","73","","667.50","667.50","667.50","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","150.98","44.45","","123.77","123.77","123.77","1 through 10","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.66","254.74","WELLPOINT [1015]","HB CH WELLPOINT","264.63","77.91","","483.51","229.32","1316.08","96","150.98","339.66","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.66","254.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.42","59.3","","439.50","225.34","1872.27","197","169.83","266.46","percent of total billed charges",""
"OBLIQUE PLATE 2X19MM HOLE BONE MINI FRAGMENT L SHAPE LEFT SS","SUP-ITM-10002352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.66","254.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","266.46","78.45","","385.32","55.36","1815.62","58","169.83","266.46","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200001","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200002","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200003","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200004","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200005","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation 1 Hr","PX-76200006","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation Carve Out (10000 - 29999) - Integumentary/Musculoskeletal","PX-76200008","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation Carve Out (50000 - 59999) - Urinary/Male/Female/Maternity","PX-76200009","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation Carve Out (60000 - 69999) - Endo/Nervous/Eye/Auditory","PX-76200010","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","74.28","74.28","81.63","722","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","95.63","95.63","95.63","18","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","103.18","103.18","103.18","289","60.01","7249","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","inpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.31","70.6","","4834.21","4834.21","4834.21","1 through 10","75.6","95.31","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,538).","393.11","131.00","884.50","285","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","","","Payment is accumulated by procedure count. Procedures 1 - 9999, Case rate ($3,709).","363.30","191.21","1211.00","871","80.06","4642","other","Observation Flat Rate <=24 units"
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","690.89","76.77","1458.55","26","80.06","4642","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","80.06","59.3","","76.75","76.75","76.75","23","80.06","4642","percent of total billed charges",""
"Observation Carve Out (90785 - 98965) - Medicine","PX-76200012","CDM","G0378","HCPCS","0762","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","59.68","59.68","100.71","489","80.06","4642","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB CH AETNA HMO / PPO","254.77","58.3","","240.98","240.98","240.98","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.66","110.06","110.96","11","110.05","364.8","fee schedule",""
"Occupational Therapy Evaluation, High Complexity","PX-43000110","CDM","97167","CPT","0434","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB CH WELLPOINT","340.47","77.91","","334.73","334.73","334.73","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB CH AETNA HMO / PPO","254.77","58.3","","240.98","240.98","240.98","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.06","1 through 10","110.05","364.8","fee schedule",""
"Occupational Therapy Evaluation, Low Complexity","PX-43000108","CDM","97165","CPT","0434","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB CH WELLPOINT","340.47","77.91","","334.73","334.73","334.73","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","AETNA [1001]","HB CH AETNA HMO / PPO","254.77","58.3","","240.98","240.98","240.98","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","254.77","58.3","","212.50","212.50","212.50","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","231.61","53","","225.25","225.25","225.25","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","319.01","73","","378.25","378.25","378.25","1 through 10","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","TRICARE [160005]","HB BWF TRICARE","112.30","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount.","107.14","107.14","107.14","1 through 10","110.05","364.8","fee schedule",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","110.05","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($112.30). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($82.68). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","110.06","110.06","110.96","45","110.05","364.8","fee schedule",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","both","","","437.00","327.75","WELLPOINT [1015]","HB CH WELLPOINT","340.47","77.91","","334.73","334.73","334.73","11","110.05","364.8","percent of total billed charges",""
"Occupational Therapy Evaluation, Moderate Complexity","PX-43000109","CDM","97166","CPT","0434","RC","","","","outpatient","","","437.00","327.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","259.14","59.3","","249.05","249.05","249.05","1 through 10","218.5","455.7","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","27","53.34","157.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","53.34","157.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","17.49","17.49","17.49","1 through 10","53.34","157.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","20.58","16.98","20.58","16","53.34","157.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","21.62","20.99","21.62","1 through 10","53.34","157.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000080","CDM","99211","CPT","0510","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","22.49","21.83","22.49","50","53.34","157.63","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","389.30","85","","259.95","259.95","259.95","20","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","458.00","100","","252.36","252.36","296.88","1 through 10","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000084","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","458.00","100","","334.12","334.12","648.62","117","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","389.30","85","","259.95","259.95","259.95","20","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","458.00","100","","252.36","252.36","296.88","1 through 10","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-51000619","CDM","99215","CPT","0510","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","458.00","100","","334.12","334.12","648.62","117","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","389.30","85","","259.95","259.95","259.95","20","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","458.00","100","","252.36","252.36","296.88","1 through 10","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","both","","","458.00","343.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","458.00","100","","334.12","334.12","648.62","117","145.39","458","percent of total billed charges",""
"Office Visit, Established Pat","PX-90000103","CDM","99215","CPT","0914","RC","","","","outpatient","","","458.00","343.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","271.59","59.3","","65.00","65.00","65.00","1 through 10","79.3","359.3","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","AETNA [1001]","HB CH AETNA HMO / PPO","22.15","58.3","","66.34","66.34","66.34","27","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","22.15","58.3","","66.34","66.34","66.34","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","32.30","85","","17.49","17.49","17.49","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","38.00","100","","20.58","16.98","20.58","16","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","38.00","100","","21.62","20.99","21.62","1 through 10","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","both","","","38.00","28.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","38.00","100","","22.49","21.83","22.49","50","8.89","130.03","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100045","CDM","99211","CPT","0961","RC","","","","outpatient","","","38.00","28.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","22.53","59.3","","117.00","45.75","117.00","1 through 10","22.41","344","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","532.10","85","","259.95","259.95","259.95","20","147.01","626","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","626.00","100","","252.36","252.36","296.88","1 through 10","147.01","626","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","626.00","100","","334.12","334.12","648.62","117","147.01","626","percent of total billed charges",""
"Office Visit, Established Pat","PX-96100049","CDM","99215","CPT","0961","RC","","","","outpatient","","","626.00","469.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.22","59.3","","65.00","65.00","65.00","1 through 10","79.3","491.1","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","532.10","85","","259.95","259.95","259.95","20","147.01","626","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","626.00","100","","252.36","252.36","296.88","1 through 10","147.01","626","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","both","","","626.00","469.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","626.00","100","","334.12","334.12","648.62","117","147.01","626","percent of total billed charges",""
"Office Visit, Established Pat","PX-98300524","CDM","99215","CPT","0983","RC","","","","outpatient","","","626.00","469.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.22","59.3","","65.00","65.00","65.00","1 through 10","79.3","491.1","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","AETNA [1001]","HB CH AETNA HMO / PPO","2434.23","58.3","","554.95","91.85","1421.75","94","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3048.01","73","","2490.03","2490.03","2490.03","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2434.23","58.3","","750.00","750.00","750.00","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2212.94","53","","1192.50","120.84","4149.90","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3549.05","85","","750.00","75.00","750.00","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4175.35","100","","657.00","121.50","1971.00","14","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4175.35","100","","75.00","75.00","75.00","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4175.35","100","","366.00","144.00","1971.00","45","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3048.01","73","","667.50","667.50","667.50","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1855.94","44.45","","123.77","123.77","123.77","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","WELLPOINT [1015]","HB CH WELLPOINT","3253.02","77.91","","483.51","229.32","1316.08","96","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","2475.98","59.3","","439.50","225.34","1872.27","197","2087.68","3275.56","percent of total billed charges",""
"OLECRANON PLATE 113MM 6 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10082699","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3275.56","78.45","","385.32","55.36","1815.62","58","2087.68","3275.56","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","AETNA [1001]","HB CH AETNA HMO / PPO","2484.15","58.3","","554.95","91.85","1421.75","94","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3110.52","73","","2490.03","2490.03","2490.03","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2484.15","58.3","","750.00","750.00","750.00","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2258.32","53","","1192.50","120.84","4149.90","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3621.83","85","","750.00","75.00","750.00","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4260.98","100","","657.00","121.50","1971.00","14","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4260.98","100","","75.00","75.00","75.00","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4260.98","100","","366.00","144.00","1971.00","45","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3110.52","73","","667.50","667.50","667.50","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1894.01","44.45","","123.77","123.77","123.77","1 through 10","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","both","","","4260.98","3195.73","WELLPOINT [1015]","HB CH WELLPOINT","3319.73","77.91","","483.51","229.32","1316.08","96","1894.01","4260.98","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.98","3195.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","2526.76","59.3","","439.50","225.34","1872.27","197","2130.49","3342.74","percent of total billed charges",""
"OLECRANON PLATE 137MM 8 HOLE VARIAX TITANIUM LEFT","SUP-ITM-10139455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4260.98","3195.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3342.74","78.45","","385.32","55.36","1815.62","58","2130.49","3342.74","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","AETNA [1001]","HB CH AETNA HMO / PPO","1439.88","58.3","","554.95","91.85","1421.75","94","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1802.94","73","","2490.03","2490.03","2490.03","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1439.88","58.3","","750.00","750.00","750.00","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1308.98","53","","1192.50","120.84","4149.90","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2099.31","85","","750.00","75.00","750.00","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2469.78","100","","657.00","121.50","1971.00","14","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2469.78","100","","75.00","75.00","75.00","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2469.78","100","","366.00","144.00","1971.00","45","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1802.94","73","","667.50","667.50","667.50","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1097.82","44.45","","123.77","123.77","123.77","1 through 10","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","both","","","2469.78","1852.33","WELLPOINT [1015]","HB CH WELLPOINT","1924.21","77.91","","483.51","229.32","1316.08","96","1097.82","2469.78","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.78","1852.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1464.58","59.3","","439.50","225.34","1872.27","197","1234.89","1937.54","percent of total billed charges",""
"OLECRANON PLATE 79MM SM 10 HOLE BONE HUMERAL A.L.P.S.","SUP-ITM-10071501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2469.78","1852.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1937.54","78.45","","385.32","55.36","1815.62","58","1234.89","1937.54","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","AETNA [1001]","HB CH AETNA HMO / PPO","2434.23","58.3","","1634.24","1004.95","1718.99","42","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3048.01","73","","2123.89","1900.92","2123.89","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2434.23","58.3","","3729.00","1254.19","3729.00","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2212.94","53","","939.37","939.37","5593.65","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3549.05","85","","2323.25","1864.50","2882.25","16","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4175.35","100","","2909.44","1772.40","10952.08","45","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4175.35","100","","2323.25","2323.25","2323.25","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4175.35","100","","2882.25","1772.40","10169.17","187","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3048.01","73","","1659.41","1659.41","1659.41","1 through 10","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","both","","","4175.35","3131.51","WELLPOINT [1015]","HB CH WELLPOINT","3253.02","77.91","","2050.91","1468.48","2902.83","52","1855.94","4175.35","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","2475.98","59.3","","1548.60","1092.60","3613.79","82","2087.68","3275.56","percent of total billed charges",""
"OLECRANON PLATE 89MM 4 HOLE VARIAX TITANIUM RIGHT","SUP-ITM-10114001","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4175.35","3131.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3275.56","78.45","","2085.51","998.68","6202.11","56","2087.68","3275.56","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","554.95","91.85","1421.75","94","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","2490.03","2490.03","2490.03","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","750.00","750.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","1192.50","120.84","4149.90","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.20","85","","750.00","75.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","312.00","100","","657.00","121.50","1971.00","14","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","312.00","100","","75.00","75.00","75.00","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","312.00","100","","366.00","144.00","1971.00","45","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","667.50","667.50","667.50","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","123.77","123.77","123.77","1 through 10","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","483.51","229.32","1316.08","96","138.68","312","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","439.50","225.34","1872.27","197","156","244.76","percent of total billed charges",""
"OLIVE WIRE THREADED 1.6MMX80MM","SUP-ITM-10303598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","385.32","55.36","1815.62","58","156","244.76","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.07","9.05","AETNA [1001]","HB CH AETNA HMO / PPO","7.04","58.3","","2.21","2.21","2.21","7865","0.32","8.81","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.07","9.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","7.04","58.3","","2.21","0.35","2.21","227","0.32","8.81","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0255","RC","","","","both","","","12.07","9.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6.40","53","","9.68","4.59","206.35","1 through 10","0.32","8.81","percent of total billed charges",""
"Omnipaque 350 per 1 Ml","PX-25500050","CDM","Q9967","HCPCS","0636","RC","","","","outpatient","","","12.07","9.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","6.30","52.2","","597.26","0.48","597.26","454","6.04","6.3","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6.69","","APC Price ($6.50). Final payment is multiplied by 103%.","6.69","6.62","6.69","465","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","AETNA [1001]","HB CH AETNA HMO / PPO","14.71","58.3","","15.38","15.38","15.50","9235","6.18","19.73","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","6.37","6.30","6.37","1240","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","6.37","6.30","6.38","1550","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","18.43","73","","19.81","19.81","19.81","155","6.18","19.73","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","MEDICARE [2001]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","6.47","6.41","6.47","16515","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","6.37","6.34","6.37","310","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","MOLINA [1014]","HB BWF MEDICARE","6.50","","APC Price ($6.50).","12.84","12.84","12.84","400","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","18.43","73","","3076.77","3076.77","3076.77","1 through 10","6.18","19.73","percent of total billed charges",""
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","TRICARE [160005]","HB BWF TRICARE","6.18","","APC Price ($6.50). Final payment is multiplied by 95%.","6.48","6.47","6.48","606","6.18","19.73","other","Tricare OPPS"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","6.34","6.30","6.37","620","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","both","","","25.24","18.93","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6.37","","APC Price ($6.50). Final payment is multiplied by 98%.","12.68","6.28","12.74","8660","6.18","19.73","other","OPPS APC"
"Onabotulinum Toxin Vl 1u","PX-63600071","CDM","J0585","HCPCS","0636","RC","","","","outpatient","","","25.24","18.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.18","52.2","","13.97","13.97","14.08","7127","0.01","13.18","percent of total billed charges",""
"Open Exc/Dstrj Intra-Abdl Tumor/Cst 5 Cm or Less","PX-36000512","CDM","49186","CPT","0361","RC","","","","outpatient","","","7719.00","5789.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3867.22","50.1","","2038.94","2038.94","2038.94","1 through 10","3087.6","6055.56","percent of total billed charges",""
"Open Exc/Dstrj Intra-Abdl Tumor/Cst 5 Cm or Less","PX-98302546","CDM","49186","CPT","0983","RC","","","","outpatient","","","5743.00","4307.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2877.24","50.1","","2038.94","2038.94","2038.94","1 through 10","2297.2","4505.38","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","both","","","0.90","0.67","AETNA [1001]","HB CH AETNA HMO / PPO","0.52","58.3","","0.30","0.30","0.30","40","0.19","0.73","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","both","","","0.90","0.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","0.48","53","","0.13","0.13","0.13","49","0.19","0.73","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","both","","","0.90","0.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","0.66","73","","0.48","0.48","0.48","40","0.19","0.73","percent of total billed charges",""
"Oral Dexamethasone","PX-63601226","CDM","J8540","HCPCS","0636","RC","","","","outpatient","","","0.90","0.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","0.47","52.2","","0.29","0.26","0.29","80","0.04","0.47","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","191.00","143.25","AETNA [1001]","HB CH AETNA HMO / PPO","111.35","58.3","","105.46","105.46","105.46","1 through 10","20.79","139.43","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","both","","","191.00","143.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","101.23","53","","98.58","98.58","98.58","1 through 10","20.79","139.43","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","191.00","143.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","113.26","59.3","","109.00","109.00","760.04","1 through 10","16.96","149.84","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","191.00","143.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","113.26","59.3","","109.00","109.00","109.00","1 through 10","16.96","149.84","percent of total billed charges",""
"Organic Acid Single Qn","PX-30000592","CDM","83921","CPT","0301","RC","","","","outpatient","","","191.00","143.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.84","78.45","","143.00","143.00","143.00","1 through 10","16.96","149.84","percent of total billed charges",""
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","35057.70","26293.27","FALLON HEALTH [1008]","HB BWF MEDICARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15127.19","15127.19","15127.19","1 through 10","186.24","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","35057.70","26293.27","HUMANA [1012]","HB BWF MEDICARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15405.62","15405.62","15405.62","1 through 10","186.24","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","35057.70","26293.27","MEDICARE [2001]","HB BWF MEDICARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16746.75","0.03","16858.75","39","186.24","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","35057.70","26293.27","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15173.03","15173.03","15173.03","1 through 10","186.24","16515.36","other","Inpatient Psych"
"Organic Disturbances And Intellectual Disability","884","MS-DRG","","","","","","","","inpatient","","","35057.70","26293.27","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","186.24","","Case rate ($186.24) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15139.51","15139.51","15139.51","1 through 10","186.24","16515.36","other","Inpatient Psych"
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","284.00","213.00","AETNA [1001]","HB CH AETNA HMO / PPO","165.57","58.3","","156.49","156.49","156.49","1 through 10","56.36","364.8","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-42000107","CDM","97763","CPT","0421","RC","","","","both","","","284.00","213.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","56.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($57.51). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($36.99). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","57.26","57.26","57.26","1 through 10","56.36","364.8","fee schedule",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","284.00","213.00","AETNA [1001]","HB CH AETNA HMO / PPO","165.57","58.3","","156.49","156.49","156.49","1 through 10","56.36","364.8","percent of total billed charges",""
"Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min","PX-43000114","CDM","97763","CPT","0431","RC","","","","both","","","284.00","213.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","56.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($57.51). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($36.99). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","57.26","57.26","57.26","1 through 10","56.36","364.8","fee schedule",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","both","","","63.00","47.25","AETNA [1001]","HB CH AETNA HMO / PPO","36.73","58.3","","34.59","34.59","34.59","1 through 10","6.48","45.99","percent of total billed charges",""
"Osmolality Blood","PX-30000594","CDM","83930","CPT","0301","RC","","","","outpatient","","","63.00","47.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","37.36","59.3","","35.74","35.74","35.74","1 through 10","6.82","49.42","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","both","","","65.00","48.75","AETNA [1001]","HB CH AETNA HMO / PPO","37.90","58.3","","35.72","35.72","35.72","1 through 10","6.68","47.45","percent of total billed charges",""
"Osmolality Urine","PX-30000595","CDM","83935","CPT","0301","RC","","","","outpatient","","","65.00","48.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.55","59.3","","36.91","36.91","36.91","1 through 10","7.02","50.99","percent of total billed charges",""
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","36549.92","27412.44","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12029.39","","Case rate ($12,274.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,294.34, add-ons for qualifying new technology services are included. If operating cost exceeds $57,818.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,477.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,019.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,955.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $916.43. The transfer capital threshold is the transfer adjustment factor * $916.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11819.31","11819.31","11819.31","1 through 10","12029.39","13306.52","other","Inpatient DRG"
"Osteomyelitis With Cc","540","MS-DRG","","","","","","","","inpatient","","","36549.92","27412.44","MEDICARE [2001]","HB BWF MEDICARE","12274.89","","Case rate ($12,274.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,294.34, add-ons for qualifying new technology services are included. If operating cost exceeds $57,818.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,477.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $11,019.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,955.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $916.43. The transfer capital threshold is the transfer adjustment factor * $916.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13032.24","13032.24","13119.01","1 through 10","12029.39","13306.52","other","Inpatient Replacement Plans DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","39681.53","29761.15","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","18105.68","","Case rate ($18,475.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,504.74, add-ons for qualifying new technology services are included. If operating cost exceeds $64,028.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,953.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $16,743.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,165.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.50. The transfer capital threshold is the transfer adjustment factor * $1,392.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18280.11","18280.11","18280.11","1 through 10","18105.68","20209.13","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","39681.53","29761.15","MEDICARE [2001]","HB BWF MEDICARE","20209.13","","Case rate ($20,209.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,504.74, add-ons for qualifying new technology services are included. If operating cost exceeds $64,028.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,953.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $18,477.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,165.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.50. The transfer capital threshold is the transfer adjustment factor * $1,392.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","20225.20","13018.79","20360.83","1 through 10","18105.68","20209.13","other","Inpatient DRG"
"Osteomyelitis With McC","539","MS-DRG","","","","","","","","inpatient","","","39681.53","29761.15","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","18105.68","","Case rate ($18,475.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,504.74, add-ons for qualifying new technology services are included. If operating cost exceeds $64,028.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,953.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.2. The base transfer operating payment is the transfer adjustment factor * $16,743.45 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,165.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,392.50. The transfer capital threshold is the transfer adjustment factor * $1,392.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18317.61","18317.61","18317.61","1 through 10","18105.68","20209.13","other","Inpatient DRG"
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","33023.65","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","28962.02","","Fee schedule rate ($28,962.02). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,350.45) multiplied by length of stay and the outlier percent (100%).","27647.51","27647.51","27647.51","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","33023.65","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","18360.4012","","Per diem ($4,837). If length of stay < 8, first 1 days paid at a per diem of $9,674 instead.","18360.4012","37201.08","37201.08","1 through 10","2120","60802.51","per diem","Estimated amount calculated based on 1 day length of stay."
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","33023.65","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","12328.41","","Case rate ($13,631.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,065.33 and the sum of the standard inlier and any outlier amount.","13627.84","13627.84","13627.84","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MAJOR","344","DRG","","","","","","","","inpatient","","","33023.65","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","12328.41","","Case rate ($13,631.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,061.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,065.33 and the sum of the standard inlier and any outlier amount.","13627.84","13627.84","13627.84","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MINOR","344","DRG","","","","","","","","inpatient","","","4165.46","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7247.17","","Case rate ($8,012.99). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,442.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8011.03","8011.03","8011.03","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","24816.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","21688.68","","Standard inlier is a Case rate ($21,688.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,361, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,078.62) for the length of stay and the standard reimbursement.","21688.68","21688.68","21688.68","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","24816.95","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","13845.25","","Fee schedule rate ($13,845.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10095.95","10095.95","10095.95","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","24816.95","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","29510.47","","Fee schedule rate ($29,510.47). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21519.03","21519.03","21519.03","1 through 10","2120","60802.51","case rate",""
"Osteomyelitis, Septic Arthritis And Other Musculoskeletal Infections,MODERATE","344","DRG","","","","","","","","inpatient","","","24816.95","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8535.76","","Case rate ($9,437.75). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,867.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9435.43","9435.43","9435.43","1 through 10","2120","60802.51","case rate",""
"Ot Contrast Bath 15 Min","PX-43000019","CDM","97034","CPT","0431","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14.81","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($15.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($11.24). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","11.24","11.24","11.24","1 through 10","14.81","364.8","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","167.51","95.26","167.78","265","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.86","58.3","","336.00","336.00","336.00","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.69","53","","83.74","83.74","83.74","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","89.90","89.90","285.60","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","27.69","24.19","31.84","945","31.47","364.8","fee schedule",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.59","59.3","","180.75","180.75","180.75","1 through 10","86.5","232","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","168.00","168.00","168.00","1 through 10","86.5","232","percent of total billed charges",""
"Ot Exercise Therapeutic 15 Min","PX-43000023","CDM","97110","CPT","0431","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","129.16","129.16","129.16","1 through 10","86.5","232","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","62.79","62.78","62.79","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","77.38","77.38","154.76","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","129.94","129.94","129.94","1 through 10","31.47","364.8","percent of total billed charges",""
"Ot Gait Training 15 Min","PX-43000026","CDM","97116","CPT","0431","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","23.36","23.31","23.94","14","31.47","364.8","fee schedule",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","75.57","178.76","23","35.26","364.8","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","109.02","58.3","","364.00","91.00","364.00","1 through 10","35.26","364.8","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","99.11","53","","96.46","96.46","96.46","1 through 10","35.26","364.8","percent of total billed charges",""
"Ot Home Instruction/Program 15min","PX-43000034","CDM","97535","CPT","0431","RC","","","","both","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","35.26","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.98). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.72). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.24","25.75","35.27","72","35.26","364.8","fee schedule",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","66.96","66.96","154.85","93","29.66","364.8","percent of total billed charges",""
"Ot Manual Therapy 15 Min","PX-43000029","CDM","97140","CPT","0431","RC","","","","both","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","29.66","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","22.25","22.08","22.53","139","29.66","364.8","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","99.79","75.60","99.79","1 through 10","35.02","364.8","percent of total billed charges",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","35.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.66","26.43","35.54","25","35.02","364.8","fee schedule",""
"Ot Neuromuscular Re-ED 15 Min","PX-43000024","CDM","97112","CPT","0431","RC","","","","outpatient","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","107.33","59.3","","94.95","94.95","94.95","1 through 10","90.5","240.73","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","100.93","100.93","100.93","1 through 10","38.35","364.8","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","96.99","53","","94.34","89.04","94.34","1 through 10","38.35","364.8","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.59","73","","158.42","158.42","158.42","1 through 10","38.35","364.8","percent of total billed charges",""
"Ot Therapeutic Activity 15 Min","PX-43000031","CDM","97530","CPT","0431","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","38.48","32.77","40.64","84","38.35","364.8","fee schedule",""
"Ot Ultrasound 15 Min","PX-43000020","CDM","97035","CPT","0431","RC","","","","both","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15.19","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($15.50). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($11.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","11.43","11.43","11.43","1 through 10","15.19","364.8","fee schedule",""
"Other Aftercare And Convalescence,MINOR","862","DRG","","","","","","","","inpatient","","","6813.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12089.94","","Standard inlier is a Case rate ($12,089.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,193, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,716.12) for the length of stay and the standard reimbursement.","11540.89","11540.89","11540.89","1 through 10","4275.88","18643.48","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,EXTREME","253","DRG","","","","","","","","inpatient","","","63007.66","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","19252.29","","Fee schedule rate ($19,252.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19252.29","19252.29","19252.29","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,EXTREME","253","DRG","","","","","","","","inpatient","","","63007.66","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","18707.39","","Case rate ($20,684.23). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $63,114.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20679.15","20679.15","20679.15","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,EXTREME","253","DRG","","","","","","","","inpatient","","","63007.66","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","18707.39","","Case rate ($20,684.23). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $63,114.23, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20679.15","20679.15","20679.15","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","50914.07","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11400.8028","","Fee schedule rate ($25,842.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11400.8028","25842.34","25842.34","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","50914.07","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","25452.87","","Fee schedule rate ($25,452.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25452.87","25452.87","25452.87","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","50914.07","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10227.60","","Case rate ($11,308.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,738.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11305.60","11305.60","11305.60","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MAJOR","253","DRG","","","","","","","","inpatient","","","50914.07","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10227.60","","Case rate ($11,308.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,738.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11305.60","11305.60","25429.59","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MODERATE","253","DRG","","","","","","","","inpatient","","","29686.19","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11400.8028","","Fee schedule rate ($25,842.34). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11400.8028","15395.71","15395.71","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MODERATE","253","DRG","","","","","","","","inpatient","","","29686.19","","MASSHEALTH [3001]","HB BWF MEDICAID","7062.11","","Case rate ($7,808.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,238.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7806.45","7806.45","7806.45","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MODERATE","253","DRG","","","","","","","","inpatient","","","29686.19","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7062.11","","Case rate ($7,808.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,238.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7806.46","7806.46","7806.46","1 through 10","7062.11","86997.54","case rate",""
"Other And Unspecified Gastrointestinal Hemorrhage,MODERATE","253","DRG","","","","","","","","inpatient","","","29686.19","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7062.11","","Case rate ($7,808.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,238.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7806.46","7806.46","7806.46","1 through 10","7062.11","86997.54","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","33704.09","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22561.15","","Standard inlier is a Case rate ($22,561.15). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,792, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,202.64) for the length of stay and the standard reimbursement.","22561.15","22561.15","22561.15","1 through 10","2273","34949.27","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","33704.09","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10298.4861","","Fee schedule rate ($22,240.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10298.4861","22240.56","22240.56","1 through 10","2273","34949.27","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MAJOR","663","DRG","","","","","","","","inpatient","","","33704.09","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,742.50 and the sum of the standard inlier and any outlier amount.","10117.33","10117.33","10117.33","1 through 10","2273","34949.27","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","18054.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12269.01","","Standard inlier is a Case rate ($12,269.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,366, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,741.53) for the length of stay and the standard reimbursement.","12269.01","12269.01","12269.01","1 through 10","2273","34949.27","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","18054.83","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","13604.52","","Fee schedule rate ($13,604.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13604.52","13604.52","13604.52","1 through 10","2273","34949.27","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MINOR","663","DRG","","","","","","","","inpatient","","","18054.83","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4913.32","","Case rate ($5,432.52). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,862.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5431.18","5431.18","5431.18","1 through 10","2273","34949.27","case rate",""
"Other Anemia And Disorders Of Blood And Blood-Forming Organs,MODERATE","663","DRG","","","","","","","","inpatient","","","23473.53","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6465.79","","Case rate ($7,149.04). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,579.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7147.29","7147.29","7147.29","1 through 10","2273","34949.27","case rate",""
"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC","833","MS-DRG","","","","","","","","inpatient","","","28838.50","21628.87","MEDICARE [2001]","HB BWF MEDICARE","5153.82","","Case rate ($5,153.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,161.67, add-ons for qualifying new technology services are included. If operating cost exceeds $50,685.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,930.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.7. The base transfer operating payment is the transfer adjustment factor * $4,444.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $4,822.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $369.67. The transfer capital threshold is the transfer adjustment factor * $369.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","5384.93","5384.93","5384.93","1 through 10","5050.74","5308.43","other","Inpatient Replacement Plans DRG"
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","65165.59","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10204.8324","","Fee schedule rate ($14,232.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10204.8324","23208.08","23208.08","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","65165.59","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15047.08","","Fee schedule rate ($15,047.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19524.90","19524.90","19524.90","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MAJOR","347","DRG","","","","","","","","inpatient","","","65165.59","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9152.64","","Case rate ($10,119.81). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,549.81, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10117.33","10117.33","10117.33","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","25084.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14218.70","","Standard inlier is a Case rate ($14,218.70). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,018.40) for the length of stay and the standard reimbursement.","13573.26","13573.26","13573.26","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MINOR","347","DRG","","","","","","","","inpatient","","","25084.33","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15273.72","","Standard inlier is a Case rate ($15,273.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,168.04) for the length of stay and the standard reimbursement.","15273.72","15273.72","15273.72","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","35192.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17930.27","","Standard inlier is a Case rate ($17,930.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,234, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,545.27) for the length of stay and the standard reimbursement.","17930.27","17930.27","17930.27","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","35192.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19260.69","","Standard inlier is a Case rate ($19,260.69). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,043, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,733.97) for the length of stay and the standard reimbursement.","19137.81","19137.81","19260.68","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","35192.36","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6254.45","","Case rate ($6,915.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,345.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6913.68","6913.68","6913.68","1 through 10","5019.56","101007.55","case rate",""
"Other Back And Neck Disorders, Fractures And Injuries,MODERATE","347","DRG","","","","","","","","inpatient","","","35192.36","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6254.45","","Case rate ($6,915.37). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,345.37, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6913.68","6913.68","6913.68","1 through 10","5019.56","101007.55","case rate",""
"Other Bladder Procedures,MAJOR","445","DRG","","","","","","","","inpatient","","","59906.94","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","20400.63","","Fee schedule rate ($20,400.63). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","20400.63","20400.63","20400.63","1 through 10","8177.06","59457.94","case rate",""
"Other Bladder Procedures,MODERATE","445","DRG","","","","","","","","inpatient","","","55071.06","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","29136.08","","Standard inlier is a Case rate ($29,136.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,139, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,135.98) for the length of stay and the standard reimbursement.","29136.07","29136.07","29136.07","1 through 10","8177.06","59457.94","case rate",""
"Other Cerebrovascular Disorders With Cc","071","MS-DRG","","","","","","","","inpatient","","","31714.06","23785.54","MEDICARE [2001]","HB BWF MEDICARE","10689.30","","Case rate ($10,689.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,801.49, add-ons for qualifying new technology services are included. If operating cost exceeds $55,325.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,286.13, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,624.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,462.26 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $725.34. The transfer capital threshold is the transfer adjustment factor * $725.34. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10659.93","10659.93","10659.93","1 through 10","9590.38","10689.3","other","Inpatient DRG"
"Other Cerebrovascular Disorders With McC","070","MS-DRG","","","","","","","","inpatient","","","30222.47","22666.85","MEDICARE [2001]","HB BWF MEDICARE","17133.37","","Case rate ($17,133.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,692.81, add-ons for qualifying new technology services are included. If operating cost exceeds $61,216.54 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,737.72, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.5. The base transfer operating payment is the transfer adjustment factor * $15,617.19 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,353.57 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,176.95. The transfer capital threshold is the transfer adjustment factor * $1,176.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11527.51","11527.51","17424.28","1 through 10","15354.46","17133.37","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","23895.31","17921.48","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","9208.80","","Case rate ($9,208.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,223.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,746.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,241.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,188.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,884.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.01. The transfer capital threshold is the transfer adjustment factor * $681.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8860.62","8860.62","8860.62","1 through 10","9024.62","9516.1847","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","23895.31","17921.48","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9024.62","","Case rate ($9,208.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,223.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,746.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,241.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,188.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,884.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.01. The transfer capital threshold is the transfer adjustment factor * $681.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8802.89","8802.89","8802.89","1 through 10","9024.62","9516.1847","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","23895.31","17921.48","MEDICARE [2001]","HB BWF MEDICARE","9208.80","","Case rate ($9,208.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,223.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,746.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,241.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,188.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,884.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.01. The transfer capital threshold is the transfer adjustment factor * $681.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9755.24","9755.24","9819.77","1 through 10","9024.62","9516.1847","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","23895.31","17921.48","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","9208.80","","Case rate ($9,208.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,223.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,746.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,241.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,188.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,884.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.01. The transfer capital threshold is the transfer adjustment factor * $681.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8802.89","8802.89","8802.89","1 through 10","9024.62","9516.1847","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","23895.31","17921.48","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9024.62","","Case rate ($9,208.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,223.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,746.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,241.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,188.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,884.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.01. The transfer capital threshold is the transfer adjustment factor * $681.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8860.62","8860.62","8860.62","1 through 10","9024.62","9516.1847","other","Inpatient DRG"
"Other Circulatory System Diagnoses With Cc","315","MS-DRG","","","","","","","","inpatient","","","23895.31","17921.48","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9024.62","","Case rate ($9,208.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,223.26, add-ons for qualifying new technology services are included. If operating cost exceeds $54,746.99 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,241.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $8,188.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,884.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $681.01. The transfer capital threshold is the transfer adjustment factor * $681.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8825.39","8825.39","8825.39","1 through 10","9024.62","9516.1847","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","40288.66","30216.49","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","20124.80","","Case rate ($19,538.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,569.94, add-ons for qualifying new technology services are included. If operating cost exceeds $65,093.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,034.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,725.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,230.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,474.15. The transfer capital threshold is the transfer adjustment factor * $1,474.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","20414.23","20414.23","20414.23","1 through 10","19147.87","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","40288.66","30216.49","MEDICARE [2001]","HB BWF MEDICARE","19538.64","","Case rate ($19,538.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,569.94, add-ons for qualifying new technology services are included. If operating cost exceeds $65,093.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,034.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,725.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,230.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,474.15. The transfer capital threshold is the transfer adjustment factor * $1,474.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13360.37","0.03","21664.43","21","19147.87","21404.58","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","40288.66","30216.49","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","19538.64","","Case rate ($19,538.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,569.94, add-ons for qualifying new technology services are included. If operating cost exceeds $65,093.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,034.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,725.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,230.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,474.15. The transfer capital threshold is the transfer adjustment factor * $1,474.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19394.98","19394.98","19394.98","1 through 10","19147.87","21404.58","other","Inpatient Replacement Plans DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","40288.66","30216.49","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","19147.87","","Case rate ($19,538.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,569.94, add-ons for qualifying new technology services are included. If operating cost exceeds $65,093.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,034.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,725.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,230.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,474.15. The transfer capital threshold is the transfer adjustment factor * $1,474.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","19463.15","19463.15","19463.15","1 through 10","19147.87","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses With McC","314","MS-DRG","","","","","","","","inpatient","","","40288.66","30216.49","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","19147.87","","Case rate ($19,538.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,569.94, add-ons for qualifying new technology services are included. If operating cost exceeds $65,093.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,034.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $17,725.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,230.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,474.15. The transfer capital threshold is the transfer adjustment factor * $1,474.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","19394.98","19394.98","19449.15","1 through 10","19147.87","21404.58","other","Inpatient DRG"
"Other Circulatory System Diagnoses,EXTREME","207","DRG","","","","","","","","inpatient","","","32475.14","","MASSHEALTH [3001]","HB BWF MEDICAID","17558.17","","Case rate ($19,413.57). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,843.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19408.80","19408.80","19408.80","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","34685.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22043.89","","Standard inlier is a Case rate ($22,043.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,261, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,129.22) for the length of stay and the standard reimbursement.","21042.17","21042.17","21042.17","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","34685.55","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9792.4962","","Fee schedule rate ($23,004.84). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9792.4962","23004.84","23004.84","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","34685.55","","MASSHEALTH [3001]","HB BWF MEDICAID","9526.19","","Case rate ($10,532.84). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,962.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10530.26","10530.26","10530.26","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","34685.55","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","23117.99","","Fee schedule rate ($23,117.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11166.60","11166.60","11166.60","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MAJOR","207","DRG","","","","","","","","inpatient","","","34685.55","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9526.19","","Case rate ($10,532.84). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,962.84, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13485.98","13485.98","13485.98","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","14881.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12649.74","","Standard inlier is a Case rate ($12,649.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,624, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,795.68) for the length of stay and the standard reimbursement.","12649.74","12649.74","12649.74","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MINOR","207","DRG","","","","","","","","inpatient","","","14881.45","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5920.29","","Fee schedule rate ($5,920.29). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5920.29","5920.29","5920.29","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System Diagnoses,MODERATE","207","DRG","","","","","","","","inpatient","","","17626.16","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6675.99","","Case rate ($7,381.45). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,811.45, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,836.18 and the sum of the standard inlier and any outlier amount.","7379.64","7379.64","7379.64","1 through 10","4606.02","90444.42","case rate",""
"Other Circulatory System O.R. Procedures","264","MS-DRG","","","","","","","","inpatient","","","37765.89","28324.42","WELLSENSE [1003]","HB BWF MEDICARE","31097.72","","Case rate ($31,097.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $31,147.84, add-ons for qualifying new technology services are included. If operating cost exceeds $76,671.57 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,922.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. The base transfer operating payment is the transfer adjustment factor * $28,396.79 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $30,808.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,361.67. The transfer capital threshold is the transfer adjustment factor * $2,361.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","51755.03","51755.03","51755.03","1 through 10","30475.77","34291.26","other","Inpatient Replacement Plans DRG"
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","40841.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14130.8244","","Standard inlier is a Case rate ($25,243.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,757, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,583.25) for the length of stay and the standard reimbursement.","14130.8244","25243.77","25243.77","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","40841.07","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16331.2494","","Fee schedule rate ($23,131.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16331.2494","23131.87","23131.87","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","40841.07","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9491.5494","","Fee schedule rate ($23,131.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9491.5494","23131.87","23131.87","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","40841.07","","MASSHEALTH [3001]","HB BWF MEDICAID","11496.77","","Case rate ($12,711.66). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,141.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,775.47 and the sum of the standard inlier and any outlier amount.","12708.54","12708.54","12708.54","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MAJOR","813","DRG","","","","","","","","inpatient","","","40841.07","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11496.77","","Case rate ($12,711.66). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,141.66, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,775.47 and the sum of the standard inlier and any outlier amount.","12708.54","12708.54","12708.54","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","5169.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13154.749","","Standard inlier is a Case rate ($13,154.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,867.37) for the length of stay and the standard reimbursement.","13154.749","13154.74","13154.74","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MINOR","813","DRG","","","","","","","","inpatient","","","5169.26","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14130.8244","","Standard inlier is a Case rate ($14,130.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,005.81) for the length of stay and the standard reimbursement.","14130.8244","13488.51","13488.51","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","16693.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13154.749","","Standard inlier is a Case rate ($13,154.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,867.37) for the length of stay and the standard reimbursement.","13154.749","16204.41","16204.41","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","16693.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14130.8244","","Standard inlier is a Case rate ($14,130.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,143, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,005.81) for the length of stay and the standard reimbursement.","14130.8244","16615.55","16615.55","1 through 10","5235.46","197565.09","case rate",""
"Other Complications Of Treatment,MODERATE","813","DRG","","","","","","","","inpatient","","","16693.56","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","17862.83","","Fee schedule rate ($17,862.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17862.83","17862.83","17862.83","1 through 10","5235.46","197565.09","case rate",""
"Other Digestive System And Abdominal Procedures,MODERATE","229","DRG","","","","","","","","inpatient","","","40757.43","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","39959.21","","Standard inlier is a Case rate ($39,959.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $49,809, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,672.04) for the length of stay and the standard reimbursement.","39959.21","39959.21","39959.21","1 through 10","10490.35","104116.74","case rate",""
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20933.01","15699.76","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","9778.39","","Case rate ($9,778.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,968.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,492.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,222.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,777.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,629.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.50. The transfer capital threshold is the transfer adjustment factor * $661.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9457.17","9457.17","9457.17","1 through 10","8775.59","9778.39","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20933.01","15699.76","MEDICARE [2001]","HB BWF MEDICARE","9778.39","","Case rate ($9,778.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,968.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,492.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,222.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $8,777.63 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,629.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.50. The transfer capital threshold is the transfer adjustment factor * $661.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9547.83","0.03","9610.95","35","8775.59","9778.39","other","Inpatient DRG"
"Other Digestive System Diagnoses With Cc","394","MS-DRG","","","","","","","","inpatient","","","20933.01","15699.76","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8775.59","","Case rate ($8,954.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,968.71, add-ons for qualifying new technology services are included. If operating cost exceeds $54,492.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,222.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $7,953.92 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,629.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $661.50. The transfer capital threshold is the transfer adjustment factor * $661.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8616.14","8616.14","8646.83","1 through 10","8775.59","9778.39","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","36584.23","27438.17","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14763.45","","Case rate ($15,064.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,088.75, add-ons for qualifying new technology services are included. If operating cost exceeds $60,612.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,691.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,594.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,749.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.64. The transfer capital threshold is the transfer adjustment factor * $1,130.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15086.81","15086.81","15086.81","1 through 10","14763.45","15815.4777","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","36584.23","27438.17","MEDICARE [2001]","HB BWF MEDICARE","15064.74","","Case rate ($15,064.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,088.75, add-ons for qualifying new technology services are included. If operating cost exceeds $60,612.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,691.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,594.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,749.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.64. The transfer capital threshold is the transfer adjustment factor * $1,130.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16717.54","16606.50","16717.54","19","14763.45","15815.4777","other","Inpatient Replacement Plans DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","36584.23","27438.17","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14763.45","","Case rate ($15,064.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,088.75, add-ons for qualifying new technology services are included. If operating cost exceeds $60,612.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,691.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,594.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,749.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.64. The transfer capital threshold is the transfer adjustment factor * $1,130.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14995.22","14995.22","14995.22","1 through 10","14763.45","15815.4777","other","Inpatient DRG"
"Other Digestive System Diagnoses With McC","393","MS-DRG","","","","","","","","inpatient","","","36584.23","27438.17","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14763.45","","Case rate ($15,064.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,088.75, add-ons for qualifying new technology services are included. If operating cost exceeds $60,612.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,691.42, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $13,594.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,749.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,130.64. The transfer capital threshold is the transfer adjustment factor * $1,130.64. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15012.88","15012.88","15012.88","1 through 10","14763.45","15815.4777","other","Inpatient DRG"
"Other Digestive System Diagnoses Without Cc/McC","395","MS-DRG","","","","","","","","inpatient","","","13002.29","9751.72","MEDICARE [2001]","HB BWF MEDICARE","6886.21","","Case rate ($6,886.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,324.63, add-ons for qualifying new technology services are included. If operating cost exceeds $51,848.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,019.60, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,088.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,985.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $458.82. The transfer capital threshold is the transfer adjustment factor * $458.82. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6579.20","288.83","6579.20","1 through 10","6188.59","6886.21","other","Inpatient DRG"
"Other Digestive System Diagnoses,EXTREME","254","DRG","","","","","","","","inpatient","","","66690.20","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($56,210.61). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","22971.62","22971.62","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","23473.11","","Standard inlier is a Case rate ($23,473.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,730, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,332.10) for the length of stay and the standard reimbursement.","23473.11","23473.11","23473.11","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9360.618","","Fee schedule rate ($22,971.62). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9360.618","22971.62","22971.62","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","MASSHEALTH [3001]","HB BWF MEDICAID","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13019.18","13019.18","13019.18","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","13954.20","","Fee schedule rate ($13,954.20). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13954.20","13954.20","13954.20","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13019.18","257.67","13019.18","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13019.18","13019.18","13019.18","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MAJOR","254","DRG","","","","","","","","inpatient","","","35887.89","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","11777.79","","Case rate ($13,022.38). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,452.38, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13019.18","13019.18","13019.18","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","15718.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12561.32","","Standard inlier is a Case rate ($12,561.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,783.03) for the length of stay and the standard reimbursement.","12561.31","11990.34","12561.31","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","15718.32","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","16299.18","","Fee schedule rate ($16,299.18). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15824.38","15824.38","15824.38","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","15718.32","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5274.30","","Case rate ($5,831.65). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,261.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5830.22","1233.67","5830.22","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MINOR","254","DRG","","","","","","","","inpatient","","","15718.32","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5274.30","","Case rate ($5,831.65). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,261.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5830.22","1200.99","5830.22","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","16324.54","","Standard inlier is a Case rate ($16,324.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,644, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,317.33) for the length of stay and the standard reimbursement.","16324.53","16324.53","16324.53","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17535.81","","Standard inlier is a Case rate ($17,535.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $28,395, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,489.13) for the length of stay and the standard reimbursement.","17535.81","17535.81","17535.81","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","FALLON HEALTH [1008]","HB BWF MEDICAID","7034.69","","Case rate ($7,778.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,208.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7776.15","7776.15","7776.15","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9828.601","","Fee schedule rate ($24,120.08). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9828.601","14849.60","14849.60","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","29741.76","","Fee schedule rate ($29,741.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21105.72","21105.72","21105.72","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7034.69","","Case rate ($7,778.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,208.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7776.15","1759.31","8112.65","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System Diagnoses,MODERATE","254","DRG","","","","","","","","inpatient","","","21364.68","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7034.69","","Case rate ($7,778.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,208.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7776.15","1008.57","7776.15","1 through 10","5274.3","92746.64","case rate",""
"Other Digestive System O.R. Procedures With Cc","357","MS-DRG","","","","","","","","inpatient","","","40757.43","30568.07","MEDICARE [2001]","HB BWF MEDICARE","21751.20","","Case rate ($21,751.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,786.10, add-ons for qualifying new technology services are included. If operating cost exceeds $67,309.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,204.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $19,767.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,446.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,644.04. The transfer capital threshold is the transfer adjustment factor * $1,644.04. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","22492.84","22492.84","22492.84","1 through 10","21316.18","22403.74","other","Inpatient Replacement Plans DRG"
"Other Digestive System O.R. Procedures With McC","356","MS-DRG","","","","","","","","inpatient","","","103673.22","77754.91","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","39970.09","","Case rate ($40,785.81). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $40,851.72, add-ons for qualifying new technology services are included. If operating cost exceeds $86,375.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,666.32, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $37,341.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $40,512.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,105.53. The transfer capital threshold is the transfer adjustment factor * $3,105.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","38283.87","38283.87","38283.87","1 through 10","39970.09","42183.5073","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","28389.05","21291.79","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","9758.48","","Case rate ($9,758.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,773.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,297.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,696.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,434.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.22. The transfer capital threshold is the transfer adjustment factor * $723.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10605.87","10605.87","10605.87","1 through 10","9563.31","10116.447","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","28389.05","21291.79","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9563.31","","Case rate ($9,758.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,773.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,297.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,696.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,434.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.22. The transfer capital threshold is the transfer adjustment factor * $723.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","35614.31","35614.31","35614.31","1 through 10","9563.31","10116.447","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","28389.05","21291.79","MEDICARE [2001]","HB BWF MEDICARE","9758.48","","Case rate ($9,758.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,773.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,297.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,696.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,434.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.22. The transfer capital threshold is the transfer adjustment factor * $723.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10778.32","979.52","10778.32","22","9563.31","10116.447","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","28389.05","21291.79","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9563.31","","Case rate ($9,758.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,773.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,297.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,696.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,434.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.22. The transfer capital threshold is the transfer adjustment factor * $723.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10831.88","10831.88","10831.88","1 through 10","9563.31","10116.447","other","Inpatient DRG"
"Other Disorders Of Nervous System With Cc","092","MS-DRG","","","","","","","","inpatient","","","28389.05","21291.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9563.31","","Case rate ($9,758.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,773.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,297.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $8,696.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,434.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.22. The transfer capital threshold is the transfer adjustment factor * $723.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9660.07","9660.07","9660.07","1 through 10","9563.31","10116.447","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","35299.22","26474.41","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","18055.41","","Case rate ($18,055.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,535.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,059.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,802.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,474.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,196.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.56. The transfer capital threshold is the transfer adjustment factor * $1,241.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16548.11","16548.11","16548.11","1 through 10","16179.21","18055.41","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","35299.22","26474.41","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","16179.21","","Case rate ($16,509.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,535.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,059.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,802.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,928.59 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,196.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.56. The transfer capital threshold is the transfer adjustment factor * $1,241.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16455.30","16455.30","16455.30","1 through 10","16179.21","18055.41","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","35299.22","26474.41","MEDICARE [2001]","HB BWF MEDICARE","18055.41","","Case rate ($18,055.41). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,535.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,059.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,802.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $16,474.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,196.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.56. The transfer capital threshold is the transfer adjustment factor * $1,241.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18254.88","0.03","18377.11","17","16179.21","18055.41","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","35299.22","26474.41","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","16179.21","","Case rate ($16,509.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,535.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,059.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,802.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,928.59 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,196.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.56. The transfer capital threshold is the transfer adjustment factor * $1,241.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16476.30","16476.30","16476.30","1 through 10","16179.21","18055.41","other","Inpatient DRG"
"Other Disorders Of Nervous System With McC","091","MS-DRG","","","","","","","","inpatient","","","35299.22","26474.41","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16179.21","","Case rate ($16,509.40). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,535.75, add-ons for qualifying new technology services are included. If operating cost exceeds $62,059.48 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,802.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $14,928.59 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,196.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,241.56. The transfer capital threshold is the transfer adjustment factor * $1,241.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16455.30","16455.30","16455.30","1 through 10","16179.21","18055.41","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","26380.38","19785.28","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7517.72","","Case rate ($7,671.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,683.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,206.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,123.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,768.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,343.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.95. The transfer capital threshold is the transfer adjustment factor * $562.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9686.70","9686.70","9686.70","1 through 10","7517.72","7901.27","other","Inpatient DRG"
"Other Disorders Of Nervous System Without Cc/McC","093","MS-DRG","","","","","","","","inpatient","","","26380.38","19785.28","MEDICARE [2001]","HB BWF MEDICARE","7671.14","","Case rate ($7,671.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,683.09, add-ons for qualifying new technology services are included. If operating cost exceeds $53,206.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,123.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,768.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,343.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $562.95. The transfer capital threshold is the transfer adjustment factor * $562.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8099.54","8099.54","8099.54","1 through 10","7517.72","7901.27","other","Inpatient Replacement Plans DRG"
"Other Disorders Of Nervous System,MAJOR","058","DRG","","","","","","","","inpatient","","","29964.31","","MASSHEALTH [3001]","HB BWF MEDICAID","14110.50","","Case rate ($15,601.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,031.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11062.24","11062.24","11062.24","1 through 10","2087","100427.16","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","23421.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18501.47","","Standard inlier is a Case rate ($18,501.47). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,627, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,626.36) for the length of stay and the standard reimbursement.","17660.73","17660.73","18501.47","1 through 10","2087","100427.16","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","23421.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19874.27","","Standard inlier is a Case rate ($19,874.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,627, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,821.07) for the length of stay and the standard reimbursement.","19874.26","19874.26","19874.26","1 through 10","2087","100427.16","case rate",""
"Other Disorders Of Nervous System,MINOR","058","DRG","","","","","","","","inpatient","","","23421.75","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6047.69","","Case rate ($6,686.76). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,116.76, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3290.39","3290.39","3290.39","1 through 10","2087","100427.16","case rate",""
"Other Disorders Of The Eye Without McC","125","MS-DRG","","","","","","","","inpatient","","","8176.71","6132.53","MEDICARE [2001]","HB BWF MEDICARE","7408.74","","Case rate ($7,408.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,420.25, add-ons for qualifying new technology services are included. If operating cost exceeds $52,943.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,103.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,526.69 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,081.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $542.80. The transfer capital threshold is the transfer adjustment factor * $542.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8406.12","8406.12","8406.12","1 through 10","7260.57","7881.47","other","Inpatient Replacement Plans DRG"
"Other Disorders Of The Liver,EXTREME","283","DRG","","","","","","","","inpatient","","","16159.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","44675.63","","Fee schedule rate ($44,675.63). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($5,169.24) multiplied by length of stay and the outlier percent (100%).","6341.51","6341.51","6341.51","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,EXTREME","283","DRG","","","","","","","","inpatient","","","16159.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10664.0694","","Per diem ($11,823). If length of stay < 5, first 1 days paid at a per diem of $23,646 instead.","10664.0694","59116.50","59116.50","1 through 10","2492","44675.63","per diem","Estimated amount calculated based on 2 day length of stay."
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","44426.59","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22181.17","","Standard inlier is a Case rate ($22,181.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,148.70) for the length of stay and the standard reimbursement.","22181.17","22181.17","22181.17","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","44426.59","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","23827.00","","Standard inlier is a Case rate ($23,827.00). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,402, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,382.14) for the length of stay and the standard reimbursement.","22743.95","22743.95","22743.95","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","44426.59","","MASSHEALTH [3001]","HB BWF MEDICAID","10157.92","","Case rate ($11,231.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,661.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11228.57","11228.57","11228.57","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","44426.59","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10157.92","","Case rate ($11,231.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,661.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11228.57","11228.57","11228.57","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,MAJOR","283","DRG","","","","","","","","inpatient","","","44426.59","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10157.92","","Case rate ($11,231.33). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,661.33, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11228.57","11228.57","11228.57","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","36284.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15243.43","","Standard inlier is a Case rate ($15,243.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,867, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,163.86) for the length of stay and the standard reimbursement.","14550.74","14550.74","15243.42","1 through 10","2492","44675.63","case rate",""
"Other Disorders Of The Liver,MODERATE","283","DRG","","","","","","","","inpatient","","","36284.48","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","6880.47","","Case rate ($7,607.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,037.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7605.68","7605.68","7605.68","1 through 10","2492","44675.63","case rate",""
"Other Drug Abuse And Dependence,MODERATE","776","DRG","","","","","","","","inpatient","","","14426.07","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","13363.67","","Fee schedule rate ($13,363.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13363.67","13363.67","13363.67","1 through 10","954.59","16770.1","case rate",""
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","155","MS-DRG","","","","","","","","inpatient","","","18475.76","13856.82","MEDICARE [2001]","HB BWF MEDICARE","9584.69","","Case rate ($9,584.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,791.64, add-ons for qualifying new technology services are included. If operating cost exceeds $54,315.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,208.71, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,597.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,452.40 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.93. The transfer capital threshold is the transfer adjustment factor * $647.93. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9471.79","9471.79","9534.39","1 through 10","8602.32","9584.69","other","Inpatient DRG"
"Other Ear, Nose, Mouth And Throat Diagnoses With McC","154","MS-DRG","","","","","","","","inpatient","","","35729.11","26796.83","MEDICARE [2001]","HB BWF MEDICARE","14735.11","","Case rate ($14,735.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,758.58, add-ons for qualifying new technology services are included. If operating cost exceeds $60,282.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,666.11, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,290.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,419.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,105.33. The transfer capital threshold is the transfer adjustment factor * $1,105.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16313.17","16313.17","16313.17","1 through 10","14440.41","16049.33","other","Inpatient Replacement Plans DRG"
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","33459.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22644.51","","Standard inlier is a Case rate ($22,644.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,880, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,214.48) for the length of stay and the standard reimbursement.","22644.50","22644.50","22644.50","1 through 10","4760.24","75966.86","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","33459.68","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8424.5562","","Fee schedule rate ($46,040.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8424.5562","13058.62","13058.62","1 through 10","4760.24","75966.86","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MAJOR","115","DRG","","","","","","","","inpatient","","","33459.68","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10953.01","","Case rate ($12,110.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,540.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12107.46","12107.46","12107.46","1 through 10","4760.24","75966.86","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","26174.72","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11631.73","","Standard inlier is a Case rate ($11,631.73). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,756, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,651.07) for the length of stay and the standard reimbursement.","11103.01","11103.01","11103.01","1 through 10","4760.24","75966.86","case rate",""
"Other Ear, Nose, Mouth, Throat And Cranial Or Facial Diagnoses,MINOR","115","DRG","","","","","","","","inpatient","","","26174.72","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4760.24","","Case rate ($5,263.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,693.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5261.97","5261.97","5261.97","1 through 10","4760.24","75966.86","case rate",""
"Other Ear, Nose, Mouth, Throat, Craniofacial, And Neck Procedures,MODERATE","098","DRG","","","","","","","","inpatient","","","47340.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27606.34","","Standard inlier is a Case rate ($27,606.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $32,102, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,918.83) for the length of stay and the standard reimbursement.","27351.86","27351.86","27351.86","1 through 10","13754.09","72774.71","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","48371.73","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9514.9998","","Fee schedule rate ($25,553.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9514.9998","25553.12","25553.12","1 through 10","5162.35","93871.96","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","48371.73","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","28108.17","","Fee schedule rate ($28,108.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","785.00","785.00","785.00","1 through 10","5162.35","93871.96","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","48371.73","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14129.16","14129.16","14129.16","1 through 10","5162.35","93871.96","case rate",""
"Other Endocrine Disorders,MAJOR","424","DRG","","","","","","","","inpatient","","","48371.73","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9439.37","","Case rate ($10,436.85). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,866.85, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14129.16","14129.16","14129.16","1 through 10","5162.35","93871.96","case rate",""
"Other Endocrine Disorders,MODERATE","424","DRG","","","","","","","","inpatient","","","24403.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14900.22","","Standard inlier is a Case rate ($14,900.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,729, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,115.14) for the length of stay and the standard reimbursement.","15484.44","15484.44","15484.44","1 through 10","5162.35","93871.96","case rate",""
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","43383.09","32537.32","MEDICARE [2001]","HB BWF MEDICARE","22318.50","","Case rate ($22,318.50). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,433.17, add-ons for qualifying new technology services are included. If operating cost exceeds $65,956.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,101.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $20,438.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $20,093.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.32. The transfer capital threshold is the transfer adjustment factor * $1,540.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18165.99","18165.99","22615.01","1 through 10","19992.46","22365.38","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","629","MS-DRG","","","","","","","","inpatient","","","43383.09","32537.32","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","19992.46","","Case rate ($20,400.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,433.17, add-ons for qualifying new technology services are included. If operating cost exceeds $65,956.90 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,101.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.9. The base transfer operating payment is the transfer adjustment factor * $18,520.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $20,093.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,540.32. The transfer capital threshold is the transfer adjustment factor * $1,540.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","20341.13","20341.13","20341.13","1 through 10","19992.46","22365.38","other","Inpatient DRG"
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With McC","628","MS-DRG","","","","","","","","inpatient","","","50091.94","37568.95","MEDICARE [2001]","HB BWF MEDICARE","37934.37","","Case rate ($37,934.37). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $34,709.55, add-ons for qualifying new technology services are included. If operating cost exceeds $80,233.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,195.48, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.3. The base transfer operating payment is the transfer adjustment factor * $34,960.44 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $34,370.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,634.70. The transfer capital threshold is the transfer adjustment factor * $2,634.70. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","39220.52","39220.52","39220.52","1 through 10","33960.55","38255.6","other","Inpatient DRG"
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","36764.29","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","23529.43","","Fee schedule rate ($23,529.43). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23529.43","23529.43","23529.43","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","36764.29","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10180.77","","Case rate ($11,256.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,686.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","826.98","826.98","11253.82","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","36764.29","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","10180.77","","Case rate ($11,256.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,686.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11253.82","11253.82","11253.82","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MAJOR","243","DRG","","","","","","","","inpatient","","","36764.29","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10180.77","","Case rate ($11,256.59). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,686.59, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25414.45","25414.45","25414.45","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","28777.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15988.68","","Standard inlier is a Case rate ($15,988.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $24,403, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,269.66) for the length of stay and the standard reimbursement.","12790.94","12790.94","12790.94","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","28777.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","17175.03","","Standard inlier is a Case rate ($17,175.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $28,051, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,437.92) for the length of stay and the standard reimbursement.","17175.03","17175.03","17175.03","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","28777.25","","MASSHEALTH [3001]","HB BWF MEDICAID","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7058.89","7058.89","7058.89","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","28777.25","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1390.58","1390.58","1390.58","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","28777.25","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7058.90","1191.59","7058.90","1 through 10","4898.47","85801.28","case rate",""
"Other Esophageal Disorders,MODERATE","243","DRG","","","","","","","","inpatient","","","28777.25","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7058.90","7058.90","7058.90","1 through 10","4898.47","85801.28","case rate",""
"Other Factors Influencing Health Status","951","MS-DRG","","","","","","","","inpatient","","","12740.01","9555.01","MEDICARE [2001]","HB BWF MEDICARE","5948.04","","Case rate ($5,948.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,466.93, add-ons for qualifying new technology services are included. If operating cost exceeds $50,990.66 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,953.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.8. The base transfer operating payment is the transfer adjustment factor * $5,215.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,127.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $393.07. The transfer capital threshold is the transfer adjustment factor * $393.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","5889.11","5889.11","5889.11","1 through 10","5349.42","5948.04","other","Inpatient DRG"
"Other Female Reproductive System And Related Procedures,MODERATE","518","DRG","","","","","","","","inpatient","","","13784.73","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","22390.23","","Fee schedule rate ($22,390.23). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22390.23","22390.23","22390.23","1 through 10","8197.62","33585.35","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","67508.97","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","18345.26","","Case rate ($20,283.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,713.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,EXTREME","249","DRG","","","","","","","","inpatient","","","67508.97","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","18345.26","","Case rate ($20,283.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,713.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21100.51","21100.51","21100.51","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","19178.08","","Standard inlier is a Case rate ($19,178.08). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,722.40) for the length of stay and the standard reimbursement.","19178.08","19178.08","19178.08","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","20601.09","","Standard inlier is a Case rate ($20,601.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $31,322, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,924.24) for the length of stay and the standard reimbursement.","20601.08","20601.08","20601.08","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7672.1892","","Fee schedule rate ($15,707.86). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7672.1892","15707.86","15707.86","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8055.7594","","Fee schedule rate ($16,493.17). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8055.7594","32986.32","32986.32","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","11713.94","11713.94","11713.94","1 through 10","3991.43","222741.55","percent of total billed charges",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8645.43","","Case rate ($9,559). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,989, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5772.13","3696.16","9556.66","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MAJOR","249","DRG","","","","","","","","inpatient","","","29491.75","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8645.43","","Case rate ($9,559). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $51,989, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9556.66","1687.62","9556.66","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10607.64","","Standard inlier is a Case rate ($10,607.64). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,530, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,505.80) for the length of stay and the standard reimbursement.","10607.64","10607.64","10607.64","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11394.72","","Standard inlier is a Case rate ($11,394.72). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,530, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,617.43) for the length of stay and the standard reimbursement.","11394.72","11394.72","11394.72","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","FALLON HEALTH [1008]","HB BWF MEDICAID","3991.43","","Case rate ($4,413.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,843.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4412.13","4412.13","4412.13","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","MASSHEALTH [3001]","HB BWF MEDICAID","3991.43","","Case rate ($4,413.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,843.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4590.89","4590.89","4590.89","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","MEDICAID NON MASSACHUSETTS [3002]","HB BWF MEDICAID","3991.43","","Case rate ($4,413.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,843.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4522.68","4522.68","4522.68","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","3991.43","","Case rate ($4,413.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,843.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4412.13","4412.13","4412.13","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MINOR","249","DRG","","","","","","","","inpatient","","","24664.11","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","3991.43","","Case rate ($4,413.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,843.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4412.13","4412.13","4412.13","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13260.16","","Standard inlier is a Case rate ($13,260.16). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,530, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,882.33) for the length of stay and the standard reimbursement.","13260.16","13260.16","13260.16","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14244.06","","Standard inlier is a Case rate ($14,244.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,021.88) for the length of stay and the standard reimbursement.","14244.06","14244.06","14724.02","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7672.1892","","Fee schedule rate ($10,089.53). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7672.1892","10089.54","10089.54","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8055.7594","","Fee schedule rate ($10,593.96). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8055.7594","11098.40","11098.40","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","12929.12","12929.12","12929.12","1 through 10","3991.43","222741.55","percent of total billed charges",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","MASSHEALTH [3001]","HB BWF MEDICAID","5221.75","","Case rate ($5,773.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,203.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5772.13","5772.13","5772.13","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5618.81","","Fee schedule rate ($5,618.81). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","5618.81","5618.81","5618.81","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6610.31","","Fee schedule rate ($6,610.31). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6417.82","6417.82","6417.82","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","14089.56","","Fee schedule rate ($14,089.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14089.56","14089.56","14089.56","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5221.75","","Case rate ($5,773.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,203.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5772.13","1119.16","5772.13","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5221.75","","Case rate ($5,773.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,203.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5772.13","5772.13","5772.13","1 through 10","3991.43","222741.55","case rate",""
"Other Gastroenteritis, Nausea And Vomiting,MODERATE","249","DRG","","","","","","","","inpatient","","","20213.01","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5221.75","","Case rate ($5,773.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,203.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5772.13","5772.13","9556.66","1 through 10","3991.43","222741.55","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,EXTREME","264","DRG","","","","","","","","inpatient","","","159834.22","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","172950.37","","Fee schedule rate ($172,950.37). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","140249.27","140249.27","140249.27","1 through 10","12603.1615","259425.55","case rate",""
"Other Hepatobiliary, Pancreas And Abdominal Procedures,MAJOR","264","DRG","","","","","","","","inpatient","","","57858.82","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","21268.57","","Case rate ($23,516.06). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,946.06, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","23510.29","23510.29","23510.29","1 through 10","12603.1615","259425.55","case rate",""
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","22317.84","16738.38","HUMANA [1012]","HB BWF MEDICARE","9833.06","","Case rate ($9,833.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,848.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,372.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,764.87 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,509.29 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.95. The transfer capital threshold is the transfer adjustment factor * $728.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9589.03","9589.03","9589.03","1 through 10","9636.4","10384.4389","other","Inpatient Replacement Plans DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","22317.84","16738.38","MEDICARE [2001]","HB BWF MEDICARE","9833.06","","Case rate ($9,833.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,848.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,372.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,764.87 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,509.29 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.95. The transfer capital threshold is the transfer adjustment factor * $728.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10692.79","10692.79","10692.79","1 through 10","9636.4","10384.4389","other","Inpatient Replacement Plans DRG"
"Other Infectious And Parasitic Diseases Diagnoses With Cc","868","MS-DRG","","","","","","","","inpatient","","","22317.84","16738.38","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","9833.06","","Case rate ($9,833.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,848.53, add-ons for qualifying new technology services are included. If operating cost exceeds $55,372.26 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,289.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,764.87 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,509.29 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $728.95. The transfer capital threshold is the transfer adjustment factor * $728.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9590.59","9590.59","9590.59","1 through 10","9636.4","10384.4389","other","Inpatient Replacement Plans DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","17097.18","12822.88","MEDICARE [2001]","HB BWF MEDICARE","21454.99","","Case rate ($21,454.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,643.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,167.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,040.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $19,635.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,304.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,479.81. The transfer capital threshold is the transfer adjustment factor * $1,479.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21429.16","21429.16","21429.16","1 through 10","19220.07","21454.99","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases Diagnoses With McC","867","MS-DRG","","","","","","","","inpatient","","","17097.18","12822.88","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","19220.07","","Case rate ($19,612.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,643.72, add-ons for qualifying new technology services are included. If operating cost exceeds $65,167.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,040.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $17,793.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,304.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,479.81. The transfer capital threshold is the transfer adjustment factor * $1,479.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","19319.19","19319.19","19319.19","1 through 10","19220.07","21454.99","other","Inpatient DRG"
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","37055.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28651.39","","Standard inlier is a Case rate ($28,651.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,010, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,066.94) for the length of stay and the standard reimbursement.","27349.05","27349.05","27349.05","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","37055.75","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12647.5824","","Fee schedule rate ($15,690.27). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12647.5824","26737.36","26737.36","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","37055.75","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","19612.44","","Fee schedule rate ($19,612.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34888.89","34888.89","34888.89","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MAJOR","724","DRG","","","","","","","","inpatient","","","37055.75","","MASSHEALTH [3001]","HB BWF MEDICAID","9303.43","","Case rate ($10,286.54). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,716.54, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10284.02","10284.02","10284.02","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MINOR","724","DRG","","","","","","","","inpatient","","","3242.00","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14333.60","","Standard inlier is a Case rate ($14,333.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,034.59) for the length of stay and the standard reimbursement.","13682.06","13682.06","13682.06","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","16660.32","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","15986.23","","Standard inlier is a Case rate ($15,986.23). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,336, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,269.31) for the length of stay and the standard reimbursement.","15986.23","15986.23","15986.23","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","16660.32","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13279.8968","","Fee schedule rate ($28,074.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13279.8968","23249.44","23249.44","1 through 10","6121.73","44116.24","case rate",""
"Other Infectious And Parasitic Diseases,MODERATE","724","DRG","","","","","","","","inpatient","","","16660.32","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6570.89","","Case rate ($7,265.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,695.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7263.46","7263.46","7263.46","1 through 10","6121.73","44116.24","case rate",""
"Other Injury, Poisoning And Toxic Effect Diagnoses With McC","922","MS-DRG","","","","","","","","inpatient","","","41036.33","30777.25","MEDICARE [2001]","HB BWF MEDICARE","17986.80","","Case rate ($17,986.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,473.03, add-ons for qualifying new technology services are included. If operating cost exceeds $61,996.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,797.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $16,410.81 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,133.80 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,236.76. The transfer capital threshold is the transfer adjustment factor * $1,236.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16936.38","16936.38","16936.38","1 through 10","16117.84","17986.8","other","Inpatient DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses Without McC","923","MS-DRG","","","","","","","","inpatient","","","25232.71","18924.53","MEDICARE [2001]","HB BWF MEDICARE","9709.68","","Case rate ($9,709.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,724.96, add-ons for qualifying new technology services are included. If operating cost exceeds $55,248.69 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,280.25, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $8,650.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,385.71 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $719.47. The transfer capital threshold is the transfer adjustment factor * $719.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10324.12","10324.12","10324.12","1 through 10","9515.49","10085.7911","other","Inpatient Replacement Plans DRG"
"Other Injury, Poisoning And Toxic Effect Diagnoses,MODERATE","815","DRG","","","","","","","","inpatient","","","13963.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13095.91","","Standard inlier is a Case rate ($13,095.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $21,084, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,859.02) for the length of stay and the standard reimbursement.","12500.81","12500.81","12500.81","1 through 10","6151.07","17466.57","case rate",""
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","24613.23","18459.92","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","9975.37","","Case rate ($9,684.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,700.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,223.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,278.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,628.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,360.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.56. The transfer capital threshold is the transfer adjustment factor * $717.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","9839.34","9839.34","9839.34","1 through 10","9491.13","10578.35","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","24613.23","18459.92","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10578.35","","Case rate ($10,578.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,700.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,223.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,278.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,521.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,360.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.56. The transfer capital threshold is the transfer adjustment factor * $717.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9393.19","9393.19","9393.19","1 through 10","9491.13","10578.35","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","24613.23","18459.92","MEDICARE [2001]","HB BWF MEDICARE","10578.35","","Case rate ($10,578.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,700.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,223.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,278.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $9,521.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,360.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.56. The transfer capital threshold is the transfer adjustment factor * $717.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10392.51","0.03","10392.51","27","9491.13","10578.35","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With Cc","699","MS-DRG","","","","","","","","inpatient","","","24613.23","18459.92","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9491.13","","Case rate ($9,684.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,700.06, add-ons for qualifying new technology services are included. If operating cost exceeds $55,223.79 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,278.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $8,628.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,360.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $717.56. The transfer capital threshold is the transfer adjustment factor * $717.56. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9338.76","9338.76","9340.70","1 through 10","9491.13","10578.35","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","39938.95","29954.21","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15260.64","","Case rate ($15,572.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $61,120.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,730.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,063.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,257.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.59. The transfer capital threshold is the transfer adjustment factor * $1,169.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15234.92","15234.92","15234.92","1 through 10","15260.64","16982.42","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","39938.95","29954.21","MEDICARE [2001]","HB BWF MEDICARE","15572.08","","Case rate ($15,572.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $61,120.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,730.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,063.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,257.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.59. The transfer capital threshold is the transfer adjustment factor * $1,169.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16852.42","0.03","16965.13","35","15260.64","16982.42","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","39938.95","29954.21","MOLINA [1014]","HB BWF MEDICARE","15572.08","","Case rate ($15,572.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $61,120.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,730.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,063.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,257.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.59. The transfer capital threshold is the transfer adjustment factor * $1,169.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","30780.76","30780.76","30780.76","1 through 10","15260.64","16982.42","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","39938.95","29954.21","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15260.64","","Case rate ($15,572.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $61,120.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,730.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,063.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,257.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.59. The transfer capital threshold is the transfer adjustment factor * $1,169.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15234.92","15232.65","15254.92","1 through 10","15260.64","16982.42","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses With McC","698","MS-DRG","","","","","","","","inpatient","","","39938.95","29954.21","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15260.64","","Case rate ($15,572.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,596.90, add-ons for qualifying new technology services are included. If operating cost exceeds $61,120.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,730.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,063.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,257.66 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,169.59. The transfer capital threshold is the transfer adjustment factor * $1,169.59. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15192.65","15192.65","15192.65","1 through 10","15260.64","16982.42","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses Without Cc/McC","700","MS-DRG","","","","","","","","inpatient","","","19640.26","14730.19","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6892.22","","Case rate ($6,691.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,701.83, add-ons for qualifying new technology services are included. If operating cost exceeds $52,225.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,048.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,864.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,362.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.73. The transfer capital threshold is the transfer adjustment factor * $487.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","6758.23","6758.23","6758.23","1 through 10","6557.65","6892.22","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses Without Cc/McC","700","MS-DRG","","","","","","","","inpatient","","","19640.26","14730.19","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6557.65","","Case rate ($6,691.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,701.83, add-ons for qualifying new technology services are included. If operating cost exceeds $52,225.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,048.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $5,864.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,362.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $487.73. The transfer capital threshold is the transfer adjustment factor * $487.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6442.65","6442.65","6442.65","1 through 10","6557.65","6892.22","other","Inpatient DRG"
"Other Kidney And Urinary Tract Diagnoses, Signs And Symptoms,MAJOR","468","DRG","","","","","","","","inpatient","","","34424.72","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10427.52","","Case rate ($11,529.41). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,959.41, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11526.58","11526.58","11526.58","1 through 10","9157.91","106318.14","case rate",""
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","58080.54","43560.40","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","22527.97","","Case rate ($21,871.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,906.92, add-ons for qualifying new technology services are included. If operating cost exceeds $67,430.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,214.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,879.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,567.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.30. The transfer capital threshold is the transfer adjustment factor * $1,653.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","21887.74","21887.74","21887.74","1 through 10","21434.38","22827.7676","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","58080.54","43560.40","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","21434.38","","Case rate ($21,871.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,906.92, add-ons for qualifying new technology services are included. If operating cost exceeds $67,430.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,214.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,879.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,567.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.30. The transfer capital threshold is the transfer adjustment factor * $1,653.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","20830.42","20830.42","20830.42","1 through 10","21434.38","22827.7676","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","58080.54","43560.40","MEDICARE [2001]","HB BWF MEDICARE","21871.82","","Case rate ($21,871.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,906.92, add-ons for qualifying new technology services are included. If operating cost exceeds $67,430.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,214.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,879.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,567.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.30. The transfer capital threshold is the transfer adjustment factor * $1,653.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","23204.67","23204.67","23204.67","1 through 10","21434.38","22827.7676","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","58080.54","43560.40","MOLINA [1014]","HB BWF MEDICARE","21871.82","","Case rate ($21,871.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,906.92, add-ons for qualifying new technology services are included. If operating cost exceeds $67,430.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,214.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,879.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,567.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.30. The transfer capital threshold is the transfer adjustment factor * $1,653.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","42085.95","42085.95","42085.95","1 through 10","21434.38","22827.7676","other","Inpatient Replacement Plans DRG"
"Other Kidney And Urinary Tract Procedures With Cc","674","MS-DRG","","","","","","","","inpatient","","","58080.54","43560.40","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","21434.38","","Case rate ($21,871.82). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,906.92, add-ons for qualifying new technology services are included. If operating cost exceeds $67,430.65 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,214.07, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $19,879.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $21,567.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,653.30. The transfer capital threshold is the transfer adjustment factor * $1,653.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","20811.86","20811.86","20811.86","1 through 10","21434.38","22827.7676","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","96276.35","72207.26","MEDICARE [2001]","HB BWF MEDICARE","42724.07","","Case rate ($42,724.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,088.39, add-ons for qualifying new technology services are included. If operating cost exceeds $84,612.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,531.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,414.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $38,749.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,970.36. The transfer capital threshold is the transfer adjustment factor * $2,970.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","41629.38","41629.38","41629.38","1 through 10","38244.83","43129.42","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures With McC","673","MS-DRG","","","","","","","","inpatient","","","96276.35","72207.26","MOLINA [1014]","HB BWF MEDICARE","42724.07","","Case rate ($42,724.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,088.39, add-ons for qualifying new technology services are included. If operating cost exceeds $84,612.12 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,531.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 10.2. The base transfer operating payment is the transfer adjustment factor * $39,414.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $38,749.14 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,970.36. The transfer capital threshold is the transfer adjustment factor * $2,970.36. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","76010.70","76010.70","76010.70","1 through 10","38244.83","43129.42","other","Inpatient DRG"
"Other Kidney And Urinary Tract Procedures Without Cc/McC","675","MS-DRG","","","","","","","","inpatient","","","63124.14","47343.10","MEDICARE [2001]","HB BWF MEDICARE","16897.33","","Case rate ($16,897.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,477.02, add-ons for qualifying new technology services are included. If operating cost exceeds $61,000.75 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,721.18, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $15,397.68 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,137.77 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,160.40. The transfer capital threshold is the transfer adjustment factor * $1,160.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15710.72","15710.72","15710.72","1 through 10","15143.33","16897.33","other","Inpatient DRG"
"Other Male Reproductive System And Related Procedures,MAJOR","484","DRG","","","","","","","","inpatient","","","75312.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","40491.43","","Standard inlier is a Case rate ($40,491.43). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $53,187, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,747.92) for the length of stay and the standard reimbursement.","38651.43","38651.43","38651.43","1 through 10","9758.09","62504.99","case rate",""
"Other Male Reproductive System And Related Procedures,MAJOR","484","DRG","","","","","","","","inpatient","","","75312.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","43495.87","","Standard inlier is a Case rate ($43,495.87). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $53,187, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,174.05) for the length of stay and the standard reimbursement.","43495.86","43495.86","43495.86","1 through 10","9758.09","62504.99","case rate",""
"Other Male Reproductive System And Related Procedures,MODERATE","484","DRG","","","","","","","","inpatient","","","55739.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","33764.51","","Standard inlier is a Case rate ($33,764.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,752, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,793.00) for the length of stay and the standard reimbursement.","33764.50","33764.50","33764.50","1 through 10","9758.09","62504.99","case rate",""
"Other Male Reproductive System And Related Procedures,MODERATE","484","DRG","","","","","","","","inpatient","","","55739.50","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","36269.82","","Standard inlier is a Case rate ($36,269.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $46,287, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,148.35) for the length of stay and the standard reimbursement.","36269.81","36269.81","36269.81","1 through 10","9758.09","62504.99","case rate",""
"Other Male Reproductive System Diagnoses With Cc/McC","729","MS-DRG","","","","","","","","inpatient","","","24975.69","18731.77","MEDICARE [2001]","HB BWF MEDICARE","11019.17","","Case rate ($11,019.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,103.07, add-ons for qualifying new technology services are included. If operating cost exceeds $55,626.80 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,309.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,931.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,763.83 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $748.46. The transfer capital threshold is the transfer adjustment factor * $748.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","9885.44","11019.17","other","Inpatient DRG"
"Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC","717","MS-DRG","","","","","","","","inpatient","","","48436.66","36327.49","MEDICARE [2001]","HB BWF MEDICARE","19410.18","","Case rate ($19,410.18). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,774.32, add-ons for qualifying new technology services are included. If operating cost exceeds $63,298.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,897.29, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $17,734.44 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,435.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,336.51. The transfer capital threshold is the transfer adjustment factor * $1,336.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18701.28","18576.85","18701.28","1 through 10","17391.03","19410.18","other","Inpatient DRG"
"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/McC","718","MS-DRG","","","","","","","","inpatient","","","47794.24","35845.68","MEDICARE [2001]","HB BWF MEDICARE","13888.13","","Case rate ($13,888.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,725.94, add-ons for qualifying new technology services are included. If operating cost exceeds $58,249.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,510.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,599.38 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,386.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $949.52. The transfer capital threshold is the transfer adjustment factor * $949.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12500.52","12500.52","12500.52","1 through 10","12182.2591","13888.13","other","Inpatient DRG"
"Other Multiple Significant Trauma With McC","963","MS-DRG","","","","","","","","inpatient","","","55817.51","41863.13","MEDICARE [2001]","HB BWF MEDICARE","27917.21","","Case rate ($27,917.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,551.64, add-ons for qualifying new technology services are included. If operating cost exceeds $71,075.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,493.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $25,645.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,212.40 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,932.69. The transfer capital threshold is the transfer adjustment factor * $1,932.69. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","25094.21","25094.21","25094.21","1 through 10","25000.4","27917.21","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","34535.46","25901.59","MEDICARE [2001]","HB BWF MEDICARE","10168.78","","Case rate ($10,168.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,325.62, add-ons for qualifying new technology services are included. If operating cost exceeds $54,849.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,249.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $9,140.67 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,986.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $688.86. The transfer capital threshold is the transfer adjustment factor * $688.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10390.53","10322.16","10390.53","1 through 10","9124.78","10168.78","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","565","MS-DRG","","","","","","","","inpatient","","","34535.46","25901.59","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9124.78","","Case rate ($9,311). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,325.62, add-ons for qualifying new technology services are included. If operating cost exceeds $54,849.35 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,249.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,282.89 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,986.38 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $688.86. The transfer capital threshold is the transfer adjustment factor * $688.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9366.44","9366.44","9366.44","1 through 10","9124.78","10168.78","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses With McC","564","MS-DRG","","","","","","","","inpatient","","","45073.46","33805.09","MEDICARE [2001]","HB BWF MEDICARE","15910.74","","Case rate ($15,910.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,575.05, add-ons for qualifying new technology services are included. If operating cost exceeds $60,098.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,652.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $14,480.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,235.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,091.26. The transfer capital threshold is the transfer adjustment factor * $1,091.26. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15749.24","15749.24","15854.45","1 through 10","14260.85","15910.74","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC","566","MS-DRG","","","","","","","","inpatient","","","32863.66","24647.74","MEDICARE [2001]","HB BWF MEDICARE","7898.01","","Case rate ($7,898.01). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,249.64, add-ons for qualifying new technology services are included. If operating cost exceeds $52,773.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,090.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,029.05 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,910.40 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $529.73. The transfer capital threshold is the transfer adjustment factor * $529.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7689.86","7689.86","7689.86","1 through 10","7093.62","7898.01","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","79830.77","","MASSHEALTH [3001]","HB BWF MEDICAID","15842.33","","Case rate ($17,516.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,946.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17512.12","17512.12","17512.12","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","79830.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","15842.33","","Case rate ($17,516.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,946.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20306.67","20306.67","20306.67","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,EXTREME","351","DRG","","","","","","","","inpatient","","","79830.77","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","15842.33","","Case rate ($17,516.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,946.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17512.12","17512.12","17512.12","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","38494.53","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","22330.71","","Standard inlier is a Case rate ($22,330.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,557, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,169.93) for the length of stay and the standard reimbursement.","21318.83","21318.83","21318.83","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","38494.53","","FALLON HEALTH [1008]","HB BWF MEDICAID","9493.06","","Case rate ($10,496.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,926.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,650.56 and the sum of the standard inlier and any outlier amount.","10493.64","10493.64","10493.64","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","38494.53","","MASSHEALTH [3001]","HB BWF MEDICAID","9493.06","","Case rate ($10,496.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,926.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,650.56 and the sum of the standard inlier and any outlier amount.","10493.64","10493.64","10493.64","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","38494.53","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9493.06","","Case rate ($10,496.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,926.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,650.56 and the sum of the standard inlier and any outlier amount.","10493.64","10493.64","10493.64","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","38494.53","","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","7967.5277","","Fee schedule rate ($22,261.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7967.5277","11032.72","11032.72","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MAJOR","351","DRG","","","","","","","","inpatient","","","38494.53","","UNITED HEALTHCARE [1016]","HB CH HPHC PPO / PREFERRED A","9354.6121","","Fee schedule rate ($22,261.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9354.6121","11032.72","11032.72","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","21975.14","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","12221.61","","Standard inlier is a Case rate ($12,221.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,320, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,734.81) for the length of stay and the standard reimbursement.","11666.08","11666.08","11666.08","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MINOR","351","DRG","","","","","","","","inpatient","","","21975.14","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4689.41","","Case rate ($5,184.95). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,614.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10493.64","10493.64","10493.64","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15494.93","","Standard inlier is a Case rate ($15,494.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,446, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,199.44) for the length of stay and the standard reimbursement.","14791.44","14790.61","15494.92","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7588.1586","","Fee schedule rate ($21,201.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7588.1586","12149.26","12149.26","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8909.1978","","Fee schedule rate ($21,201.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8909.1978","12149.26","12149.26","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","7967.5277","","Fee schedule rate ($22,261.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7967.5277","12756.68","12756.68","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9354.6121","","Fee schedule rate ($22,261.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9354.6121","12756.68","12756.68","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","MASSHEALTH [3001]","HB BWF MEDICAID","5710.69","","Case rate ($6,314.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,744.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1594.09","521.82","6312.60","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","22408.82","","Fee schedule rate ($22,408.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14991.38","14991.38","14991.38","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5710.69","","Case rate ($6,314.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,744.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6312.60","6312.60","6312.60","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5710.69","","Case rate ($6,314.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,744.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6312.60","6312.60","6312.60","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue Diagnoses,MODERATE","351","DRG","","","","","","","","inpatient","","","21796.11","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5710.69","","Case rate ($6,314.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,744.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6312.60","860.65","6312.60","1 through 10","4689.41","69805.04","case rate",""
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","39949.68","29962.26","MEDICARE [2001]","HB BWF MEDICARE","19473.27","","Case rate ($19,473.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,504.46, add-ons for qualifying new technology services are included. If operating cost exceeds $65,028.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,029.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,664.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,165.22 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,469.13. The transfer capital threshold is the transfer adjustment factor * $1,469.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","20254.44","20254.44","20254.44","1 through 10","19083.8","20057.47","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","516","MS-DRG","","","","","","","","inpatient","","","39949.68","29962.26","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","19083.80","","Case rate ($19,473.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,504.46, add-ons for qualifying new technology services are included. If operating cost exceeds $65,028.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,029.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $17,664.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,165.22 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,469.13. The transfer capital threshold is the transfer adjustment factor * $1,469.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13821.87","13821.87","13821.87","1 through 10","19083.8","20057.47","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC","515","MS-DRG","","","","","","","","inpatient","","","84300.07","63225.05","MEDICARE [2001]","HB BWF MEDICARE","32487.98","","Case rate ($32,487.98). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $29,730.34, add-ons for qualifying new technology services are included. If operating cost exceeds $75,254.07 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,813.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.7. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 6.7)) / 2. The base transfer operating payment is the transfer adjustment factor * $29,895.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,391.10 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,253.01. The transfer capital threshold is the transfer adjustment factor * $2,253.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","30792.96","30792.96","30792.96","1 through 10","29088.86","32487.98","other","Inpatient DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","31261.69","23446.27","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","14488.35","","Case rate ($14,488.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,511.41, add-ons for qualifying new technology services are included. If operating cost exceeds $60,035.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,647.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,062.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,172.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.39. The transfer capital threshold is the transfer adjustment factor * $1,086.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13595.35","13595.35","13595.35","1 through 10","14198.58","14923","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC","517","MS-DRG","","","","","","","","inpatient","","","31261.69","23446.27","MEDICARE [2001]","HB BWF MEDICARE","14488.35","","Case rate ($14,488.35). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,511.41, add-ons for qualifying new technology services are included. If operating cost exceeds $60,035.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,647.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $13,062.73 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,172.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,086.39. The transfer capital threshold is the transfer adjustment factor * $1,086.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15093.77","15093.77","15093.77","1 through 10","14198.58","14923","other","Inpatient Replacement Plans DRG"
"Other Musculoskeletal System And Connective Tissue Procedures,MINOR","320","DRG","","","","","","","","inpatient","","","34848.48","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10368.11","","Case rate ($11,463.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,893.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11925.29","11925.29","11925.29","1 through 10","10368.11","52145","case rate",""
"Other Musculoskeletal System And Connective Tissue Procedures,MODERATE","320","DRG","","","","","","","","inpatient","","","92016.77","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","20071.37","","Case rate ($22,192.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,622.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14180.93","14180.93","14180.93","1 through 10","10368.11","52145","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","26311.50","","MASSHEALTH [3001]","HB BWF MEDICAID","8767.66","","Case rate ($9,694.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,124.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9691.77","9691.77","9691.77","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","26311.50","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8767.66","","Case rate ($9,694.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,124.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9691.78","9691.78","9691.78","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MAJOR","425","DRG","","","","","","","","inpatient","","","26311.50","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8767.66","","Case rate ($9,694.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,124.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2439.81","2439.81","9691.78","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MINOR","425","DRG","","","","","","","","inpatient","","","19012.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10364.94","","Standard inlier is a Case rate ($10,364.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,280, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,471.34) for the length of stay and the standard reimbursement.","12691.41","12691.41","12691.41","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","10134.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","12691.42","","Standard inlier is a Case rate ($12,691.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,280, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,801.60) for the length of stay and the standard reimbursement.","12691.41","12691.41","12691.41","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","10134.87","","MASSHEALTH [3001]","HB BWF MEDICAID","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6001.95","6001.95","6001.95","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","10134.87","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4103.38","32685.74","case rate",""
"Other Non-Hypovolemic Electrolyte Disorders,MODERATE","425","DRG","","","","","","","","inpatient","","","10134.87","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5429.67","","Case rate ($6,003.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,433.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6001.96","6001.96","6001.96","1 through 10","4103.38","32685.74","case rate",""
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","41659.82","31244.86","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","18709.97","","Case rate ($18,709.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,739.91, add-ons for qualifying new technology services are included. If operating cost exceeds $64,263.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,971.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $16,960.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,400.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.53. The transfer capital threshold is the transfer adjustment factor * $1,410.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19983.22","19983.22","19983.22","1 through 10","18335.77","19947.1019","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures For Injuries With Cc","908","MS-DRG","","","","","","","","inpatient","","","41659.82","31244.86","MEDICARE [2001]","HB BWF MEDICARE","18709.97","","Case rate ($18,709.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,739.91, add-ons for qualifying new technology services are included. If operating cost exceeds $64,263.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,971.31, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.6. The base transfer operating payment is the transfer adjustment factor * $16,960.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $18,400.68 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,410.53. The transfer capital threshold is the transfer adjustment factor * $1,410.53. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","20172.88","20172.88","20172.88","1 through 10","18335.77","19947.1019","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures For Injuries With McC","907","MS-DRG","","","","","","","","inpatient","","","60421.39","45316.04","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","35689.47","","Case rate ($35,689.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $35,747.09, add-ons for qualifying new technology services are included. If operating cost exceeds $81,270.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,275.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.8. The base transfer operating payment is the transfer adjustment factor * $32,636.00 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $35,407.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,714.23. The transfer capital threshold is the transfer adjustment factor * $2,714.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","36437.11","36437.11","36437.11","1 through 10","34975.68","39410.41","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures For Injuries Without Cc/McC","909","MS-DRG","","","","","","","","inpatient","","","39004.22","29253.16","MEDICARE [2001]","HB BWF MEDICARE","12425.88","","Case rate ($12,425.88). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,445.58, add-ons for qualifying new technology services are included. If operating cost exceeds $57,969.31 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,488.81, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $11,158.62 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,106.34 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $928.03. The transfer capital threshold is the transfer adjustment factor * $928.03. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12862.47","12862.47","12862.47","1 through 10","12177.36","12798.66","other","Inpatient Replacement Plans DRG"
"Other O.R. Procedures For Multiple Significant Trauma With Cc","958","MS-DRG","","","","","","","","inpatient","","","70454.93","52841.20","MEDICARE [2001]","HB BWF MEDICARE","42848.14","","Case rate ($42,848.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $39,201.82, add-ons for qualifying new technology services are included. If operating cost exceeds $84,725.55 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,539.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.5. The base transfer operating payment is the transfer adjustment factor * $39,529.84 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $38,862.58 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,979.06. The transfer capital threshold is the transfer adjustment factor * $2,979.06. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","41116.83","41116.83","41116.83","1 through 10","38355.82","42848.14","other","Inpatient DRG"
"Other O.R. Procedures Of The Blood And Blood Forming Organs With McC","802","MS-DRG","","","","","","","","inpatient","","","127577.81","95683.36","MEDICARE [2001]","HB BWF MEDICARE","40529.97","","Case rate ($40,529.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $37,082.50, add-ons for qualifying new technology services are included. If operating cost exceeds $82,606.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,377.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $37,374.13 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $36,743.26 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,816.60. The transfer capital threshold is the transfer adjustment factor * $2,816.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35656.11","35656.11","35656.11","1 through 10","35450.0872","40529.97","other","Inpatient DRG"
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","49150.20","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($42,339.70). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","42339.70","42339.70","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","49150.20","","MASSHEALTH [3001]","HB BWF MEDICAID","12895.03","","Case rate ($14,257.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,687.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14254.17","14254.17","14831.72","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","49150.20","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","28666.02","","Fee schedule rate ($28,666.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28666.02","28666.02","28666.02","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","49150.20","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","12895.03","","Case rate ($14,257.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,687.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14254.17","14254.17","14254.17","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,EXTREME","139","DRG","","","","","","","","inpatient","","","49150.20","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","12895.03","","Case rate ($14,257.67). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,687.67, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3461.48","2165.25","14254.17","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","10798.8575","","Standard inlier is a Case rate ($14,978.67). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,726, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,126.28) for the length of stay and the standard reimbursement.","10798.8575","15854.64","19818.30","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11600.127","","Standard inlier is a Case rate ($16,090.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,015, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,283.92) for the length of stay and the standard reimbursement.","11600.127","22302.26","22302.26","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","9880.4352","","Fee schedule rate ($23,358.55). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9880.4352","23358.56","23358.56","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","10374.4064","","Fee schedule rate ($24,526.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10374.4064","39235.39","39235.39","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","MASSHEALTH [3001]","HB BWF MEDICAID","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","8423.95","8423.95","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","4960.98","8423.95","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MAJOR","139","DRG","","","","","","","","inpatient","","","20044.22","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","8423.95","22386.31","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MINOR","139","DRG","","","","","","","","inpatient","","","20053.22","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","3946.87","","Case rate ($4,363.95). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,793.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","8423.95","8423.95","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","18498.92","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11600.127","","Standard inlier is a Case rate ($16,090.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,015, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,283.92) for the length of stay and the standard reimbursement.","11600.127","16090.07","16090.07","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","18498.92","","FALLON HEALTH [1008]","HB BWF MEDICAID","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8423.95","8423.95","8423.95","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","18498.92","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4798.02","","Fee schedule rate ($4,798.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","4798.02","4798.02","4798.02","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","18498.92","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5639.54","5639.54","5639.54","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","18498.92","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5639.54","5639.54","6810.13","1 through 10","3946.87","69859.85","case rate",""
"Other Pneumonia,MODERATE","139","DRG","","","","","","","","inpatient","","","18498.92","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5101.81","","Case rate ($5,640.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,070.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3946.87","69859.85","case rate",""
"Other Respiratory And Chest Procedures,EXTREME","121","DRG","","","","","","","","inpatient","","","110439.68","","MASSHEALTH [3001]","HB BWF MEDICAID","46905.55","","Case rate ($51,862.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $94,292.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","54960.38","54960.38","54960.38","1 through 10","11623.57","119393.31","case rate",""
"Other Respiratory And Chest Procedures,MAJOR","121","DRG","","","","","","","","inpatient","","","84755.50","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24669.8208","","Fee schedule rate ($62,927.19). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24669.8208","60502.46","60502.46","1 through 10","11623.57","119393.31","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","35235.23","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24669.8208","","Fee schedule rate ($24,669.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24669.8208","24669.82","24669.82","1 through 10","11623.57","119393.31","case rate",""
"Other Respiratory And Chest Procedures,MINOR","121","DRG","","","","","","","","inpatient","","","35235.23","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","13350.67","","Fee schedule rate ($13,350.67). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13350.67","13350.67","13350.67","1 through 10","11623.57","119393.31","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","68820.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","15259.73","","Case rate ($16,872.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,302.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16868.11","16868.11","16868.11","1 through 10","11623.57","119393.31","case rate",""
"Other Respiratory And Chest Procedures,MODERATE","121","DRG","","","","","","","","inpatient","","","68820.13","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","15259.73","","Case rate ($16,872.25). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,302.25, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16868.11","16868.11","16868.11","1 through 10","11623.57","119393.31","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,EXTREME","143","DRG","","","","","","","","inpatient","","","23568.92","","MASSHEALTH [3001]","HB BWF MEDICAID","17156.05","","Case rate ($18,968.97). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,398.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","18964.31","18964.31","18964.31","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","143","DRG","","","","","","","","inpatient","","","17482.94","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10971.28","","Case rate ($12,130.64). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,560.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12127.66","12127.66","12127.66","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","27424.87","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10320.1302","","Fee schedule rate ($10,320.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10320.1302","10320.14","10320.14","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MINOR","143","DRG","","","","","","","","inpatient","","","27424.87","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11926.4826","","Fee schedule rate ($10,320.13). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11926.4826","10320.14","10320.14","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","24239.55","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18291.60","","Standard inlier is a Case rate ($18,291.60). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,118, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,596.41) for the length of stay and the standard reimbursement.","17460.16","17460.16","17460.16","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory Diagnoses Except Signs, Symptoms And Miscellaneous Diagnoses,MODERATE","143","DRG","","","","","","","","inpatient","","","24239.55","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6590.31","","Case rate ($7,286.72). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,716.72, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7722.03","7722.03","7722.03","1 through 10","5030.51","65332.79","case rate",""
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","39057.19","29292.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","16854.16","","Case rate ($17,198.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,225.59, add-ons for qualifying new technology services are included. If operating cost exceeds $62,749.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,855.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,564.43 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,886.35 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.44. The transfer capital threshold is the transfer adjustment factor * $1,294.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17067.12","17067.12","17067.12","1 through 10","16854.16","18809.97","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","39057.19","29292.89","MEDICARE [2001]","HB BWF MEDICARE","18809.97","","Case rate ($18,809.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,225.59, add-ons for qualifying new technology services are included. If operating cost exceeds $62,749.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,855.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $17,176.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,886.35 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.44. The transfer capital threshold is the transfer adjustment factor * $1,294.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16936.95","0.03","19022.43","1 through 10","16854.16","18809.97","other","Inpatient DRG"
"Other Respiratory System Diagnoses With McC","205","MS-DRG","","","","","","","","inpatient","","","39057.19","29292.89","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16854.16","","Case rate ($17,198.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,225.59, add-ons for qualifying new technology services are included. If operating cost exceeds $62,749.32 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,855.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $15,564.43 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,886.35 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,294.44. The transfer capital threshold is the transfer adjustment factor * $1,294.44. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17079.89","17079.89","17079.89","1 through 10","16854.16","18809.97","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","24638.79","18479.09","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8824.30","","Case rate ($9,004.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,018.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,542.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,226.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,999.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,679.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $665.32. The transfer capital threshold is the transfer adjustment factor * $665.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8334.02","8334.02","8334.02","1 through 10","8824.3","9832.85","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","24638.79","18479.09","ELDER SERVICES [1037]","HB BWF MEDICARE","9832.85","","Case rate ($9,832.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,018.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,542.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,226.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,828.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,679.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $665.32. The transfer capital threshold is the transfer adjustment factor * $665.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","32615.53","32615.53","32615.53","1 through 10","8824.3","9832.85","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","24638.79","18479.09","MEDICARE [2001]","HB BWF MEDICARE","9832.85","","Case rate ($9,832.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,018.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,542.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,226.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,828.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,679.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $665.32. The transfer capital threshold is the transfer adjustment factor * $665.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","9257.98","1 through 10","8824.3","9832.85","other","Inpatient DRG"
"Other Respiratory System Diagnoses Without McC","206","MS-DRG","","","","","","","","inpatient","","","24638.79","18479.09","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8824.30","","Case rate ($9,004.39). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,018.50, add-ons for qualifying new technology services are included. If operating cost exceeds $54,542.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,226.10, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,999.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,679.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $665.32. The transfer capital threshold is the transfer adjustment factor * $665.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8323.28","8323.28","8323.28","1 through 10","8824.3","9832.85","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","59320.48","44490.36","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","34058.92","","Case rate ($34,754). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $34,810.08, add-ons for qualifying new technology services are included. If operating cost exceeds $80,333.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,203.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $31,772.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $34,470.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,642.40. The transfer capital threshold is the transfer adjustment factor * $2,642.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","44849.30","44849.30","44849.30","1 through 10","34058.92","38367.49","other","Inpatient DRG"
"Other Respiratory System O.R. Procedures With McC","166","MS-DRG","","","","","","","","inpatient","","","59320.48","44490.36","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","34058.92","","Case rate ($34,754). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $34,810.08, add-ons for qualifying new technology services are included. If operating cost exceeds $80,333.81 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,203.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. The base transfer operating payment is the transfer adjustment factor * $31,772.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $34,470.84 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,642.40. The transfer capital threshold is the transfer adjustment factor * $2,642.40. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","30669.12","30669.12","30669.12","1 through 10","34058.92","38367.49","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Disorders,EXTREME","385","DRG","","","","","","","","inpatient","","","127352.62","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","19896.59","","Case rate ($21,999.10). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,429.10, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","21993.70","21993.70","21993.70","1 through 10","4396.86","62395.36","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MAJOR","385","DRG","","","","","","","","inpatient","","","35429.17","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6029.41","","Case rate ($6,666.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,096.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11348.53","11348.53","11348.53","1 through 10","4396.86","62395.36","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MINOR","385","DRG","","","","","","","","inpatient","","","20135.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","10920.71","","Standard inlier is a Case rate ($10,920.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,550.15) for the length of stay and the standard reimbursement.","7818.23","7818.23","7818.23","1 through 10","4396.86","62395.36","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","28346.23","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","13409.71","","Standard inlier is a Case rate ($13,409.71). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,077, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,903.56) for the length of stay and the standard reimbursement.","12800.34","12800.34","12800.34","1 through 10","4396.86","62395.36","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","28346.23","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6029.41","","Case rate ($6,666.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,096.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6664.91","6664.91","6664.91","1 through 10","4396.86","62395.36","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Disorders,MODERATE","385","DRG","","","","","","","","inpatient","","","28346.23","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6029.41","","Case rate ($6,666.55). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,096.55, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6664.91","6664.91","6664.91","1 through 10","4396.86","62395.36","case rate",""
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","41938.45","31453.84","MEDICARE [2001]","HB BWF MEDICARE","17770.92","","Case rate ($17,770.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,275.67, add-ons for qualifying new technology services are included. If operating cost exceeds $61,799.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,782.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $16,210.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,936.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,221.63. The transfer capital threshold is the transfer adjustment factor * $1,221.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8786.37","6928.65","16928.51","1 through 10","15924.75","17770.92","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","580","MS-DRG","","","","","","","","inpatient","","","41938.45","31453.84","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15924.75","","Case rate ($16,249.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,275.67, add-ons for qualifying new technology services are included. If operating cost exceeds $61,799.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,782.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $14,688.88 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,936.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,221.63. The transfer capital threshold is the transfer adjustment factor * $1,221.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13029.67","13029.67","13029.67","1 through 10","15924.75","17770.92","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","92542.23","69406.67","MEDICARE [2001]","HB BWF MEDICARE","33008.52","","Case rate ($33,008.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,206.22, add-ons for qualifying new technology services are included. If operating cost exceeds $75,729.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,850.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $30,379.79 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,866.98 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,289.49. The transfer capital threshold is the transfer adjustment factor * $2,289.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","32660.89","32660.89","32660.89","1 through 10","29554.47","33008.52","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures With McC","579","MS-DRG","","","","","","","","inpatient","","","92542.23","69406.67","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","33008.52","","Case rate ($33,008.52). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,206.22, add-ons for qualifying new technology services are included. If operating cost exceeds $75,729.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,850.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.5. The base transfer operating payment is the transfer adjustment factor * $30,379.79 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,866.98 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,289.49. The transfer capital threshold is the transfer adjustment factor * $2,289.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","29310.56","29310.56","29310.56","1 through 10","29554.47","33008.52","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC","581","MS-DRG","","","","","","","","inpatient","","","63022.19","47266.64","MEDICARE [2001]","HB BWF MEDICARE","13626.53","","Case rate ($13,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,648.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,171.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,580.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $12,267.08 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,308.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.21. The transfer capital threshold is the transfer adjustment factor * $1,020.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13880.61","13880.61","13880.61","1 through 10","13354","14232.2488","other","Inpatient Replacement Plans DRG"
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC","581","MS-DRG","","","","","","","","inpatient","","","63022.19","47266.64","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13354.00","","Case rate ($13,626.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,648.19, add-ons for qualifying new technology services are included. If operating cost exceeds $59,171.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,580.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $12,267.08 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,308.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,020.21. The transfer capital threshold is the transfer adjustment factor * $1,020.21. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13875.11","13875.11","13875.11","1 through 10","13354","14232.2488","other","Inpatient DRG"
"Other Skin, Subcutaneous Tissue And Related Procedures,MAJOR","364","DRG","","","","","","","","inpatient","","","58021.25","","MASSHEALTH [3001]","HB BWF MEDICAID","17811.77","","Case rate ($19,693.97). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,123.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","311.64","311.64","311.64","1 through 10","7136.36","75102.72","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MAJOR","364","DRG","","","","","","","","inpatient","","","58021.25","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","17811.77","","Case rate ($19,693.97). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,123.97, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19689.14","19689.14","19689.14","1 through 10","7136.36","75102.72","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","26390.20","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8645.82","","Fee schedule rate ($8,645.82). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8645.82","8645.82","8645.82","1 through 10","7136.36","75102.72","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MINOR","364","DRG","","","","","","","","inpatient","","","26390.20","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7136.36","","Case rate ($7,890.47). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,320.47, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7888.54","7888.54","7888.54","1 through 10","7136.36","75102.72","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","46277.46","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","26676.34","","Standard inlier is a Case rate ($26,676.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $37,125, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,786.59) for the length of stay and the standard reimbursement.","26676.34","26676.34","26676.34","1 through 10","7136.36","75102.72","case rate",""
"Other Skin, Subcutaneous Tissue And Related Procedures,MODERATE","364","DRG","","","","","","","","inpatient","","","46277.46","","MASSHEALTH [3001]","HB BWF MEDICAID","9319.42","","Case rate ($10,304.22). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,734.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10301.70","10301.70","10301.70","1 through 10","7136.36","75102.72","case rate",""
"Other Stomach, Esophageal And Duodenal Procedures,MAJOR","222","DRG","","","","","","","","inpatient","","","35172.22","","MASSHEALTH [3001]","HB BWF MEDICAID","23272.28","","Case rate ($25,731.51). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $68,161.51, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","25725.20","25725.20","25725.20","1 through 10","16937.0514","117790.56","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","53654.80","","MASSHEALTH [3001]","HB BWF MEDICAID","25279.42","","Case rate ($27,950.74). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,380.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27943.89","27943.89","27943.89","1 through 10","22998.16","62917.19","case rate",""
"Other Upper Vascular Procedures,MAJOR","182","DRG","","","","","","","","inpatient","","","53654.80","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","25279.42","","Case rate ($27,950.74). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,380.74, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27943.88","3230.00","27943.88","1 through 10","22998.16","62917.19","case rate",""
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","50347.68","37760.76","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","26523.09","","Case rate ($26,523.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,277.09, add-ons for qualifying new technology services are included. If operating cost exceeds $69,800.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,395.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $24,348.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,937.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,834.99. The transfer capital threshold is the transfer adjustment factor * $1,834.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","25226.65","25226.65","25226.65","1 through 10","23753.39","26523.09","other","Inpatient DRG"
"Other Vascular Procedures With Cc","253","MS-DRG","","","","","","","","inpatient","","","50347.68","37760.76","MEDICARE [2001]","HB BWF MEDICARE","26523.09","","Case rate ($26,523.09). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $24,277.09, add-ons for qualifying new technology services are included. If operating cost exceeds $69,800.82 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,395.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $24,348.86 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $23,937.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,834.99. The transfer capital threshold is the transfer adjustment factor * $1,834.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","23753.39","26523.09","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","74199.08","55649.31","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","33431.37","","Case rate ($32,457.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,509.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,033.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $29,652.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,170.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,466.09. The transfer capital threshold is the transfer adjustment factor * $2,466.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","32286.56","32286.56","32286.56","1 through 10","31808.49","35807.4","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","74199.08","55649.31","ELDER SERVICES [1037]","HB BWF MEDICARE","35528.44","","Case rate ($35,528.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,509.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,033.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $32,723.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,170.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,466.09. The transfer capital threshold is the transfer adjustment factor * $2,466.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","31146.66","31146.66","31146.66","1 through 10","31808.49","35807.4","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","74199.08","55649.31","MEDICARE [2001]","HB BWF MEDICARE","35528.44","","Case rate ($35,528.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,509.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,033.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $32,723.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,170.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,466.09. The transfer capital threshold is the transfer adjustment factor * $2,466.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","34131.20","0.03","34131.20","1 through 10","31808.49","35807.4","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","74199.08","55649.31","MOLINA [1014]","HB BWF MEDICARE","35528.44","","Case rate ($35,528.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,509.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,033.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $32,723.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,170.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,466.09. The transfer capital threshold is the transfer adjustment factor * $2,466.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","62140.41","62140.41","62140.41","1 through 10","31808.49","35807.4","other","Inpatient DRG"
"Other Vascular Procedures With McC","252","MS-DRG","","","","","","","","inpatient","","","74199.08","55649.31","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","31808.49","","Case rate ($32,457.64). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,509.99, add-ons for qualifying new technology services are included. If operating cost exceeds $78,033.72 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,026.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.3. The base transfer operating payment is the transfer adjustment factor * $29,652.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,170.75 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,466.09. The transfer capital threshold is the transfer adjustment factor * $2,466.09. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","34210.61","34210.61","34210.61","1 through 10","31808.49","35807.4","other","Inpatient DRG"
"Other Vascular Procedures,MAJOR","173","DRG","","","","","","","","inpatient","","","57768.87","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","29445.8856","","Fee schedule rate ($65,493.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29445.8856","65493.06","65493.06","1 through 10","29445.8856","108062.54","case rate",""
"Otitis Media And Uri With McC","152","MS-DRG","","","","","","","","inpatient","","","29937.87","22453.40","MEDICARE [2001]","HB BWF MEDICARE","12265.02","","Case rate ($12,265.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,242.05, add-ons for qualifying new technology services are included. If operating cost exceeds $56,765.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,396.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,090.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,902.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $835.77. The transfer capital threshold is the transfer adjustment factor * $835.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11458.92","11458.92","11535.02","1 through 10","10999.82","12265.02","other","Inpatient DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","19353.19","14514.89","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6993.48","","Case rate ($7,136.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,147.27, add-ons for qualifying new technology services are included. If operating cost exceeds $52,671.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,082.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,275.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,808.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.88. The transfer capital threshold is the transfer adjustment factor * $521.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","6625.97","6625.97","6625.97","1 through 10","6993.48","7350.29","other","Inpatient DRG"
"Otitis Media And Uri Without McC","153","MS-DRG","","","","","","","","inpatient","","","19353.19","14514.89","MEDICARE [2001]","HB BWF MEDICARE","7136.20","","Case rate ($7,136.20). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,147.27, add-ons for qualifying new technology services are included. If operating cost exceeds $52,671.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,082.66, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $6,275.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,808.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $521.88. The transfer capital threshold is the transfer adjustment factor * $521.88. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7280.20","7280.20","7280.20","1 through 10","6993.48","7350.29","other","Inpatient Replacement Plans DRG"
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","AETNA [1001]","HB CH AETNA HMO / PPO","1311.75","58.3","","554.95","91.85","1421.75","94","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1642.50","73","","2490.03","2490.03","2490.03","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1311.75","58.3","","750.00","750.00","750.00","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1192.50","53","","1192.50","120.84","4149.90","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1912.50","85","","750.00","75.00","750.00","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2250.00","100","","657.00","121.50","1971.00","14","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2250.00","100","","75.00","75.00","75.00","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2250.00","100","","366.00","144.00","1971.00","45","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1642.50","73","","667.50","667.50","667.50","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1000.13","44.45","","123.77","123.77","123.77","1 through 10","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","both","","","2250.00","1687.50","WELLPOINT [1015]","HB CH WELLPOINT","1752.98","77.91","","483.51","229.32","1316.08","96","1000.13","2250","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1334.25","59.3","","439.50","225.34","1872.27","197","1125","1765.13","percent of total billed charges",""
"PACK ANCHOR SIZE 1 LENGTH4.5MM SUTURE HEALICOIL ULTRATAPE 72203981","SUP-ITM-10151410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2250.00","1687.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1765.13","78.45","","385.32","55.36","1815.62","58","1125","1765.13","percent of total billed charges",""
"PACK FILLER 2 D VITOSS GRAFT BONE BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029651","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1094.38","78.45","","555.84","555.84","555.84","1 through 10","697.5","1094.38","percent of total billed charges",""
"PACK GRAFT 1.2ML BONE VITOSS BIOACTIVE SUBSTITUTE FOAM","SUP-ITM-10029650","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","813.00","609.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","637.80","78.45","","555.84","555.84","555.84","1 through 10","406.5","637.8","percent of total billed charges",""
"PACK GRAFT 10ML BONE SUBSTITUTE VITOSS BIOACTIVE FOAM","SUP-ITM-10029653","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4215.00","3161.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3306.67","78.45","","555.84","555.84","555.84","1 through 10","2107.5","3306.67","percent of total billed charges",""
"PACK GRAFT 5ML IMPLANT SYNTHETIC TISSUE CALCIUM PHOSPHATE RESORBABLE VITOSS","SUP-ITM-10029652","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","2739.00","2054.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2148.75","78.45","","555.84","555.84","555.84","1 through 10","1369.5","2148.75","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","866.40","649.80","AETNA [1001]","HB CH AETNA HMO / PPO","505.11","58.3","","1830.28","315.58","1830.28","1 through 10","385.11","866.4","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","866.40","649.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","632.47","73","","4170.85","4170.85","4170.85","1 through 10","385.11","866.4","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","866.40","649.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.11","44.45","","649.55","649.55","649.55","1 through 10","385.11","866.4","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","both","","","866.40","649.80","WELLPOINT [1015]","HB CH WELLPOINT","675.01","77.91","","8998.38","2542.37","8998.38","20","385.11","866.4","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","866.40","649.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","513.78","59.3","","1891.61","1609.14","3664.18","25","433.2","679.69","percent of total billed charges",""
"PACK NAIL 1.6MM SMALL FIXATION BONE INTRAMEDULLARY AWL EXCHANGER LOCKING DEVICE CAP","SUP-ITM-10028133","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","866.40","649.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","679.69","78.45","","1470.68","1310.06","2481.69","19","433.2","679.69","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1634.24","1004.95","1718.99","42","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2123.89","1900.92","2123.89","1 through 10","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","3729.00","1254.19","3729.00","1 through 10","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","939.37","939.37","5593.65","1 through 10","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","2323.25","1864.50","2882.25","16","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","2909.44","1772.40","10952.08","45","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","2323.25","2323.25","2323.25","1 through 10","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","2882.25","1772.40","10169.17","187","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","1659.41","1659.41","1659.41","1 through 10","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","2050.91","1468.48","2902.83","52","33.34","75","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1548.60","1092.60","3613.79","82","37.5","58.84","percent of total billed charges",""
"PACK PEG FEMORAL FIXATION TRIATHLON MODULAR DISTAL","SUP-ITM-10017024","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","2085.51","998.68","6202.11","56","37.5","58.84","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"PACK PIN SMOOTH PK/6EA","SUP-ITM-10301125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"Pancreas, Liver And Shunt Procedures With McC","405","MS-DRG","","","","","","","","inpatient","","","30736.71","23052.53","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","49694.52","","Case rate ($50,708.69). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $50,790.79, add-ons for qualifying new technology services are included. If operating cost exceeds $96,314.52 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,428.20, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.4. The base transfer operating payment is the transfer adjustment factor * $46,502.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $50,451.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,867.42. The transfer capital threshold is the transfer adjustment factor * $3,867.42. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","23050.83","23050.83","23050.83","1 through 10","49694.52","53684.4143","other","Inpatient DRG"
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Pancreatic Elastase-1","PX-30003733","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","341.00","255.75","AETNA [1001]","HB CH AETNA HMO / PPO","198.80","58.3","","188.24","188.24","188.24","19","40.45","248.93","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","both","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.80","58.3","","664.00","664.00","664.00","1 through 10","40.45","248.93","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","341.00","255.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.21","59.3","","583.65","194.55","585.94","51","42.57","267.51","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","341.00","255.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","345.79","345.79","345.79","1 through 10","42.57","267.51","percent of total billed charges",""
"Parathormone (Pth)","PX-30000600","CDM","83970","CPT","0301","RC","","","","outpatient","","","341.00","255.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.51","78.45","","255.24","151.26","255.24","18","42.57","267.51","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","61.00","45.75","AETNA [1001]","HB CH AETNA HMO / PPO","35.56","58.3","","33.45","33.45","33.46","21","5.89","44.53","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","both","","","61.00","45.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.33","53","","31.27","31.27","31.27","1 through 10","5.89","44.53","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","61.00","45.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.17","59.3","","34.58","34.57","185.16","38","6.2","47.85","percent of total billed charges",""
"Partial Thromboplastin Time (Ptt)","PX-30001129","CDM","85730","CPT","0305","RC","","","","outpatient","","","61.00","45.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.85","78.45","","45.36","26.88","45.36","23","6.2","47.85","percent of total billed charges",""
"Parvovirus Antibody","PX-30000980","CDM","86747","CPT","0302","RC","","","","outpatient","","","81.00","60.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.03","59.3","","46.30","46.30","46.30","1 through 10","9.6","63.54","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","AETNA [1001]","HB CH AETNA HMO / PPO","244.86","58.3","","554.95","91.85","1421.75","94","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","2490.03","2490.03","2490.03","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","244.86","58.3","","750.00","750.00","750.00","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.60","53","","1192.50","120.84","4149.90","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.00","85","","750.00","75.00","750.00","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.00","100","","657.00","121.50","1971.00","14","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.00","100","","75.00","75.00","75.00","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.00","100","","366.00","144.00","1971.00","45","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","667.50","667.50","667.50","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","123.77","123.77","123.77","1 through 10","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB CH WELLPOINT","327.22","77.91","","483.51","229.32","1316.08","96","186.69","420","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.06","59.3","","439.50","225.34","1872.27","197","210","329.49","percent of total billed charges",""
"PASSER SUTURE 1.8MM 45DEGREE RIGHT NITINOL LF PRELOADED STERILE DISPOSABLE","SUP-ITM-10019628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","385.32","55.36","1815.62","58","210","329.49","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","both","","","899.40","674.55","AETNA [1001]","HB CH AETNA HMO / PPO","524.35","58.3","","585.96","347.85","5016.82","1 through 10","399.78","899.4","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","both","","","899.40","674.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","764.49","85","","1295.16","1295.16","1295.16","1 through 10","399.78","899.4","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","both","","","899.40","674.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","899.40","100","","2700.00","1008.69","2700.00","1 through 10","399.78","899.4","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","both","","","899.40","674.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","899.40","100","","2520.00","797.10","5898.60","1 through 10","399.78","899.4","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","both","","","899.40","674.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","399.78","44.45","","1953.42","1953.42","1953.42","1 through 10","399.78","899.4","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","both","","","899.40","674.55","WELLPOINT [1015]","HB CH WELLPOINT","700.72","77.91","","1490.36","627.80","7327.37","1 through 10","399.78","899.4","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","899.40","674.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.34","59.3","","536.35","188.54","1772.63","17","449.7","705.58","percent of total billed charges",""
"PATCH HERNIA 4.6CM GRAFT MESH PARIETEX REPAIR","SUP-ITM-10148179","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","899.40","674.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","705.58","78.45","","562.30","246.20","3344.28","1 through 10","449.7","705.58","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","AETNA [1001]","HB CH AETNA HMO / PPO","2536.05","58.3","","585.96","347.85","5016.82","1 through 10","1933.58","4350","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3697.50","85","","1295.16","1295.16","1295.16","1 through 10","1933.58","4350","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4350.00","100","","2700.00","1008.69","2700.00","1 through 10","1933.58","4350","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4350.00","100","","2520.00","797.10","5898.60","1 through 10","1933.58","4350","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1933.58","44.45","","1953.42","1953.42","1953.42","1 through 10","1933.58","4350","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","both","","","4350.00","3262.50","WELLPOINT [1015]","HB CH WELLPOINT","3389.09","77.91","","1490.36","627.80","7327.37","1 through 10","1933.58","4350","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2579.55","59.3","","536.35","188.54","1772.63","17","2175","3412.58","percent of total billed charges",""
"PATCH SEPRA 24.5CM 19.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094836","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4350.00","3262.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3412.58","78.45","","562.30","246.20","3344.28","1 through 10","2175","3412.58","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2535.00","1901.25","AETNA [1001]","HB CH AETNA HMO / PPO","1477.91","58.3","","585.96","347.85","5016.82","1 through 10","1126.81","2535","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2535.00","1901.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2154.75","85","","1295.16","1295.16","1295.16","1 through 10","1126.81","2535","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2535.00","1901.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2535.00","100","","2700.00","1008.69","2700.00","1 through 10","1126.81","2535","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2535.00","1901.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2535.00","100","","2520.00","797.10","5898.60","1 through 10","1126.81","2535","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2535.00","1901.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1126.81","44.45","","1953.42","1953.42","1953.42","1 through 10","1126.81","2535","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","both","","","2535.00","1901.25","WELLPOINT [1015]","HB CH WELLPOINT","1975.02","77.91","","1490.36","627.80","7327.37","1 through 10","1126.81","2535","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2535.00","1901.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1503.26","59.3","","536.35","188.54","1772.63","17","1267.5","1988.71","percent of total billed charges",""
"PATCH SEPRA 3.1X4.7IN SM GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094834","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2535.00","1901.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1988.71","78.45","","562.30","246.20","3344.28","1 through 10","1267.5","1988.71","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4075.00","3056.25","AETNA [1001]","HB CH AETNA HMO / PPO","2375.73","58.3","","585.96","347.85","5016.82","1 through 10","1811.34","4075","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4075.00","3056.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3463.75","85","","1295.16","1295.16","1295.16","1 through 10","1811.34","4075","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4075.00","3056.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4075.00","100","","2700.00","1008.69","2700.00","1 through 10","1811.34","4075","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4075.00","3056.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4075.00","100","","2520.00","797.10","5898.60","1 through 10","1811.34","4075","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4075.00","3056.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1811.34","44.45","","1953.42","1953.42","1953.42","1 through 10","1811.34","4075","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","both","","","4075.00","3056.25","WELLPOINT [1015]","HB CH WELLPOINT","3174.83","77.91","","1490.36","627.80","7327.37","1 through 10","1811.34","4075","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4075.00","3056.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2416.48","59.3","","536.35","188.54","1772.63","17","2037.5","3196.84","percent of total billed charges",""
"PATCH SEPRA L18CM 13 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CA/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094835","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","4075.00","3056.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3196.84","78.45","","562.30","246.20","3344.28","1 through 10","2037.5","3196.84","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","6480.00","4860.00","AETNA [1001]","HB CH AETNA HMO / PPO","3777.84","58.3","","585.96","347.85","5016.82","1 through 10","2880.36","6480","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","6480.00","4860.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5508.00","85","","1295.16","1295.16","1295.16","1 through 10","2880.36","6480","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","6480.00","4860.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6480.00","100","","2700.00","1008.69","2700.00","1 through 10","2880.36","6480","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","6480.00","4860.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6480.00","100","","2520.00","797.10","5898.60","1 through 10","2880.36","6480","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","6480.00","4860.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2880.36","44.45","","1953.42","1953.42","1953.42","1 through 10","2880.36","6480","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","both","","","6480.00","4860.00","WELLPOINT [1015]","HB CH WELLPOINT","5048.57","77.91","","1490.36","627.80","7327.37","1 through 10","2880.36","6480","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6480.00","4860.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3842.64","59.3","","536.35","188.54","1772.63","17","3240","5083.56","percent of total billed charges",""
"PATCH SEPRA L35CM 27.5 W GRAFT MESH VENTRIO ST POLYPROPYLENE HERNIA HYDROGEL POCKET ANTERIOR OPEN REPAIR OVAL CS/1EA - DISCONTINUED PER CONTRACTS","SUP-ITM-10094837","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","6480.00","4860.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5083.56","78.45","","562.30","246.20","3344.28","1 through 10","3240","5083.56","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","985.07","738.80","AETNA [1001]","HB CH AETNA HMO / PPO","574.30","58.3","","585.96","347.85","5016.82","1 through 10","437.86","985.07","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","985.07","738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","837.31","85","","1295.16","1295.16","1295.16","1 through 10","437.86","985.07","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","985.07","738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","985.07","100","","2700.00","1008.69","2700.00","1 through 10","437.86","985.07","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","985.07","738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","985.07","100","","2520.00","797.10","5898.60","1 through 10","437.86","985.07","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","985.07","738.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","437.86","44.45","","1953.42","1953.42","1953.42","1 through 10","437.86","985.07","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","both","","","985.07","738.80","WELLPOINT [1015]","HB CH WELLPOINT","767.47","77.91","","1490.36","627.80","7327.37","1 through 10","437.86","985.07","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","985.07","738.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","584.15","59.3","","536.35","188.54","1772.63","17","492.54","772.79","percent of total billed charges",""
"PATCH SYNTHETIC 4.3 XCM SM ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041542","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","985.07","738.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","772.79","78.45","","562.30","246.20","3344.28","1 through 10","492.54","772.79","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","1178.13","883.60","AETNA [1001]","HB CH AETNA HMO / PPO","686.85","58.3","","585.96","347.85","5016.82","1 through 10","523.68","1178.13","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","1178.13","883.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1001.41","85","","1295.16","1295.16","1295.16","1 through 10","523.68","1178.13","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","1178.13","883.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1178.13","100","","2700.00","1008.69","2700.00","1 through 10","523.68","1178.13","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","1178.13","883.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1178.13","100","","2520.00","797.10","5898.60","1 through 10","523.68","1178.13","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","1178.13","883.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.68","44.45","","1953.42","1953.42","1953.42","1 through 10","523.68","1178.13","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","both","","","1178.13","883.60","WELLPOINT [1015]","HB CH WELLPOINT","917.88","77.91","","1490.36","627.80","7327.37","1 through 10","523.68","1178.13","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1178.13","883.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","698.63","59.3","","536.35","188.54","1772.63","17","589.07","924.24","percent of total billed charges",""
"PATCH SYNTHETIC 6.4 XCM MD ABDOMINAL PARTIALLY ABSORBABLE CIRCLE POLYPROPYLENEPOLYDIOXANONE PROCEED BX/2EA","SUP-ITM-10041541","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1178.13","883.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","924.24","78.45","","562.30","246.20","3344.28","1 through 10","589.07","924.24","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","AETNA [1001]","HB CH AETNA HMO / PPO","787.05","58.3","","1634.24","1004.95","1718.99","42","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","985.50","73","","2123.89","1900.92","2123.89","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","787.05","58.3","","3729.00","1254.19","3729.00","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","715.50","53","","939.37","939.37","5593.65","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1147.50","85","","2323.25","1864.50","2882.25","16","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1350.00","100","","2909.44","1772.40","10952.08","45","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1350.00","100","","2323.25","2323.25","2323.25","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1350.00","100","","2882.25","1772.40","10169.17","187","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","985.50","73","","1659.41","1659.41","1659.41","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","WELLPOINT [1015]","HB CH WELLPOINT","1051.79","77.91","","2050.91","1468.48","2902.83","52","600.08","1350","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","800.55","59.3","","1548.60","1092.60","3613.79","82","675","1059.08","percent of total billed charges",""
"PATELLA BUTTON 30MM HEMICAP","SUP-ITM-10090884","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1059.08","78.45","","2085.51","998.68","6202.11","56","675","1059.08","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","AETNA [1001]","HB CH AETNA HMO / PPO","787.05","58.3","","1634.24","1004.95","1718.99","42","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","985.50","73","","2123.89","1900.92","2123.89","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","787.05","58.3","","3729.00","1254.19","3729.00","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","715.50","53","","939.37","939.37","5593.65","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1147.50","85","","2323.25","1864.50","2882.25","16","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1350.00","100","","2909.44","1772.40","10952.08","45","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1350.00","100","","2323.25","2323.25","2323.25","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1350.00","100","","2882.25","1772.40","10169.17","187","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","985.50","73","","1659.41","1659.41","1659.41","1 through 10","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","both","","","1350.00","1012.50","WELLPOINT [1015]","HB CH WELLPOINT","1051.79","77.91","","2050.91","1468.48","2902.83","52","600.08","1350","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","800.55","59.3","","1548.60","1092.60","3613.79","82","675","1059.08","percent of total billed charges",""
"PATELLA COMPONENT 30MM 9MM DOME","SUP-ITM-10094391","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1350.00","1012.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1059.08","78.45","","2085.51","998.68","6202.11","56","675","1059.08","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","AETNA [1001]","HB CH AETNA HMO / PPO","795.80","58.3","","1634.24","1004.95","1718.99","42","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","996.45","73","","2123.89","1900.92","2123.89","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","795.80","58.3","","3729.00","1254.19","3729.00","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","723.45","53","","939.37","939.37","5593.65","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1160.25","85","","2323.25","1864.50","2882.25","16","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1365.00","100","","2909.44","1772.40","10952.08","45","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1365.00","100","","2323.25","2323.25","2323.25","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1365.00","100","","2882.25","1772.40","10169.17","187","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","996.45","73","","1659.41","1659.41","1659.41","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB CH WELLPOINT","1063.47","77.91","","2050.91","1468.48","2902.83","52","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","809.45","59.3","","1548.60","1092.60","3613.79","82","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 29MM POROUS ROUND","SUP-ITM-10289212","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1070.84","78.45","","2085.51","998.68","6202.11","56","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","AETNA [1001]","HB CH AETNA HMO / PPO","795.80","58.3","","1634.24","1004.95","1718.99","42","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","996.45","73","","2123.89","1900.92","2123.89","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","795.80","58.3","","3729.00","1254.19","3729.00","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","723.45","53","","939.37","939.37","5593.65","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1160.25","85","","2323.25","1864.50","2882.25","16","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1365.00","100","","2909.44","1772.40","10952.08","45","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1365.00","100","","2323.25","2323.25","2323.25","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1365.00","100","","2882.25","1772.40","10169.17","187","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","996.45","73","","1659.41","1659.41","1659.41","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB CH WELLPOINT","1063.47","77.91","","2050.91","1468.48","2902.83","52","606.74","1365","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","809.45","59.3","","1548.60","1092.60","3613.79","82","682.5","1070.84","percent of total billed charges",""
"PATELLA IMPLANT 32MM POROUS ROUND","SUP-ITM-10289211","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1070.84","78.45","","2085.51","998.68","6202.11","56","682.5","1070.84","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","AETNA [1001]","HB CH AETNA HMO / PPO","529.95","58.3","","1634.24","1004.95","1718.99","42","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","663.57","73","","2123.89","1900.92","2123.89","1 through 10","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.95","58.3","","3729.00","1254.19","3729.00","1 through 10","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","481.77","53","","939.37","939.37","5593.65","1 through 10","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","772.65","85","","2323.25","1864.50","2882.25","16","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","909.00","100","","2909.44","1772.40","10952.08","45","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","909.00","100","","2323.25","2323.25","2323.25","1 through 10","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","909.00","100","","2882.25","1772.40","10169.17","187","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","663.57","73","","1659.41","1659.41","1659.41","1 through 10","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","both","","","909.00","681.75","WELLPOINT [1015]","HB CH WELLPOINT","708.20","77.91","","2050.91","1468.48","2902.83","52","404.05","909","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","909.00","681.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","539.04","59.3","","1548.60","1092.60","3613.79","82","454.5","713.11","percent of total billed charges",""
"PATELLA PEG 8.5X34MM INSERT POLYETHYLENE 3","SUP-ITM-10119293","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","909.00","681.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","713.11","78.45","","2085.51","998.68","6202.11","56","454.5","713.11","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","AETNA [1001]","HB CH AETNA HMO / PPO","795.80","58.3","","554.95","91.85","1421.75","94","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","996.45","73","","2490.03","2490.03","2490.03","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","795.80","58.3","","750.00","750.00","750.00","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","723.45","53","","1192.50","120.84","4149.90","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1160.25","85","","750.00","75.00","750.00","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1365.00","100","","657.00","121.50","1971.00","14","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1365.00","100","","75.00","75.00","75.00","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1365.00","100","","366.00","144.00","1971.00","45","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","996.45","73","","667.50","667.50","667.50","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","606.74","44.45","","123.77","123.77","123.77","1 through 10","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","both","","","1365.00","1023.75","WELLPOINT [1015]","HB CH WELLPOINT","1063.47","77.91","","483.51","229.32","1316.08","96","606.74","1365","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","809.45","59.3","","439.50","225.34","1872.27","197","682.5","1070.84","percent of total billed charges",""
"PATELLA RESURFACING SZ 2 E-CROSS","SUP-ITM-10300473","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1365.00","1023.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1070.84","78.45","","385.32","55.36","1815.62","58","682.5","1070.84","percent of total billed charges",""
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","32653.51","24490.13","MEDICARE [2001]","HB BWF MEDICARE","10709.47","","Case rate ($10,709.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,819.94, add-ons for qualifying new technology services are included. If operating cost exceeds $55,343.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,287.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $9,643.48 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,480.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.75. The transfer capital threshold is the transfer adjustment factor * $726.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10729.08","0.03","10800.20","36","9608.42","10709.47","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","32653.51","24490.13","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9608.42","","Case rate ($9,804.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,819.94, add-ons for qualifying new technology services are included. If operating cost exceeds $55,343.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,287.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,738.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,480.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.75. The transfer capital threshold is the transfer adjustment factor * $726.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9699.64","9699.64","9699.64","1 through 10","9608.42","10709.47","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","MS-DRG","","","","","","","","inpatient","","","32653.51","24490.13","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9608.42","","Case rate ($9,804.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,819.94, add-ons for qualifying new technology services are included. If operating cost exceeds $55,343.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,287.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $8,738.52 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,480.70 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $726.75. The transfer capital threshold is the transfer adjustment factor * $726.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9679.64","9679.64","9679.64","1 through 10","9608.42","10709.47","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","543","TRIS-DRG","","","","","","","","inpatient","","","38574.96","","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","10760.01","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($14,864.44). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,017.42, and the first day is paid a rate of $8,034.83. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,017.42, and the first day is paid a rate of $8,034.83. The transfer payment is capped at $13,603.40. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $58,685.88 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.70000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: , capped at $13,603.40. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $4,017.42, and the first day is paid a rate of $8,034.83. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $4,017.42, and the first day is paid a rate of $8,034.83. The transfer payment is capped at $13,603.40. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $58,685.88 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 3.70000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","13303.24","13303.24","13303.24","1 through 10","10760.01","10760.01","other","Inpatient DRGs"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","41647.66","31235.74","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","18159.30","","Case rate ($18,159.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,630.74, add-ons for qualifying new technology services are included. If operating cost exceeds $62,154.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,809.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $16,571.22 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,291.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.84. The transfer capital threshold is the transfer adjustment factor * $1,248.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16925.48","16925.48","16925.48","1 through 10","16272.15","18159.3","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","41647.66","31235.74","MEDICARE [2001]","HB BWF MEDICARE","18159.30","","Case rate ($18,159.30). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,630.74, add-ons for qualifying new technology services are included. If operating cost exceeds $62,154.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,809.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $16,571.22 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,291.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.84. The transfer capital threshold is the transfer adjustment factor * $1,248.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14516.40","0.03","18796.71","20","16272.15","18159.3","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","41647.66","31235.74","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","16272.15","","Case rate ($16,604.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,630.74, add-ons for qualifying new technology services are included. If operating cost exceeds $62,154.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,809.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,016.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,291.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.84. The transfer capital threshold is the transfer adjustment factor * $1,248.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16850.54","16850.54","16881.46","1 through 10","16272.15","18159.3","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC","542","MS-DRG","","","","","","","","inpatient","","","41647.66","31235.74","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","16272.15","","Case rate ($16,604.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,630.74, add-ons for qualifying new technology services are included. If operating cost exceeds $62,154.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,809.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,016.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,291.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.84. The transfer capital threshold is the transfer adjustment factor * $1,248.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","16916.96","16916.96","16916.96","1 through 10","16272.15","18159.3","other","Inpatient DRG"
"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC","544","MS-DRG","","","","","","","","inpatient","","","29704.02","22278.01","MEDICARE [2001]","HB BWF MEDICARE","7951.47","","Case rate ($7,951.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,298.51, add-ons for qualifying new technology services are included. If operating cost exceeds $52,822.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,078.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,959.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.47. The transfer capital threshold is the transfer adjustment factor * $533.47. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","7765.45","1 through 10","7141.45","7951.47","other","Inpatient DRG"
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","both","","","3407.01","2555.26","WELLPOINT [1015]","HB CH WELLPOINT","2654.40","77.91","","2948.77","2948.77","2948.77","1 through 10","1805.72","3407.01","percent of total billed charges",""
"Patient Programmer Neurostimulator T1","PX-27000125","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3407.01","2555.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","2020.36","59.3","","4673.98","4673.98","4673.98","1 through 10","1514.42","2672.8","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","AETNA [1001]","HB CH AETNA HMO / PPO","1323.99","58.3","","1634.24","1004.95","1718.99","42","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","2123.89","1900.92","2123.89","1 through 10","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1323.99","58.3","","3729.00","1254.19","3729.00","1 through 10","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1203.63","53","","939.37","939.37","5593.65","1 through 10","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1930.35","85","","2323.25","1864.50","2882.25","16","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2271.00","100","","2909.44","1772.40","10952.08","45","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2271.00","100","","2323.25","2323.25","2323.25","1 through 10","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2271.00","100","","2882.25","1772.40","10169.17","187","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","1659.41","1659.41","1659.41","1 through 10","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","WELLPOINT [1015]","HB CH WELLPOINT","1769.34","77.91","","2050.91","1468.48","2902.83","52","1009.46","2271","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1548.60","1092.60","3613.79","82","1135.5","1781.6","percent of total billed charges",""
"PEG ANCHOR 44MM GLENOID GLOBAL ADVANTAGE PREMIERON UHMWPE XLK","SUP-ITM-10026882","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1781.60","78.45","","2085.51","998.68","6202.11","56","1135.5","1781.6","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","AETNA [1001]","HB CH AETNA HMO / PPO","169.34","58.3","","554.95","91.85","1421.75","94","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","2490.03","2490.03","2490.03","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","169.34","58.3","","750.00","750.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","153.94","53","","1192.50","120.84","4149.90","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","246.89","85","","750.00","75.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","290.46","100","","657.00","121.50","1971.00","14","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","290.46","100","","75.00","75.00","75.00","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","290.46","100","","366.00","144.00","1971.00","45","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","667.50","667.50","667.50","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.11","44.45","","123.77","123.77","123.77","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","WELLPOINT [1015]","HB CH WELLPOINT","226.30","77.91","","483.51","229.32","1316.08","96","129.11","290.46","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.24","59.3","","439.50","225.34","1872.27","197","145.23","227.87","percent of total billed charges",""
"PEG BONE 15X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10151249","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","227.87","78.45","","385.32","55.36","1815.62","58","145.23","227.87","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","554.95","91.85","1421.75","94","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","2490.03","2490.03","2490.03","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","750.00","750.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","1192.50","120.84","4149.90","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.71","85","","750.00","75.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.30","100","","657.00","121.50","1971.00","14","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.30","100","","75.00","75.00","75.00","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.30","100","","366.00","144.00","1971.00","45","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","667.50","667.50","667.50","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","123.77","123.77","123.77","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","483.51","229.32","1316.08","96","105.48","237.3","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","439.50","225.34","1872.27","197","118.65","186.16","percent of total billed charges",""
"PEG BONE 16.0X2.5MM SCREW WRIST DVR ANATOMIC COBALT PARTIAL THREAD DISTAL","SUP-ITM-10043041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","385.32","55.36","1815.62","58","118.65","186.16","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","AETNA [1001]","HB CH AETNA HMO / PPO","169.34","58.3","","554.95","91.85","1421.75","94","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","2490.03","2490.03","2490.03","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","169.34","58.3","","750.00","750.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","153.94","53","","1192.50","120.84","4149.90","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","246.89","85","","750.00","75.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","290.46","100","","657.00","121.50","1971.00","14","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","290.46","100","","75.00","75.00","75.00","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","290.46","100","","366.00","144.00","1971.00","45","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","667.50","667.50","667.50","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.11","44.45","","123.77","123.77","123.77","1 through 10","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","WELLPOINT [1015]","HB CH WELLPOINT","226.30","77.91","","483.51","229.32","1316.08","96","129.11","290.46","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.24","59.3","","439.50","225.34","1872.27","197","145.23","227.87","percent of total billed charges",""
"PEG BONE 16X2.2MM SCREW WRIST DVR CROSSLOCKING COBALT LOCKING SMOOTH DISTAL","SUP-ITM-10134874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","227.87","78.45","","385.32","55.36","1815.62","58","145.23","227.87","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","AETNA [1001]","HB CH AETNA HMO / PPO","201.14","58.3","","554.95","91.85","1421.75","94","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","2490.03","2490.03","2490.03","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.14","58.3","","750.00","750.00","750.00","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","182.85","53","","1192.50","120.84","4149.90","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","293.25","85","","750.00","75.00","750.00","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","345.00","100","","657.00","121.50","1971.00","14","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","345.00","100","","75.00","75.00","75.00","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","345.00","100","","366.00","144.00","1971.00","45","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","667.50","667.50","667.50","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","123.77","123.77","123.77","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","WELLPOINT [1015]","HB CH WELLPOINT","268.79","77.91","","483.51","229.32","1316.08","96","153.35","345","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","204.59","59.3","","439.50","225.34","1872.27","197","172.5","270.65","percent of total billed charges",""
"PEG BONE 18X2.3MM THREADED GEMINUS LOCKING","SUP-ITM-10126423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","385.32","55.36","1815.62","58","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","AETNA [1001]","HB CH AETNA HMO / PPO","201.14","58.3","","554.95","91.85","1421.75","94","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","2490.03","2490.03","2490.03","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.14","58.3","","750.00","750.00","750.00","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","182.85","53","","1192.50","120.84","4149.90","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","293.25","85","","750.00","75.00","750.00","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","345.00","100","","657.00","121.50","1971.00","14","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","345.00","100","","75.00","75.00","75.00","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","345.00","100","","366.00","144.00","1971.00","45","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","667.50","667.50","667.50","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","123.77","123.77","123.77","1 through 10","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","WELLPOINT [1015]","HB CH WELLPOINT","268.79","77.91","","483.51","229.32","1316.08","96","153.35","345","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","204.59","59.3","","439.50","225.34","1872.27","197","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.3MMX16 THREADED GEMINUS LOCKING","SUP-ITM-10130563","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","385.32","55.36","1815.62","58","172.5","270.65","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","554.95","91.85","1421.75","94","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","2490.03","2490.03","2490.03","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","750.00","750.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","1192.50","120.84","4149.90","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.20","85","","750.00","75.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.24","100","","657.00","121.50","1971.00","14","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.24","100","","75.00","75.00","75.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.24","100","","366.00","144.00","1971.00","45","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","667.50","667.50","667.50","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","123.77","123.77","123.77","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","483.51","229.32","1316.08","96","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","439.50","225.34","1872.27","197","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X14MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025970","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","385.32","55.36","1815.62","58","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","554.95","91.85","1421.75","94","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","2490.03","2490.03","2490.03","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","750.00","750.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","1192.50","120.84","4149.90","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.20","85","","750.00","75.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.24","100","","657.00","121.50","1971.00","14","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.24","100","","75.00","75.00","75.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.24","100","","366.00","144.00","1971.00","45","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","667.50","667.50","667.50","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","123.77","123.77","123.77","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","483.51","229.32","1316.08","96","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","439.50","225.34","1872.27","197","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X18MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10026257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","385.32","55.36","1815.62","58","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","554.95","91.85","1421.75","94","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","2490.03","2490.03","2490.03","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","750.00","750.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","1192.50","120.84","4149.90","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.20","85","","750.00","75.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.24","100","","657.00","121.50","1971.00","14","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.24","100","","75.00","75.00","75.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.24","100","","366.00","144.00","1971.00","45","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","667.50","667.50","667.50","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","123.77","123.77","123.77","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","483.51","229.32","1316.08","96","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","439.50","225.34","1872.27","197","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X20MM SCREW COCHR MULTIDIR LOCKING THRD SQ DRV","SUP-ITM-10025971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","385.32","55.36","1815.62","58","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","554.95","91.85","1421.75","94","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","2490.03","2490.03","2490.03","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","750.00","750.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","1192.50","120.84","4149.90","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.20","85","","750.00","75.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.24","100","","657.00","121.50","1971.00","14","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.24","100","","75.00","75.00","75.00","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.24","100","","366.00","144.00","1971.00","45","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","667.50","667.50","667.50","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","123.77","123.77","123.77","1 through 10","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","483.51","229.32","1316.08","96","186.8","420.24","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","439.50","225.34","1872.27","197","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.5X26MM SCREW A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10025880","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","385.32","55.36","1815.62","58","210.12","329.68","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","AETNA [1001]","HB CH AETNA HMO / PPO","194.14","58.3","","554.95","91.85","1421.75","94","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","243.09","73","","2490.03","2490.03","2490.03","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","194.14","58.3","","750.00","750.00","750.00","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","176.49","53","","1192.50","120.84","4149.90","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","283.05","85","","750.00","75.00","750.00","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","333.00","100","","657.00","121.50","1971.00","14","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","333.00","100","","75.00","75.00","75.00","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","333.00","100","","366.00","144.00","1971.00","45","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","243.09","73","","667.50","667.50","667.50","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.02","44.45","","123.77","123.77","123.77","1 through 10","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","both","","","333.00","249.75","WELLPOINT [1015]","HB CH WELLPOINT","259.44","77.91","","483.51","229.32","1316.08","96","148.02","333","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","333.00","249.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","197.47","59.3","","439.50","225.34","1872.27","197","166.5","261.24","percent of total billed charges",""
"PEG BONE 2.7X40MM TITANIUM THREADED LOCKING","SUP-ITM-10169999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","333.00","249.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","261.24","78.45","","385.32","55.36","1815.62","58","166.5","261.24","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","AETNA [1001]","HB CH AETNA HMO / PPO","220.69","58.3","","554.95","91.85","1421.75","94","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","276.33","73","","2490.03","2490.03","2490.03","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","220.69","58.3","","750.00","750.00","750.00","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","200.63","53","","1192.50","120.84","4149.90","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","321.76","85","","750.00","75.00","750.00","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","378.54","100","","657.00","121.50","1971.00","14","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","378.54","100","","75.00","75.00","75.00","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","378.54","100","","366.00","144.00","1971.00","45","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","276.33","73","","667.50","667.50","667.50","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","168.26","44.45","","123.77","123.77","123.77","1 through 10","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.54","283.90","WELLPOINT [1015]","HB CH WELLPOINT","294.92","77.91","","483.51","229.32","1316.08","96","168.26","378.54","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.54","283.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","224.47","59.3","","439.50","225.34","1872.27","197","189.27","296.96","percent of total billed charges",""
"PEG BONE 3.2X40MM A.L.P.S. LOCKING","SUP-ITM-10174751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.54","283.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","296.96","78.45","","385.32","55.36","1815.62","58","189.27","296.96","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","554.95","91.85","1421.75","94","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","2490.03","2490.03","2490.03","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","750.00","750.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","1192.50","120.84","4149.90","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.20","85","","750.00","75.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","312.00","100","","657.00","121.50","1971.00","14","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","312.00","100","","75.00","75.00","75.00","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","312.00","100","","366.00","144.00","1971.00","45","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","667.50","667.50","667.50","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","123.77","123.77","123.77","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","483.51","229.32","1316.08","96","138.68","312","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","439.50","225.34","1872.27","197","156","244.76","percent of total billed charges",""
"PEG BONE L10X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","385.32","55.36","1815.62","58","156","244.76","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","554.95","91.85","1421.75","94","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","2490.03","2490.03","2490.03","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","750.00","750.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","1192.50","120.84","4149.90","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.20","85","","750.00","75.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","312.00","100","","657.00","121.50","1971.00","14","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","312.00","100","","75.00","75.00","75.00","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","312.00","100","","366.00","144.00","1971.00","45","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","667.50","667.50","667.50","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","123.77","123.77","123.77","1 through 10","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","483.51","229.32","1316.08","96","138.68","312","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","439.50","225.34","1872.27","197","156","244.76","percent of total billed charges",""
"PEG BONE L20X2.7MM NON LOCKING THREADED GEMINUS TITANIUM IMPLANTABLE FOSSA SPECIFIC PLATING SYSTEM FIXATION","SUP-ITM-10130577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","385.32","55.36","1815.62","58","156","244.76","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","AETNA [1001]","HB CH AETNA HMO / PPO","314.82","58.3","","554.95","91.85","1421.75","94","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","394.20","73","","2490.03","2490.03","2490.03","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","314.82","58.3","","750.00","750.00","750.00","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","286.20","53","","1192.50","120.84","4149.90","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","459.00","85","","750.00","75.00","750.00","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","540.00","100","","657.00","121.50","1971.00","14","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","540.00","100","","75.00","75.00","75.00","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","540.00","100","","366.00","144.00","1971.00","45","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","394.20","73","","667.50","667.50","667.50","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","240.03","44.45","","123.77","123.77","123.77","1 through 10","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","both","","","540.00","405.00","WELLPOINT [1015]","HB CH WELLPOINT","420.71","77.91","","483.51","229.32","1316.08","96","240.03","540","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.00","405.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","320.22","59.3","","439.50","225.34","1872.27","197","270","423.63","percent of total billed charges",""
"PEG CAL 2.7X36MM CORTITANIUM THREADED NON LOCKING TITANIUM","SUP-ITM-10198138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","540.00","405.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","423.63","78.45","","385.32","55.36","1815.62","58","270","423.63","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","554.95","91.85","1421.75","94","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","2490.03","2490.03","2490.03","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","750.00","750.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","1192.50","120.84","4149.90","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","771.38","85","","750.00","75.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","907.50","100","","657.00","121.50","1971.00","14","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","907.50","100","","75.00","75.00","75.00","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","907.50","100","","366.00","144.00","1971.00","45","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","667.50","667.50","667.50","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","123.77","123.77","123.77","1 through 10","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","483.51","229.32","1316.08","96","403.38","907.5","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","439.50","225.34","1872.27","197","453.75","711.93","percent of total billed charges",""
"PEG HINDFOOT 5X20MM PHANTOM THREADED NAIL","SUP-ITM-10286017","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","385.32","55.36","1815.62","58","453.75","711.93","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","554.95","91.85","1421.75","94","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","2490.03","2490.03","2490.03","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","750.00","750.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","1192.50","120.84","4149.90","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.71","85","","750.00","75.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.30","100","","657.00","121.50","1971.00","14","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.30","100","","75.00","75.00","75.00","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.30","100","","366.00","144.00","1971.00","45","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","667.50","667.50","667.50","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","123.77","123.77","123.77","1 through 10","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","483.51","229.32","1316.08","96","105.48","237.3","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","439.50","225.34","1872.27","197","118.65","186.16","percent of total billed charges",""
"PEG LOCKING 28X2.5MM SCREW BONE A.L.P.S. TITANIUM FULL THREAD","SUP-ITM-10016350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","385.32","55.36","1815.62","58","118.65","186.16","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","AETNA [1001]","HB CH AETNA HMO / PPO","835.58","58.3","","1634.24","1004.95","1718.99","42","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1046.27","73","","2123.89","1900.92","2123.89","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","835.58","58.3","","3729.00","1254.19","3729.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","759.62","53","","939.37","939.37","5593.65","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1218.26","85","","2323.25","1864.50","2882.25","16","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1433.25","100","","2909.44","1772.40","10952.08","45","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1433.25","100","","2323.25","2323.25","2323.25","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1433.25","100","","2882.25","1772.40","10169.17","187","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1046.27","73","","1659.41","1659.41","1659.41","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","WELLPOINT [1015]","HB CH WELLPOINT","1116.65","77.91","","2050.91","1468.48","2902.83","52","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","849.92","59.3","","1548.60","1092.60","3613.79","82","716.63","1124.38","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 29MM","SUP-ITM-10335878","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1124.38","78.45","","2085.51","998.68","6202.11","56","716.63","1124.38","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","AETNA [1001]","HB CH AETNA HMO / PPO","835.58","58.3","","554.95","91.85","1421.75","94","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1046.27","73","","2490.03","2490.03","2490.03","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","835.58","58.3","","750.00","750.00","750.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","759.62","53","","1192.50","120.84","4149.90","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1218.26","85","","750.00","75.00","750.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1433.25","100","","657.00","121.50","1971.00","14","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1433.25","100","","75.00","75.00","75.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1433.25","100","","366.00","144.00","1971.00","45","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1046.27","73","","667.50","667.50","667.50","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","637.08","44.45","","123.77","123.77","123.77","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","WELLPOINT [1015]","HB CH WELLPOINT","1116.65","77.91","","483.51","229.32","1316.08","96","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","849.92","59.3","","439.50","225.34","1872.27","197","716.63","1124.38","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 32MM","SUP-ITM-10335899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1124.38","78.45","","385.32","55.36","1815.62","58","716.63","1124.38","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","AETNA [1001]","HB CH AETNA HMO / PPO","835.58","58.3","","554.95","91.85","1421.75","94","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1046.27","73","","2490.03","2490.03","2490.03","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","835.58","58.3","","750.00","750.00","750.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","759.62","53","","1192.50","120.84","4149.90","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1218.26","85","","750.00","75.00","750.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1433.25","100","","657.00","121.50","1971.00","14","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1433.25","100","","75.00","75.00","75.00","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1433.25","100","","366.00","144.00","1971.00","45","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1046.27","73","","667.50","667.50","667.50","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","637.08","44.45","","123.77","123.77","123.77","1 through 10","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","both","","","1433.25","1074.94","WELLPOINT [1015]","HB CH WELLPOINT","1116.65","77.91","","483.51","229.32","1316.08","96","637.08","1433.25","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","849.92","59.3","","439.50","225.34","1872.27","197","716.63","1124.38","percent of total billed charges",""
"PEG PSN POROUS 3 PATELLA 35MM","SUP-ITM-10335874","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1433.25","1074.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1124.38","78.45","","385.32","55.36","1815.62","58","716.63","1124.38","percent of total billed charges",""
"Peptic Ulcer And Gastritis,EXTREME","241","DRG","","","","","","","","inpatient","","","88871.74","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","24616.84","","Case rate ($27,218.15). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $69,648.15, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27211.47","27211.47","27211.47","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","33431.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26258.02","","Standard inlier is a Case rate ($26,258.02). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,727.43) for the length of stay and the standard reimbursement.","26258.01","26258.01","26258.01","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","33431.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28206.35","","Standard inlier is a Case rate ($28,206.35). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,586, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,003.77) for the length of stay and the standard reimbursement.","28206.34","28206.34","28206.34","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","33431.40","","FALLON HEALTH [1008]","HB BWF MEDICAID","10793.07","","Case rate ($11,933.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,363.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11930.67","11930.67","11930.67","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","33431.40","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","26872.15","","Fee schedule rate ($26,872.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","26872.16","26872.16","26872.16","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","33431.40","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10793.07","","Case rate ($11,933.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,363.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11930.67","11930.67","12750.10","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MAJOR","241","DRG","","","","","","","","inpatient","","","33431.40","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10793.07","","Case rate ($11,933.60). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,363.60, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11930.67","11930.67","11930.67","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29446.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14471.20","","Standard inlier is a Case rate ($14,471.20). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,054.24) for the length of stay and the standard reimbursement.","13813.61","13813.61","13813.61","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29446.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15544.96","","Standard inlier is a Case rate ($15,544.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,206.54) for the length of stay and the standard reimbursement.","15544.96","15544.96","15544.96","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29446.77","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5026.41","","Case rate ($5,557.56). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,987.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5556.20","5556.20","5556.20","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MINOR","241","DRG","","","","","","","","inpatient","","","29446.77","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5026.41","","Case rate ($5,557.56). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,987.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5556.20","5556.20","5556.20","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","28888.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18013.62","","Standard inlier is a Case rate ($18,013.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,495, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,557.10) for the length of stay and the standard reimbursement.","18013.62","18013.62","18013.62","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","28888.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","19350.22","","Standard inlier is a Case rate ($19,350.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,128, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,746.68) for the length of stay and the standard reimbursement.","18470.66","18470.66","18470.66","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","28888.47","","FALLON HEALTH [1008]","HB BWF MEDICAID","6610.87","","Case rate ($7,309.46). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,739.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7307.66","7307.66","7307.66","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","28888.47","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19304.57","","Fee schedule rate ($19,304.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19304.57","19304.57","19304.57","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","28888.47","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6610.87","","Case rate ($7,309.46). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,739.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7307.66","7307.66","7307.66","1 through 10","5026.41","192806.22","case rate",""
"Peptic Ulcer And Gastritis,MODERATE","241","DRG","","","","","","","","inpatient","","","28888.47","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6610.87","","Case rate ($7,309.46). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,739.46, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7307.66","7307.66","7307.66","1 through 10","5026.41","192806.22","case rate",""
"Perc Decompression Pneumoperitoneum","PX-76002334","CDM","49999","CPT","0761","RC","","","","both","","","2617.00","1962.75","WELLPOINT [1015]","HB CH WELLPOINT","2038.90","77.91","","3449.15","3449.15","3449.15","1 through 10","1057.74","2488.77","percent of total billed charges",""
"Percutaneous Cardiac Intervention With Ami,MODERATE","174","DRG","","","","","","","","inpatient","","","14693.30","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","55870.21","","Standard inlier is a Case rate ($55,870.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $65,005, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,930.54) for the length of stay and the standard reimbursement.","55870.21","55870.21","55870.21","1 through 10","15512.19","73938.72","case rate",""
"Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC","322","MS-DRG","","","","","","","","inpatient","","","86703.91","65027.93","MEDICARE [2001]","HB BWF MEDICARE","18124.00","","Case rate ($18,124). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,598.46, add-ons for qualifying new technology services are included. If operating cost exceeds $62,122.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,807.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $16,538.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,259.22 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,246.37. The transfer capital threshold is the transfer adjustment factor * $1,246.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18240.89","18240.89","18240.89","1 through 10","16240.57","18124","other","Inpatient DRG"
"Percutaneous GI Tube Manipulation","PX-76002532","CDM","43999","CPT","0761","RC","","","","both","","","674.00","505.50","WELLPOINT [1015]","HB CH WELLPOINT","525.11","77.91","","2383.28","2383.28","2383.28","1 through 10","289.15","1146.7","percent of total billed charges",""
"Peripheral And Other Vascular Disorders,EXTREME","197","DRG","","","","","","","","inpatient","","","43298.28","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","38319.40","","Standard inlier is a Case rate ($38,319.40). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $50,960, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,439.59) for the length of stay and the standard reimbursement.","21028.96","21028.96","21028.96","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","27184.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","21028.97","","Standard inlier is a Case rate ($21,028.97). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,221, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,985.14) for the length of stay and the standard reimbursement.","21028.96","21028.96","21028.96","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","27184.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","22589.31","","Standard inlier is a Case rate ($22,589.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $33,221, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,206.46) for the length of stay and the standard reimbursement.","22589.30","22589.30","22589.30","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","27184.18","","MASSHEALTH [3001]","HB BWF MEDICAID","9097.80","","Case rate ($10,059.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,489.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,307.15 and the sum of the standard inlier and any outlier amount.","10056.71","10056.71","10056.71","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","27184.18","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9097.80","","Case rate ($10,059.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,489.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,307.15 and the sum of the standard inlier and any outlier amount.","10056.72","695.29","10056.72","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MAJOR","197","DRG","","","","","","","","inpatient","","","27184.18","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9097.80","","Case rate ($10,059.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,489.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,307.15 and the sum of the standard inlier and any outlier amount.","10056.72","10056.72","10056.72","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MINOR","197","DRG","","","","","","","","inpatient","","","12925.82","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5451.37","","Case rate ($6,027.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,457.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6270.11","6270.11","6270.11","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MINOR","197","DRG","","","","","","","","inpatient","","","12925.82","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5451.37","","Case rate ($6,027.43). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,457.43, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6025.95","6025.95","6025.95","1 through 10","2043","88248.6","case rate",""
"Peripheral And Other Vascular Disorders,MODERATE","197","DRG","","","","","","","","inpatient","","","25585.46","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6385.83","","Case rate ($7,060.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,490.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,619.41 and the sum of the standard inlier and any outlier amount.","1619.01","1619.01","7058.90","1 through 10","2043","88248.6","case rate",""
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26333.06","19749.79","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","10473.27","","Case rate ($10,168.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,184.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,707.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,074.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,844.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.68. The transfer capital threshold is the transfer adjustment factor * $754.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","10321.94","10321.94","10321.94","1 through 10","9964.86","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26333.06","19749.79","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9964.86","","Case rate ($10,168.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,184.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,707.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,074.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,844.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.68. The transfer capital threshold is the transfer adjustment factor * $754.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9792.81","9792.81","9825.45","1 through 10","9964.86","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26333.06","19749.79","MEDICARE [2001]","HB BWF MEDICARE","10168.22","","Case rate ($10,168.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,184.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,707.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,074.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,844.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.68. The transfer capital threshold is the transfer adjustment factor * $754.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10824.86","651.14","10896.63","18","9964.86","10957.89","other","Inpatient Replacement Plans DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26333.06","19749.79","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9964.86","","Case rate ($10,168.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,184.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,707.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,074.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,844.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.68. The transfer capital threshold is the transfer adjustment factor * $754.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9825.45","9825.45","9825.45","1 through 10","9964.86","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With Cc","300","MS-DRG","","","","","","","","inpatient","","","26333.06","19749.79","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9964.86","","Case rate ($10,168.22). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,184.24, add-ons for qualifying new technology services are included. If operating cost exceeds $55,707.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,315.46, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,074.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,844.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $754.68. The transfer capital threshold is the transfer adjustment factor * $754.68. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9792.81","9792.81","9792.81","1 through 10","9964.86","10957.89","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","36340.44","27255.33","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","15833.45","","Case rate ($15,372.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,396.78, add-ons for qualifying new technology services are included. If operating cost exceeds $60,920.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,715.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,878.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,057.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,154.25. The transfer capital threshold is the transfer adjustment factor * $1,154.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","15408.36","15408.36","15408.36","1 through 10","15064.83","16809.57","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","36340.44","27255.33","MEDICARE [2001]","HB BWF MEDICARE","16809.57","","Case rate ($16,809.57). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,396.78, add-ons for qualifying new technology services are included. If operating cost exceeds $60,920.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,715.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $15,316.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,057.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,154.25. The transfer capital threshold is the transfer adjustment factor * $1,154.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16227.26","0.03","16335.72","12","15064.83","16809.57","other","Inpatient DRG"
"Peripheral Vascular Disorders With McC","299","MS-DRG","","","","","","","","inpatient","","","36340.44","27255.33","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","15064.83","","Case rate ($15,372.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,396.78, add-ons for qualifying new technology services are included. If operating cost exceeds $60,920.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,715.03, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,878.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,057.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,154.25. The transfer capital threshold is the transfer adjustment factor * $1,154.25. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14641.79","14641.79","14641.79","1 through 10","15064.83","16809.57","other","Inpatient DRG"
"Peripheral Vascular Disorders Without Cc/McC","301","MS-DRG","","","","","","","","inpatient","","","27089.41","20317.06","MEDICARE [2001]","HB BWF MEDICARE","6965.87","","Case rate ($6,965.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,976.66, add-ons for qualifying new technology services are included. If operating cost exceeds $52,500.39 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,069.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,117.81 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,637.41 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $508.80. The transfer capital threshold is the transfer adjustment factor * $508.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7344.83","7344.83","7344.83","1 through 10","6826.55","7174.85","other","Inpatient Replacement Plans DRG"
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","FALLON HEALTH [1008]","HB BWF MEDICAID","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11650.33","11650.33","11650.33","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","10286.9088","","Fee schedule rate ($22,823.10). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10286.9088","21943.68","21943.68","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","MASSHEALTH [3001]","HB BWF MEDICAID","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11650.33","11650.33","11650.33","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10739.40","","Fee schedule rate ($10,739.40). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","10739.40","10739.40","10739.40","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11650.33","11650.33","11650.33","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MAJOR","048","DRG","","","","","","","","inpatient","","","31202.69","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10539.47","","Case rate ($11,653.19). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $54,083.19, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11650.33","11650.33","11650.33","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MINOR","048","DRG","","","","","","","","inpatient","","","26392.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14544.75","","Standard inlier is a Case rate ($14,544.75). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,569, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,064.68) for the length of stay and the standard reimbursement.","14544.74","14544.74","14544.74","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MINOR","048","DRG","","","","","","","","inpatient","","","26392.44","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4951.01","","Case rate ($5,474.20). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,904.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5472.85","5472.85","5472.85","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","32605.65","","MASSHEALTH [3001]","HB BWF MEDICAID","6739.96","","Case rate ($7,452.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,882.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,674.65 and the sum of the standard inlier and any outlier amount.","7450.36","7450.36","7450.36","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","32605.65","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6739.96","","Case rate ($7,452.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,882.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,674.65 and the sum of the standard inlier and any outlier amount.","7450.35","7450.35","7450.35","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial And Autonomic Nerve Disorders,MODERATE","048","DRG","","","","","","","","inpatient","","","32605.65","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6739.96","","Case rate ($7,452.18). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,882.18, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,674.65 and the sum of the standard inlier and any outlier amount.","7450.35","3186.62","7450.35","1 through 10","4951.01","37657.77","case rate",""
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","041","MS-DRG","","","","","","","","inpatient","","","50796.91","38097.68","MEDICARE [2001]","HB BWF MEDICARE","22519.24","","Case rate ($22,519.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,616.69, add-ons for qualifying new technology services are included. If operating cost exceeds $66,140.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,115.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 3.8)) / 2. The base transfer operating payment is the transfer adjustment factor * $20,625.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $20,277.45 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,554.39. The transfer capital threshold is the transfer adjustment factor * $1,554.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","22705.49","22705.49","22705.49","1 through 10","20172.02","22519.24","other","Inpatient DRG"
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/McC","042","MS-DRG","","","","","","","","inpatient","","","55437.84","41578.38","MEDICARE [2001]","HB BWF MEDICARE","16246.97","","Case rate ($16,246.97). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,272.91, add-ons for qualifying new technology services are included. If operating cost exceeds $61,796.64 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,782.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.3)) / 2. The base transfer operating payment is the transfer adjustment factor * $14,686.33 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,933.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,221.41. The transfer capital threshold is the transfer adjustment factor * $1,221.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","17609.94","17609.94","17609.94","1 through 10","15922.03","17734.84","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis With Cc","336","MS-DRG","","","","","","","","inpatient","","","48929.15","36696.86","MEDICARE [2001]","HB BWF MEDICARE","19755.02","","Case rate ($19,755.02). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,786.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,310.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,051.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.1. The base transfer operating payment is the transfer adjustment factor * $17,925.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,447.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,490.77. The transfer capital threshold is the transfer adjustment factor * $1,490.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","21254.74","21254.74","21254.74","1 through 10","19359.92","20888.5347","other","Inpatient Replacement Plans DRG"
"Peritoneal Adhesiolysis Without Cc/McC","337","MS-DRG","","","","","","","","inpatient","","","42284.19","31713.14","MEDICARE [2001]","HB BWF MEDICARE","15823.99","","Case rate ($15,823.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,495.74, add-ons for qualifying new technology services are included. If operating cost exceeds $60,019.47 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,645.97, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $14,399.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,156.50 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,085.18. The transfer capital threshold is the transfer adjustment factor * $1,085.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15515.38","15515.38","15515.38","1 through 10","14183.26","15823.99","other","Inpatient DRG"
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","57670.94","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","37181.90","","Standard inlier is a Case rate ($37,181.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $42,494, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,278.12) for the length of stay and the standard reimbursement.","35492.29","35492.29","35492.29","1 through 10","14292.14","53683.04","case rate",""
"Peritoneal Adhesiolysis,MODERATE","224","DRG","","","","","","","","inpatient","","","57670.94","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24974.676","","Fee schedule rate ($32,535.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24974.676","32535.48","32535.48","1 through 10","14292.14","53683.04","case rate",""
"Peritoneal Kd Cath Manipulation","PX-76002530","CDM","49999","CPT","0761","RC","","","","both","","","1464.00","1098.00","WELLPOINT [1015]","HB CH WELLPOINT","1140.60","77.91","","3449.15","3449.15","3449.15","1 through 10","628.06","1392.26","percent of total billed charges",""
"Perq Device Breast 1st Imag","PX-76001936","CDM","19281","CPT","0761","RC","","","","both","","","808.00","606.00","AETNA [1001]","HB CH AETNA HMO / PPO","471.06","58.3","","445.66","445.66","445.66","1 through 10","359.16","2253.63","percent of total billed charges",""
"Perq Device Breast 1st Imag","PX-76001936","CDM","19281","CPT","0761","RC","","","","both","","","808.00","606.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1885.65","","APC Price ($1,924.13). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1893.55","1893.15","1893.55","1 through 10","359.16","2253.63","other","OPPS APC"
"Perq Device Breast Ea Imag, Mamm Guidance","PX-76001937","CDM","19282","CPT","0761","RC","","","","both","","","253.00","189.75","AETNA [1001]","HB CH AETNA HMO / PPO","147.50","58.3","","139.48","139.48","139.48","1 through 10","112.46","197.11","percent of total billed charges",""
"Perq Device Breast Ea Imag, US Guidance","PX-76001938","CDM","19285","CPT","0761","RC","","","","both","","","447.00","335.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","818.84","","APC Price ($835.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","826.35","819.72","826.75","1 through 10","236.91","2253.63","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-75000480","CDM","43762","CPT","0750","RC","","","","both","","","480.00","360.00","MEDICARE [2001]","HB BWF MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","1 through 10","205.92","732.91","other","OPPS APC"
"Perq Replacement Gtube Not Req Revj Gstrst Trc","PX-98301825","CDM","43762","CPT","0983","RC","","","","both","","","197.00","147.75","MEDICARE [2001]","HB BWF MEDICARE","288.80","","APC Price ($288.80). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","288.83","288.83","288.83","1 through 10","84.51","732.91","other","OPPS APC"
"Perq Sft Tiss Loc Device Plmt 1st Les W/Gdnce","PX-76002177","CDM","10035","CPT","0761","RC","","","","outpatient","","","436.00","327.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","342.04","78.45","","193.17","193.17","193.17","1 through 10","193.8","1873.9","percent of total billed charges",""
"Perq Thrmbc/Nfs Dial Circuit Tcat Plmt IV Stent","PX-36000412","CDM","36906","CPT","0361","RC","","","","both","","","25872.00","19404.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","21324.68","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","18832.01","18832.01","18832.01","1 through 10","11500.1","46815.04","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Tcat Plmt IV Stent","PX-36000412","CDM","36906","CPT","0361","RC","","","","both","","","25872.00","19404.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","20898.19","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20898.19","18755.46","20983.49","1 through 10","11500.1","46815.04","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Tcat Plmt IV Stent","PX-36000412","CDM","36906","CPT","0361","RC","","","","both","","","25872.00","19404.00","MEDICARE [2001]","HB BWF MEDICARE","21324.68","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","63974.04","21324.68","63974.04","62","11500.1","46815.04","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Tcat Plmt IV Stent","PX-36000412","CDM","36906","CPT","0361","RC","","","","both","","","25872.00","19404.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","20898.19","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20983.49","20900.19","20983.49","1 through 10","11500.1","46815.04","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Tcat Plmt IV Stent","PX-36000412","CDM","36906","CPT","0361","RC","","","","both","","","25872.00","19404.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","20898.19","","APC Price ($21,324.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","20905.19","18755.46","20906.09","1 through 10","11500.1","46815.04","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Tcat Plmt IV Stent","PX-36000412","CDM","36906","CPT","0361","RC","","","","outpatient","","","25872.00","19404.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","20296.58","78.45","","19341.47","19341.47","19341.47","1 through 10","12936","20833.55","percent of total billed charges",""
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13871.64","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","13864.07","13858.17","13880.83","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11814.80","11814.80","11814.80","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","13311.73","13311.73","13311.73","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13198.26","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13252.13","13198.26","13252.13","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11766.77","11766.77","11766.77","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","MEDICARE [2001]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","40402.83","13467.61","67338.05","90","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","MOLINA [1014]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23773.68","23773.68","23773.68","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13198.26","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13199.76","13199.76","13199.76","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13198.26","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","13198.26","11766.77","13205.76","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","both","","","17072.00","12804.00","WELLSENSE [1003]","HB BWF MEDICARE","13467.61","","APC Price ($13,467.61). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11766.77","11766.77","11766.77","1 through 10","7588.5","30885.95","other","OPPS APC"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","outpatient","","","17072.00","12804.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","11057.10","","Case rate ($11,057.10). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","15988.57","15988.57","15988.57","1 through 10","7178","13392.98","other","ASC "
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","outpatient","","","17072.00","12804.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8702.14","","Case rate ($8,702.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","19441.86","19441.86","19441.86","1 through 10","7178","13392.98","other","Multiple Surgery"
"Perq Thrmbc/Nfs Dial Circuit Trluml Balo Angiop","PX-36000411","CDM","36905","CPT","0361","RC","","","","outpatient","","","17072.00","12804.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","13392.98","78.45","","19304.33","19304.33","19304.33","1 through 10","7178","13392.98","percent of total billed charges",""
"Perq Thrmbc/Nfs Dialysis Circuit Img Dx Angrph","PX-36000410","CDM","36904","CPT","0361","RC","","","","both","","","8445.00","6333.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6138.40","6138.40","6138.40","1 through 10","4210.68","15281.41","other","OPPS APC"
"Perq Thrmbc/Nfs Dialysis Circuit Img Dx Angrph","PX-36000410","CDM","36904","CPT","0361","RC","","","","both","","","8445.00","6333.75","MEDICARE [2001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","31191.05","20312.70","33854.50","13","4210.68","15281.41","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation","PX-76002084","CDM","22513","CPT","0761","RC","","","","both","","","14222.00","10666.50","MEDICARE [2001]","HB BWF MEDICARE","8482.75","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","15280.12","8483.61","15280.12","1 through 10","5129.63","16536.71","other","OPPS APC"
"Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr","PX-76002085","CDM","22514","CPT","0761","RC","","","","both","","","15272.00","11454.00","MEDICARE [2001]","HB BWF MEDICARE","8482.75","","APC Price ($8,482.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","8483.61","7808.11","8483.61","1 through 10","5129.63","16536.71","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","both","","","7610.00","5707.50","MEDICARE [2001]","HB BWF MEDICARE","3852.78","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3853.17","3853.17","3853.17","1 through 10","2361.01","5928.95","other","OPPS APC"
"Perq Vertebroplasty Uni/Bi Injection Lumbosacral","PX-76002082","CDM","22511","CPT","0761","RC","","","","both","","","7610.00","5707.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","3775.72","","APC Price ($3,852.78). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7658.95","7658.95","7658.95","1 through 10","2361.01","5928.95","other","OPPS APC"
"Pf Psy/Cd Group Therapy","PX-96100003","CDM","90853","CPT","0961","RC","","","","both","","","116.00","87.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.36","119.36","159.14","80","61.48","222.51","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","both","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.42","477.42","477.42","1 through 10","365.18","687.8","other","OPPS APC"
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","355.27","49.07","","28.28","28.28","28.88","12","122.71","567.98","percent of total billed charges",""
"Pf Psych Diag Evaluation W/Med Serv","PX-96100029","CDM","90792","CPT","0961","RC","","","","outpatient","","","724.00","543.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","362.72","50.1","","28.32","28.32","28.92","1 through 10","122.71","567.98","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","187.76","1 through 10","280.04","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","453.00","453.00","453.00","1 through 10","280.04","598.5","other","OPPS APC"
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","309.14","49.07","","28.28","28.28","28.28","1 through 10","122.71","494.24","percent of total billed charges",""
"Pf Psychiatric Diagnostic Eval","PX-96100028","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","315.63","50.1","","28.32","28.32","28.32","1 through 10","122.71","494.24","percent of total billed charges",""
"Ph Body Fluid","PX-30000601","CDM","83986","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","1 through 10","3.51","30.66","percent of total billed charges",""
"Ph Body Fluid","PX-30001467","CDM","83986","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","1 through 10","3.51","30.66","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","AETNA [1001]","HB CH AETNA HMO / PPO","660.07","58.3","","554.95","91.85","1421.75","94","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","826.51","73","","2490.03","2490.03","2490.03","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","660.07","58.3","","750.00","750.00","750.00","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","600.07","53","","1192.50","120.84","4149.90","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","962.37","85","","750.00","75.00","750.00","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1132.20","100","","657.00","121.50","1971.00","14","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1132.20","100","","75.00","75.00","75.00","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1132.20","100","","366.00","144.00","1971.00","45","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","826.51","73","","667.50","667.50","667.50","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.26","44.45","","123.77","123.77","123.77","1 through 10","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.20","849.15","WELLPOINT [1015]","HB CH WELLPOINT","882.10","77.91","","483.51","229.32","1316.08","96","503.26","1132.2","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","671.39","59.3","","439.50","225.34","1872.27","197","566.1","888.21","percent of total billed charges",""
"PHALANGE PLATE 1.5MM 2 HOLE HD 6 SHAFT VAL AL","SUP-ITM-10164623","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.20","849.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","888.21","78.45","","385.32","55.36","1815.62","58","566.1","888.21","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","AETNA [1001]","HB CH AETNA HMO / PPO","616.71","58.3","","554.95","91.85","1421.75","94","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","772.22","73","","2490.03","2490.03","2490.03","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","616.71","58.3","","750.00","750.00","750.00","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","560.65","53","","1192.50","120.84","4149.90","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","899.16","85","","750.00","75.00","750.00","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1057.83","100","","657.00","121.50","1971.00","14","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1057.83","100","","75.00","75.00","75.00","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1057.83","100","","366.00","144.00","1971.00","45","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","772.22","73","","667.50","667.50","667.50","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","470.21","44.45","","123.77","123.77","123.77","1 through 10","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","both","","","1057.83","793.37","WELLPOINT [1015]","HB CH WELLPOINT","824.16","77.91","","483.51","229.32","1316.08","96","470.21","1057.83","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1057.83","793.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","627.29","59.3","","439.50","225.34","1872.27","197","528.92","829.87","percent of total billed charges",""
"PHALANX HEAD 1.3MM PLATE BONE LOCKING PHALANGEAL LEFT","SUP-ITM-10164648","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1057.83","793.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","829.87","78.45","","385.32","55.36","1815.62","58","528.92","829.87","percent of total billed charges",""
"Phenobarbital","PX-30000186","CDM","80184","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","80.73","80.73","80.73","1 through 10","11.81","84.73","percent of total billed charges",""
"Phenytoin (Dilantin) Total","PX-30000187","CDM","80185","CPT","0301","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","83.03","83.03","83.03","1 through 10","13.67","87.08","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","157.67","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","157.52","157.52","157.52","1 through 10","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","AETNA [1001]","HB CH AETNA HMO / PPO","338.14","58.3","","319.79","319.79","319.79","1 through 10","145.42","451.88","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","MEDICARE [2001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","139.42","153.08","61","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.02","136.63","150.02","1 through 10","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","both","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","150.01","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","153.08","139.42","153.08","1 through 10","145.42","451.88","other","OPPS APC"
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","580.00","435.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","343.94","59.3","","330.50","330.50","330.50","1 through 10","175.84","455.01","percent of total billed charges",""
"Phlebotomy Therapeutic","PX-30000159","CDM","99195","CPT","0940","RC","","","","outpatient","","","580.00","435.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","455.01","78.45","","433.60","256.96","433.60","17","175.84","455.01","percent of total billed charges",""
"Phosphatase Alkaline","PX-30000613","CDM","84075","CPT","0301","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","26.37","1 through 10","5.34","36.09","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Phospho-Tau Abs CSF by Elisa","PX-30002792","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Phospholipid Neutralization Plate","PX-30001116","CDM","85597","CPT","0305","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","54.50","1 through 10","4.81","75.31","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0300","RC","","","","inpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.48","70.6","","34.60","34.60","34.60","1 through 10","25.76","32.48","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","AETNA [1001]","HB CH AETNA HMO / PPO","26.82","58.3","","25.52","25.52","25.52","19","4.65","33.58","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","33.58","73","","32.85","32.85","32.85","1 through 10","4.65","33.58","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","both","","","46.00","34.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","33.58","73","","25.52","25.52","25.52","1 through 10","4.65","33.58","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","46.00","34.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","27.28","59.3","","26.37","26.37","134.70","35","4.87","36.09","percent of total billed charges",""
"Phosphorus","PX-30000619","CDM","84100","CPT","0301","RC","","","","outpatient","","","46.00","34.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","36.09","78.45","","34.60","20.27","103.80","28","4.87","36.09","percent of total billed charges",""
"Physical Therapy Evaluation, High Complexity","PX-42000100","CDM","97163","CPT","0424","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.02","107.02","107.02","1 through 10","107.02","364.8","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","AETNA [1001]","HB CH AETNA HMO / PPO","263.52","58.3","","249.48","234.06","249.48","25","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","263.52","58.3","","220.00","220.00","220.00","1 through 10","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","239.56","53","","233.20","219.95","233.20","1 through 10","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","329.96","73","","391.60","152.89","391.60","1 through 10","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.62","80.11","109.58","93","107.02","364.8","fee schedule",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","both","","","452.00","339.00","WELLPOINT [1015]","HB CH WELLPOINT","352.15","77.91","","346.54","346.54","786.54","29","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","452.00","339.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","268.04","59.3","","257.84","257.84","257.84","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Low Complexity","PX-42000098","CDM","97161","CPT","0424","RC","","","","outpatient","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","354.59","78.45","","338.27","338.27","338.27","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","AETNA [1001]","HB CH AETNA HMO / PPO","263.52","58.3","","249.48","249.48","249.48","13","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","ELDER SERVICES [1037]","HB BWF MEDICARE","109.20","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount.","185.74","185.74","185.74","1 through 10","107.02","364.8","fee schedule",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","239.56","53","","233.20","233.20","233.20","1 through 10","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","107.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($109.20). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($81.13). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","107.22","80.51","109.35","83","107.02","364.8","fee schedule",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","both","","","452.00","339.00","WELLPOINT [1015]","HB CH WELLPOINT","352.15","77.91","","346.54","346.54","786.54","22","107.02","364.8","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","452.00","339.00","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","268.04","59.3","","237.38","237.38","237.38","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Evaluation, Moderate Complexity","PX-42000099","CDM","97162","CPT","0424","RC","","","","outpatient","","","452.00","339.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","354.59","78.45","","276.24","276.24","276.24","1 through 10","208.25","408.37","percent of total billed charges",""
"Physical Therapy Re-Eval Est Plan Care 20 Mins","PX-42000103","CDM","97164","CPT","0424","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","74.39","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($75.91). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($54.42). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","75.40","75.40","75.40","1 through 10","74.39","364.8","fee schedule",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","AETNA [1001]","HB CH AETNA HMO / PPO","2740.10","58.3","","1634.24","1004.95","1718.99","42","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","2123.89","1900.92","2123.89","1 through 10","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2740.10","58.3","","3729.00","1254.19","3729.00","1 through 10","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2491.00","53","","939.37","939.37","5593.65","1 through 10","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3995.00","85","","2323.25","1864.50","2882.25","16","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4700.00","100","","2909.44","1772.40","10952.08","45","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4700.00","100","","2323.25","2323.25","2323.25","1 through 10","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4700.00","100","","2882.25","1772.40","10169.17","187","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3431.00","73","","1659.41","1659.41","1659.41","1 through 10","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","both","","","4700.00","3525.00","WELLPOINT [1015]","HB CH WELLPOINT","3661.77","77.91","","2050.91","1468.48","2902.83","52","2089.15","4700","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2787.10","59.3","","1548.60","1092.60","3613.79","82","2350","3687.15","percent of total billed charges",""
"PIECE CONNECTION 90MM COMPONENT FEMORAL KNEE GMRS RECONSTRUCTION LEFT","SUP-ITM-10019492","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4700.00","3525.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3687.15","78.45","","2085.51","998.68","6202.11","56","2350","3687.15","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","AETNA [1001]","HB CH AETNA HMO / PPO","2119.79","58.3","","554.95","91.85","1421.75","94","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2654.28","73","","2490.03","2490.03","2490.03","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2119.79","58.3","","750.00","750.00","750.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1927.08","53","","1192.50","120.84","4149.90","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3090.60","85","","750.00","75.00","750.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3636.00","100","","657.00","121.50","1971.00","14","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3636.00","100","","75.00","75.00","75.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3636.00","100","","366.00","144.00","1971.00","45","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2654.28","73","","667.50","667.50","667.50","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1616.20","44.45","","123.77","123.77","123.77","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","WELLPOINT [1015]","HB CH WELLPOINT","2832.81","77.91","","483.51","229.32","1316.08","96","1616.2","3636","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.00","2727.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2156.15","59.3","","439.50","225.34","1872.27","197","1818","2852.44","percent of total billed charges",""
"PIN ASSEMBLY 3.0MM ROCKWOOD SS CLAVICLE COMPRESSION","SUP-ITM-10012814","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.00","2727.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2852.44","78.45","","385.32","55.36","1815.62","58","1818","2852.44","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","AETNA [1001]","HB CH AETNA HMO / PPO","549.19","58.3","","554.95","91.85","1421.75","94","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","687.66","73","","2490.03","2490.03","2490.03","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","549.19","58.3","","750.00","750.00","750.00","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","499.26","53","","1192.50","120.84","4149.90","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","800.70","85","","750.00","75.00","750.00","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","942.00","100","","657.00","121.50","1971.00","14","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","942.00","100","","75.00","75.00","75.00","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","942.00","100","","366.00","144.00","1971.00","45","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","687.66","73","","667.50","667.50","667.50","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.72","44.45","","123.77","123.77","123.77","1 through 10","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","both","","","942.00","706.50","WELLPOINT [1015]","HB CH WELLPOINT","733.91","77.91","","483.51","229.32","1316.08","96","418.72","942","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","942.00","706.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","558.61","59.3","","439.50","225.34","1872.27","197","471","739","percent of total billed charges",""
"PIN AXIS 2.5X70MM","SUP-ITM-10170018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","942.00","706.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","739.00","78.45","","385.32","55.36","1815.62","58","471","739","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","AETNA [1001]","HB CH AETNA HMO / PPO","113.69","58.3","","554.95","91.85","1421.75","94","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","142.35","73","","2490.03","2490.03","2490.03","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","113.69","58.3","","750.00","750.00","750.00","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","103.35","53","","1192.50","120.84","4149.90","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","165.75","85","","750.00","75.00","750.00","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","195.00","100","","657.00","121.50","1971.00","14","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","195.00","100","","75.00","75.00","75.00","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","195.00","100","","366.00","144.00","1971.00","45","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","142.35","73","","667.50","667.50","667.50","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.68","44.45","","123.77","123.77","123.77","1 through 10","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","WELLPOINT [1015]","HB CH WELLPOINT","151.92","77.91","","483.51","229.32","1316.08","96","86.68","195","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","115.64","59.3","","439.50","225.34","1872.27","197","97.5","152.98","percent of total billed charges",""
"PIN BEATH 2.4MM STERILE","SUP-ITM-10213095","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","152.98","78.45","","385.32","55.36","1815.62","58","97.5","152.98","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","AETNA [1001]","HB CH AETNA HMO / PPO","79.60","58.3","","1830.28","315.58","1830.28","1 through 10","60.69","136.53","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","99.67","73","","4170.85","4170.85","4170.85","1 through 10","60.69","136.53","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.69","44.45","","649.55","649.55","649.55","1 through 10","60.69","136.53","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","both","","","136.53","102.40","WELLPOINT [1015]","HB CH WELLPOINT","106.37","77.91","","8998.38","2542.37","8998.38","20","60.69","136.53","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.96","59.3","","1891.61","1609.14","3664.18","25","68.27","107.11","percent of total billed charges",""
"PIN BONE 1.8X18MM BUTTRESS SS DISTAL RADIUS PLATE","SUP-ITM-10006578","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","136.53","102.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","107.11","78.45","","1470.68","1310.06","2481.69","19","68.27","107.11","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","554.95","91.85","1421.75","94","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","2490.03","2490.03","2490.03","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","750.00","750.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","1192.50","120.84","4149.90","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1083.75","85","","750.00","75.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1275.00","100","","657.00","121.50","1971.00","14","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1275.00","100","","75.00","75.00","75.00","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1275.00","100","","366.00","144.00","1971.00","45","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","667.50","667.50","667.50","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","123.77","123.77","123.77","1 through 10","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","483.51","229.32","1316.08","96","566.74","1275","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","439.50","225.34","1872.27","197","637.5","1000.24","percent of total billed charges",""
"PIN BONE 1/8X3.5IN LONG EXTERNAL FIXATION SS HEADLESS FLUTED SQUARE END","SUP-ITM-10130388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","385.32","55.36","1815.62","58","637.5","1000.24","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","AETNA [1001]","HB CH AETNA HMO / PPO","20.89","58.3","","554.95","91.85","1421.75","94","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","26.16","73","","2490.03","2490.03","2490.03","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","20.89","58.3","","750.00","750.00","750.00","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","19.00","53","","1192.50","120.84","4149.90","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","30.46","85","","750.00","75.00","750.00","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","35.84","100","","657.00","121.50","1971.00","14","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","35.84","100","","75.00","75.00","75.00","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","35.84","100","","366.00","144.00","1971.00","45","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","26.16","73","","667.50","667.50","667.50","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.93","44.45","","123.77","123.77","123.77","1 through 10","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","both","","","35.84","26.88","WELLPOINT [1015]","HB CH WELLPOINT","27.92","77.91","","483.51","229.32","1316.08","96","15.93","35.84","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.84","26.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.25","59.3","","439.50","225.34","1872.27","197","17.92","28.12","percent of total billed charges",""
"PIN BONE 1/8X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK/ - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","35.84","26.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","28.12","78.45","","385.32","55.36","1815.62","58","17.92","28.12","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","554.95","91.85","1421.75","94","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","2490.03","2490.03","2490.03","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","134.67","58.3","","750.00","750.00","750.00","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","122.43","53","","1192.50","120.84","4149.90","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","196.35","85","","750.00","75.00","750.00","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","231.00","100","","657.00","121.50","1971.00","14","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","231.00","100","","75.00","75.00","75.00","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","231.00","100","","366.00","144.00","1971.00","45","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","168.63","73","","667.50","667.50","667.50","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","102.68","44.45","","123.77","123.77","123.77","1 through 10","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","both","","","231.00","173.25","WELLPOINT [1015]","HB CH WELLPOINT","179.97","77.91","","483.51","229.32","1316.08","96","102.68","231","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.98","59.3","","439.50","225.34","1872.27","197","115.5","181.22","percent of total billed charges",""
"PIN BONE 2.0MM DIA 77 ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","385.32","55.36","1815.62","58","115.5","181.22","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","554.95","91.85","1421.75","94","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","2490.03","2490.03","2490.03","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","750.00","750.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","1192.50","120.84","4149.90","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","153.00","85","","750.00","75.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","180.00","100","","657.00","121.50","1971.00","14","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","180.00","100","","75.00","75.00","75.00","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","180.00","100","","366.00","144.00","1971.00","45","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","667.50","667.50","667.50","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","123.77","123.77","123.77","1 through 10","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","483.51","229.32","1316.08","96","80.01","180","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","439.50","225.34","1872.27","197","90","141.21","percent of total billed charges",""
"PIN BONE 25.4MM SAL FIXATION TEMPORARY THREADED STRAIGHT SKYLINE","SUP-ITM-10027842","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","385.32","55.36","1815.62","58","90","141.21","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","AETNA [1001]","HB CH AETNA HMO / PPO","311.32","58.3","","554.95","91.85","1421.75","94","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","389.82","73","","2490.03","2490.03","2490.03","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","311.32","58.3","","750.00","750.00","750.00","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","283.02","53","","1192.50","120.84","4149.90","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","453.90","85","","750.00","75.00","750.00","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","534.00","100","","657.00","121.50","1971.00","14","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","534.00","100","","75.00","75.00","75.00","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","534.00","100","","366.00","144.00","1971.00","45","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","389.82","73","","667.50","667.50","667.50","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.36","44.45","","123.77","123.77","123.77","1 through 10","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.00","400.50","WELLPOINT [1015]","HB CH WELLPOINT","416.04","77.91","","483.51","229.32","1316.08","96","237.36","534","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.00","400.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.66","59.3","","439.50","225.34","1872.27","197","267","418.92","percent of total billed charges",""
"PIN BONE 2X45MM ARTHROSCOPY TRACKER AMZ ANCHOR BLOCK","SUP-ITM-10028882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.92","78.45","","385.32","55.36","1815.62","58","267","418.92","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","AETNA [1001]","HB CH AETNA HMO / PPO","228.79","58.3","","554.95","91.85","1421.75","94","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","286.47","73","","2490.03","2490.03","2490.03","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","228.79","58.3","","750.00","750.00","750.00","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","207.99","53","","1192.50","120.84","4149.90","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","333.57","85","","750.00","75.00","750.00","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","392.43","100","","657.00","121.50","1971.00","14","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","392.43","100","","75.00","75.00","75.00","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","392.43","100","","366.00","144.00","1971.00","45","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.47","73","","667.50","667.50","667.50","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.44","44.45","","123.77","123.77","123.77","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.43","294.32","WELLPOINT [1015]","HB CH WELLPOINT","305.74","77.91","","483.51","229.32","1316.08","96","174.44","392.43","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.43","294.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.71","59.3","","439.50","225.34","1872.27","197","196.22","307.86","percent of total billed charges",""
"PIN BONE 3.2X444MM GUIDE THREADED","SUP-ITM-10072400","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.43","294.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.86","78.45","","385.32","55.36","1815.62","58","196.22","307.86","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","AETNA [1001]","HB CH AETNA HMO / PPO","2119.79","58.3","","554.95","91.85","1421.75","94","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2654.28","73","","2490.03","2490.03","2490.03","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2119.79","58.3","","750.00","750.00","750.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1927.08","53","","1192.50","120.84","4149.90","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3090.60","85","","750.00","75.00","750.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3636.00","100","","657.00","121.50","1971.00","14","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3636.00","100","","75.00","75.00","75.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3636.00","100","","366.00","144.00","1971.00","45","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2654.28","73","","667.50","667.50","667.50","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1616.20","44.45","","123.77","123.77","123.77","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","WELLPOINT [1015]","HB CH WELLPOINT","2832.81","77.91","","483.51","229.32","1316.08","96","1616.2","3636","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.00","2727.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2156.15","59.3","","439.50","225.34","1872.27","197","1818","2852.44","percent of total billed charges",""
"PIN BONE 3.8MM CLAVICLE ASSEMBLY","SUP-ITM-10012137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.00","2727.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2852.44","78.45","","385.32","55.36","1815.62","58","1818","2852.44","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","AETNA [1001]","HB CH AETNA HMO / PPO","20.13","58.3","","554.95","91.85","1421.75","94","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","25.20","73","","2490.03","2490.03","2490.03","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","20.13","58.3","","750.00","750.00","750.00","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","18.30","53","","1192.50","120.84","4149.90","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","29.34","85","","750.00","75.00","750.00","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","34.52","100","","657.00","121.50","1971.00","14","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","34.52","100","","75.00","75.00","75.00","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","34.52","100","","366.00","144.00","1971.00","45","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","25.20","73","","667.50","667.50","667.50","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","15.34","44.45","","123.77","123.77","123.77","1 through 10","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","both","","","34.52","25.89","WELLPOINT [1015]","HB CH WELLPOINT","26.89","77.91","","483.51","229.32","1316.08","96","15.34","34.52","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","34.52","25.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.47","59.3","","439.50","225.34","1872.27","197","17.26","27.08","percent of total billed charges",""
"PIN BONE 3/32X9IN STEINMANN SS THREADED TROCAR POINT DUAL PK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10072996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","34.52","25.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","27.08","78.45","","385.32","55.36","1815.62","58","17.26","27.08","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","554.95","91.85","1421.75","94","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","2490.03","2490.03","2490.03","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","682.11","58.3","","750.00","750.00","750.00","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","620.10","53","","1192.50","120.84","4149.90","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","994.50","85","","750.00","75.00","750.00","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1170.00","100","","657.00","121.50","1971.00","14","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1170.00","100","","75.00","75.00","75.00","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1170.00","100","","366.00","144.00","1971.00","45","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","667.50","667.50","667.50","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","123.77","123.77","123.77","1 through 10","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","483.51","229.32","1316.08","96","520.07","1170","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","439.50","225.34","1872.27","197","585","917.87","percent of total billed charges",""
"PIN BONE 30MM 6X150 EXTERNAL FIXATION SS HYDROXYAPATITE COATING HALF THREAD","SUP-ITM-10062791","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","385.32","55.36","1815.62","58","585","917.87","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","554.95","91.85","1421.75","94","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","2490.03","2490.03","2490.03","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","253.61","58.3","","750.00","750.00","750.00","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","230.55","53","","1192.50","120.84","4149.90","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","369.75","85","","750.00","75.00","750.00","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","435.00","100","","657.00","121.50","1971.00","14","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","435.00","100","","75.00","75.00","75.00","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","435.00","100","","366.00","144.00","1971.00","45","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","667.50","667.50","667.50","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","123.77","123.77","123.77","1 through 10","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","483.51","229.32","1316.08","96","193.36","435","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","439.50","225.34","1872.27","197","217.5","341.26","percent of total billed charges",""
"PIN BONE 3X75MM GUIDE SHOULDER REVERSE","SUP-ITM-10149132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","385.32","55.36","1815.62","58","217.5","341.26","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","AETNA [1001]","HB CH AETNA HMO / PPO","421.32","58.3","","554.95","91.85","1421.75","94","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","527.55","73","","2490.03","2490.03","2490.03","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","421.32","58.3","","750.00","750.00","750.00","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","383.02","53","","1192.50","120.84","4149.90","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","614.27","85","","750.00","75.00","750.00","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","722.67","100","","657.00","121.50","1971.00","14","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","722.67","100","","75.00","75.00","75.00","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","722.67","100","","366.00","144.00","1971.00","45","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","527.55","73","","667.50","667.50","667.50","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.23","44.45","","123.77","123.77","123.77","1 through 10","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","both","","","722.67","542.00","WELLPOINT [1015]","HB CH WELLPOINT","563.03","77.91","","483.51","229.32","1316.08","96","321.23","722.67","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","722.67","542.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","428.54","59.3","","439.50","225.34","1872.27","197","361.34","566.93","percent of total billed charges",""
"PIN BONE 50MM 5.0X180 HALF EXTERNAL FIXATION APEX SS SELF DRILLING TAPG THREAD PK/3EA","SUP-ITM-10001852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","722.67","542.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","566.93","78.45","","385.32","55.36","1815.62","58","361.34","566.93","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","AETNA [1001]","HB CH AETNA HMO / PPO","220.37","58.3","","554.95","91.85","1421.75","94","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","275.94","73","","2490.03","2490.03","2490.03","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","220.37","58.3","","750.00","750.00","750.00","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","200.34","53","","1192.50","120.84","4149.90","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","321.30","85","","750.00","75.00","750.00","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","378.00","100","","657.00","121.50","1971.00","14","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","378.00","100","","75.00","75.00","75.00","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","378.00","100","","366.00","144.00","1971.00","45","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","275.94","73","","667.50","667.50","667.50","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","168.02","44.45","","123.77","123.77","123.77","1 through 10","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","both","","","378.00","283.50","WELLPOINT [1015]","HB CH WELLPOINT","294.50","77.91","","483.51","229.32","1316.08","96","168.02","378","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.00","283.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","224.15","59.3","","439.50","225.34","1872.27","197","189","296.54","percent of total billed charges",""
"PIN BONE 5MM 200MM SELF-DRILLING TM ANKLE","SUP-ITM-10235659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","378.00","283.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","296.54","78.45","","385.32","55.36","1815.62","58","189","296.54","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","1830.28","315.58","1830.28","1 through 10","72.01","162","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","4170.85","4170.85","4170.85","1 through 10","72.01","162","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","649.55","649.55","649.55","1 through 10","72.01","162","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","8998.38","2542.37","8998.38","20","72.01","162","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","1891.61","1609.14","3664.18","25","81","127.09","percent of total billed charges",""
"PIN BONE 5MM HIP ACETABULAR LINER LOCKING S-ROM","SUP-ITM-10002428","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","1470.68","1310.06","2481.69","19","81","127.09","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","AETNA [1001]","HB CH AETNA HMO / PPO","237.79","58.3","","554.95","91.85","1421.75","94","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","297.75","73","","2490.03","2490.03","2490.03","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","237.79","58.3","","750.00","750.00","750.00","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.18","53","","1192.50","120.84","4149.90","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","346.70","85","","750.00","75.00","750.00","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","407.88","100","","657.00","121.50","1971.00","14","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","407.88","100","","75.00","75.00","75.00","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","407.88","100","","366.00","144.00","1971.00","45","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","297.75","73","","667.50","667.50","667.50","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.30","44.45","","123.77","123.77","123.77","1 through 10","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","both","","","407.88","305.91","WELLPOINT [1015]","HB CH WELLPOINT","317.78","77.91","","483.51","229.32","1316.08","96","181.3","407.88","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","407.88","305.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","241.87","59.3","","439.50","225.34","1872.27","197","203.94","319.98","percent of total billed charges",""
"PIN BONE FIXATION SHORT","SUP-ITM-10072397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","407.88","305.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","319.98","78.45","","385.32","55.36","1815.62","58","203.94","319.98","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","AETNA [1001]","HB CH AETNA HMO / PPO","382.35","58.3","","554.95","91.85","1421.75","94","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","478.76","73","","2490.03","2490.03","2490.03","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","382.35","58.3","","750.00","750.00","750.00","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","347.59","53","","1192.50","120.84","4149.90","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","557.46","85","","750.00","75.00","750.00","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","655.83","100","","657.00","121.50","1971.00","14","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","655.83","100","","75.00","75.00","75.00","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","655.83","100","","366.00","144.00","1971.00","45","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","478.76","73","","667.50","667.50","667.50","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","291.52","44.45","","123.77","123.77","123.77","1 through 10","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","both","","","655.83","491.87","WELLPOINT [1015]","HB CH WELLPOINT","510.96","77.91","","483.51","229.32","1316.08","96","291.52","655.83","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.83","491.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","388.91","59.3","","439.50","225.34","1872.27","197","327.92","514.5","percent of total billed charges",""
"PIN BONE TRABECULAR METAL CALCANEUS","SUP-ITM-10235660","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","655.83","491.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","514.50","78.45","","385.32","55.36","1815.62","58","327.92","514.5","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","AETNA [1001]","HB CH AETNA HMO / PPO","666.54","58.3","","554.95","91.85","1421.75","94","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","834.61","73","","2490.03","2490.03","2490.03","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","666.54","58.3","","750.00","750.00","750.00","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","605.95","53","","1192.50","120.84","4149.90","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","971.81","85","","750.00","75.00","750.00","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1143.30","100","","657.00","121.50","1971.00","14","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1143.30","100","","75.00","75.00","75.00","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1143.30","100","","366.00","144.00","1971.00","45","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","834.61","73","","667.50","667.50","667.50","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","508.20","44.45","","123.77","123.77","123.77","1 through 10","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","both","","","1143.30","857.47","WELLPOINT [1015]","HB CH WELLPOINT","890.75","77.91","","483.51","229.32","1316.08","96","508.2","1143.3","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.30","857.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","677.98","59.3","","439.50","225.34","1872.27","197","571.65","896.92","percent of total billed charges",""
"PIN CABLE 1.8X4 14.6MM 56CM BONE PLATE ASSEMBLY READY SS","SUP-ITM-10004992","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1143.30","857.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","896.92","78.45","","385.32","55.36","1815.62","58","571.65","896.92","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","AETNA [1001]","HB CH AETNA HMO / PPO","2119.79","58.3","","554.95","91.85","1421.75","94","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2654.28","73","","2490.03","2490.03","2490.03","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2119.79","58.3","","750.00","750.00","750.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1927.08","53","","1192.50","120.84","4149.90","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3090.60","85","","750.00","75.00","750.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3636.00","100","","657.00","121.50","1971.00","14","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3636.00","100","","75.00","75.00","75.00","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3636.00","100","","366.00","144.00","1971.00","45","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2654.28","73","","667.50","667.50","667.50","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1616.20","44.45","","123.77","123.77","123.77","1 through 10","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","both","","","3636.00","2727.00","WELLPOINT [1015]","HB CH WELLPOINT","2832.81","77.91","","483.51","229.32","1316.08","96","1616.2","3636","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.00","2727.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2156.15","59.3","","439.50","225.34","1872.27","197","1818","2852.44","percent of total billed charges",""
"PIN CLAVICLE 2.5MM ASSEMBLY","SUP-ITM-10017630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3636.00","2727.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2852.44","78.45","","385.32","55.36","1815.62","58","1818","2852.44","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","AETNA [1001]","HB CH AETNA HMO / PPO","389.33","58.3","","554.95","91.85","1421.75","94","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","487.49","73","","2490.03","2490.03","2490.03","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","389.33","58.3","","750.00","750.00","750.00","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","353.93","53","","1192.50","120.84","4149.90","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","567.63","85","","750.00","75.00","750.00","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","667.80","100","","657.00","121.50","1971.00","14","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","667.80","100","","75.00","75.00","75.00","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","667.80","100","","366.00","144.00","1971.00","45","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","487.49","73","","667.50","667.50","667.50","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.84","44.45","","123.77","123.77","123.77","1 through 10","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.80","500.85","WELLPOINT [1015]","HB CH WELLPOINT","520.28","77.91","","483.51","229.32","1316.08","96","296.84","667.8","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.80","500.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","396.01","59.3","","439.50","225.34","1872.27","197","333.9","523.89","percent of total billed charges",""
"PIN COMPREHENSIVE 3.2MM 9.0IN REVERSE STEINMANN","SUP-ITM-10137828","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.80","500.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","523.89","78.45","","385.32","55.36","1815.62","58","333.9","523.89","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","554.95","91.85","1421.75","94","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","2490.03","2490.03","2490.03","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","750.00","750.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","1192.50","120.84","4149.90","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","892.50","85","","750.00","75.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1050.00","100","","657.00","121.50","1971.00","14","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1050.00","100","","75.00","75.00","75.00","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1050.00","100","","366.00","144.00","1971.00","45","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","667.50","667.50","667.50","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","123.77","123.77","123.77","1 through 10","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","483.51","229.32","1316.08","96","466.73","1050","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","439.50","225.34","1872.27","197","525","823.73","percent of total billed charges",""
"PIN COMPRESSION 1.9X22MM BONE FT SNAP-OFF","SUP-ITM-10318909","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","385.32","55.36","1815.62","58","525","823.73","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","554.95","91.85","1421.75","94","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","2490.03","2490.03","2490.03","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","750.00","750.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","1192.50","120.84","4149.90","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.25","85","","750.00","75.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.00","100","","657.00","121.50","1971.00","14","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.00","100","","75.00","75.00","75.00","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.00","100","","366.00","144.00","1971.00","45","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","667.50","667.50","667.50","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","123.77","123.77","123.77","1 through 10","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","483.51","229.32","1316.08","96","633.41","1425","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","439.50","225.34","1872.27","197","712.5","1117.91","percent of total billed charges",""
"PIN DISTRACTOR 12MM PK/10EA","SUP-ITM-10031501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","385.32","55.36","1815.62","58","712.5","1117.91","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","AETNA [1001]","HB CH AETNA HMO / PPO","91.82","58.3","","1830.28","315.58","1830.28","1 through 10","70.01","157.5","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.98","73","","4170.85","4170.85","4170.85","1 through 10","70.01","157.5","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.01","44.45","","649.55","649.55","649.55","1 through 10","70.01","157.5","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","both","","","157.50","118.12","WELLPOINT [1015]","HB CH WELLPOINT","122.71","77.91","","8998.38","2542.37","8998.38","20","70.01","157.5","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.40","59.3","","1891.61","1609.14","3664.18","25","78.75","123.56","percent of total billed charges",""
"PIN FEMORAL 1/8X3IN KNEE SS HEADLESS SQUARE END PK/4EA","SUP-ITM-10028784","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","157.50","118.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.56","78.45","","1470.68","1310.06","2481.69","19","78.75","123.56","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","AETNA [1001]","HB CH AETNA HMO / PPO","283.34","58.3","","554.95","91.85","1421.75","94","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","354.78","73","","2490.03","2490.03","2490.03","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","283.34","58.3","","750.00","750.00","750.00","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","257.58","53","","1192.50","120.84","4149.90","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","413.10","85","","750.00","75.00","750.00","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","486.00","100","","657.00","121.50","1971.00","14","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","486.00","100","","75.00","75.00","75.00","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","486.00","100","","366.00","144.00","1971.00","45","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","354.78","73","","667.50","667.50","667.50","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.03","44.45","","123.77","123.77","123.77","1 through 10","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.00","364.50","WELLPOINT [1015]","HB CH WELLPOINT","378.64","77.91","","483.51","229.32","1316.08","96","216.03","486","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.00","364.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.20","59.3","","439.50","225.34","1872.27","197","243","381.27","percent of total billed charges",""
"PIN FIXATION .125X3IN LEGEND II","SUP-ITM-10017972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.00","364.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","381.27","78.45","","385.32","55.36","1815.62","58","243","381.27","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","AETNA [1001]","HB CH AETNA HMO / PPO","60.08","58.3","","554.95","91.85","1421.75","94","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","75.23","73","","2490.03","2490.03","2490.03","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","60.08","58.3","","750.00","750.00","750.00","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","54.62","53","","1192.50","120.84","4149.90","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","87.59","85","","750.00","75.00","750.00","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","103.05","100","","657.00","121.50","1971.00","14","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","103.05","100","","75.00","75.00","75.00","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","103.05","100","","366.00","144.00","1971.00","45","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","75.23","73","","667.50","667.50","667.50","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.81","44.45","","123.77","123.77","123.77","1 through 10","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","both","","","103.05","77.29","WELLPOINT [1015]","HB CH WELLPOINT","80.29","77.91","","483.51","229.32","1316.08","96","45.81","103.05","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.11","59.3","","439.50","225.34","1872.27","197","51.53","80.84","percent of total billed charges",""
"PIN FIXATION ADULT SKULL S/S POINT O RING MAYFIELD BX/12EA","SUP-ITM-10015557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","103.05","77.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.84","78.45","","385.32","55.36","1815.62","58","51.53","80.84","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","AETNA [1001]","HB CH AETNA HMO / PPO","2008.44","58.3","","554.95","91.85","1421.75","94","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2514.85","73","","2490.03","2490.03","2490.03","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2008.44","58.3","","750.00","750.00","750.00","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1825.85","53","","1192.50","120.84","4149.90","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2928.25","85","","750.00","75.00","750.00","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3445.00","100","","657.00","121.50","1971.00","14","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3445.00","100","","75.00","75.00","75.00","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3445.00","100","","366.00","144.00","1971.00","45","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2514.85","73","","667.50","667.50","667.50","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.30","44.45","","123.77","123.77","123.77","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","WELLPOINT [1015]","HB CH WELLPOINT","2684.00","77.91","","483.51","229.32","1316.08","96","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3445.00","2583.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2042.89","59.3","","439.50","225.34","1872.27","197","1722.5","2702.6","percent of total billed charges",""
"PIN FULL 7X110MM THREADED SALVATION BEAM IMPLANT","SUP-ITM-10192892","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2702.60","78.45","","385.32","55.36","1815.62","58","1722.5","2702.6","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","AETNA [1001]","HB CH AETNA HMO / PPO","2008.44","58.3","","554.95","91.85","1421.75","94","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2514.85","73","","2490.03","2490.03","2490.03","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2008.44","58.3","","750.00","750.00","750.00","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1825.85","53","","1192.50","120.84","4149.90","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2928.25","85","","750.00","75.00","750.00","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3445.00","100","","657.00","121.50","1971.00","14","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3445.00","100","","75.00","75.00","75.00","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3445.00","100","","366.00","144.00","1971.00","45","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2514.85","73","","667.50","667.50","667.50","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.30","44.45","","123.77","123.77","123.77","1 through 10","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3445.00","2583.75","WELLPOINT [1015]","HB CH WELLPOINT","2684.00","77.91","","483.51","229.32","1316.08","96","1531.3","3445","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3445.00","2583.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2042.89","59.3","","439.50","225.34","1872.27","197","1722.5","2702.6","percent of total billed charges",""
"PIN FULL 7X125MM THREADED SALVATION","SUP-ITM-10192889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3445.00","2583.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2702.60","78.45","","385.32","55.36","1815.62","58","1722.5","2702.6","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","554.95","91.85","1421.75","94","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","2490.03","2490.03","2490.03","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","750.00","750.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","1192.50","120.84","4149.90","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.75","85","","750.00","75.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.00","100","","657.00","121.50","1971.00","14","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","135.00","100","","75.00","75.00","75.00","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.00","100","","366.00","144.00","1971.00","45","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","667.50","667.50","667.50","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","123.77","123.77","123.77","1 through 10","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","483.51","229.32","1316.08","96","60.01","135","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","439.50","225.34","1872.27","197","67.5","105.91","percent of total billed charges",""
"PIN GUIDE 2.4X508MM ROUND","SUP-ITM-10158035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","385.32","55.36","1815.62","58","67.5","105.91","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","AETNA [1001]","HB CH AETNA HMO / PPO","480.98","58.3","","1634.24","1004.95","1718.99","42","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","2123.89","1900.92","2123.89","1 through 10","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","480.98","58.3","","3729.00","1254.19","3729.00","1 through 10","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.25","53","","939.37","939.37","5593.65","1 through 10","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","701.25","85","","2323.25","1864.50","2882.25","16","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","825.00","100","","2909.44","1772.40","10952.08","45","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","825.00","100","","2323.25","2323.25","2323.25","1 through 10","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","825.00","100","","2882.25","1772.40","10169.17","187","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.25","73","","1659.41","1659.41","1659.41","1 through 10","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","both","","","825.00","618.75","WELLPOINT [1015]","HB CH WELLPOINT","642.76","77.91","","2050.91","1468.48","2902.83","52","366.71","825","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.23","59.3","","1548.60","1092.60","3613.79","82","412.5","647.21","percent of total billed charges",""
"PIN GUIDE 2.8MM NITINOL FOR GLENOID TARGETER","SUP-ITM-10275318","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","825.00","618.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.21","78.45","","2085.51","998.68","6202.11","56","412.5","647.21","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","554.95","91.85","1421.75","94","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","2490.03","2490.03","2490.03","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","750.00","750.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","1192.50","120.84","4149.90","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.90","85","","750.00","75.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","114.00","100","","657.00","121.50","1971.00","14","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","114.00","100","","75.00","75.00","75.00","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","114.00","100","","366.00","144.00","1971.00","45","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","667.50","667.50","667.50","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","123.77","123.77","123.77","1 through 10","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","483.51","229.32","1316.08","96","50.67","114","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","439.50","225.34","1872.27","197","57","89.43","percent of total billed charges",""
"PIN GUIDE 3.2MM IFUSE TI BLUNT","SUP-ITM-10209109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","385.32","55.36","1815.62","58","57","89.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","AETNA [1001]","HB CH AETNA HMO / PPO","228.79","58.3","","161.55","62.25","161.55","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","207.99","53","","52.44","22.90","505.57","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","333.57","85","","68.52","68.52","68.52","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","392.43","100","","62.20","62.19","81.17","14","174.44","392.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","392.43","100","","43.22","31.95","953.91","1 through 10","174.44","392.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","both","","","392.43","294.32","WELLPOINT [1015]","HB CH WELLPOINT","305.74","77.91","","63.92","25.16","245.73","18","174.44","392.43","percent of total billed charges",""
"PIN GUIDE 3.2X444MM BONE SS THREADED","SUP-ITM-10091548","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","392.43","294.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.86","78.45","","97.25","24.56","207.80","18","196.22","307.86","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"PIN KNEE 30MM SIZE 6-7 RIMMED SYSTEM SPEED BX/3EA","SUP-ITM-10203904","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","AETNA [1001]","HB CH AETNA HMO / PPO","10.33","58.3","","554.95","91.85","1421.75","94","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","12.94","73","","2490.03","2490.03","2490.03","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","10.33","58.3","","750.00","750.00","750.00","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","9.39","53","","1192.50","120.84","4149.90","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","15.06","85","","750.00","75.00","750.00","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","17.72","100","","657.00","121.50","1971.00","14","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","17.72","100","","75.00","75.00","75.00","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","17.72","100","","366.00","144.00","1971.00","45","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","12.94","73","","667.50","667.50","667.50","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.88","44.45","","123.77","123.77","123.77","1 through 10","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","both","","","17.72","13.29","WELLPOINT [1015]","HB CH WELLPOINT","13.81","77.91","","483.51","229.32","1316.08","96","7.88","17.72","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.72","13.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","10.51","59.3","","439.50","225.34","1872.27","197","8.86","13.9","percent of total billed charges",""
"PIN ORTHOPEDIC 2.4MM DIA 229 SMOOTH DOUBLE SHARP TIP S/S STE - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073000","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","17.72","13.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","13.90","78.45","","385.32","55.36","1815.62","58","8.86","13.9","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","AETNA [1001]","HB CH AETNA HMO / PPO","11.10","58.3","","554.95","91.85","1421.75","94","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","13.90","73","","2490.03","2490.03","2490.03","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","11.10","58.3","","750.00","750.00","750.00","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","10.09","53","","1192.50","120.84","4149.90","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","16.18","85","","750.00","75.00","750.00","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","19.04","100","","657.00","121.50","1971.00","14","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","19.04","100","","75.00","75.00","75.00","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19.04","100","","366.00","144.00","1971.00","45","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","13.90","73","","667.50","667.50","667.50","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","8.46","44.45","","123.77","123.77","123.77","1 through 10","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","both","","","19.04","14.28","WELLPOINT [1015]","HB CH WELLPOINT","14.83","77.91","","483.51","229.32","1316.08","96","8.46","19.04","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.04","14.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","11.29","59.3","","439.50","225.34","1872.27","197","9.52","14.94","percent of total billed charges",""
"PIN ORTHOPEDIC 3.2MMX229 SMOOTH DOUBLE SHARP TIP S/S STEINMA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10073002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","19.04","14.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","14.94","78.45","","385.32","55.36","1815.62","58","9.52","14.94","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","AETNA [1001]","HB CH AETNA HMO / PPO","358.55","58.3","","554.95","91.85","1421.75","94","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","448.95","73","","2490.03","2490.03","2490.03","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","358.55","58.3","","750.00","750.00","750.00","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","325.95","53","","1192.50","120.84","4149.90","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","522.75","85","","750.00","75.00","750.00","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","615.00","100","","657.00","121.50","1971.00","14","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","615.00","100","","75.00","75.00","75.00","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","615.00","100","","366.00","144.00","1971.00","45","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","448.95","73","","667.50","667.50","667.50","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","273.37","44.45","","123.77","123.77","123.77","1 through 10","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","WELLPOINT [1015]","HB CH WELLPOINT","479.15","77.91","","483.51","229.32","1316.08","96","273.37","615","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","615.00","461.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","364.70","59.3","","439.50","225.34","1872.27","197","307.5","482.47","percent of total billed charges",""
"PIN RADIAL PLATE LOCKING","SUP-ITM-10188478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","615.00","461.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","482.47","78.45","","385.32","55.36","1815.62","58","307.5","482.47","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"PIN RIMMED MIS 3.2MMX45MM STERILE","SUP-ITM-10320397","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","554.95","91.85","1421.75","94","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","2490.03","2490.03","2490.03","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","750.00","750.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","1192.50","120.84","4149.90","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","153.00","85","","750.00","75.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","180.00","100","","657.00","121.50","1971.00","14","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","180.00","100","","75.00","75.00","75.00","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","180.00","100","","366.00","144.00","1971.00","45","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","667.50","667.50","667.50","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","123.77","123.77","123.77","1 through 10","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","483.51","229.32","1316.08","96","80.01","180","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","439.50","225.34","1872.27","197","90","141.21","percent of total billed charges",""
"PIN SE FIXATION TRESTLE LUXE SS TEMPORARY","SUP-ITM-10108727","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","385.32","55.36","1815.62","58","90","141.21","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","AETNA [1001]","HB CH AETNA HMO / PPO","46.64","58.3","","554.95","91.85","1421.75","94","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","58.40","73","","2490.03","2490.03","2490.03","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.64","58.3","","750.00","750.00","750.00","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.40","53","","1192.50","120.84","4149.90","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","68.00","85","","750.00","75.00","750.00","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","80.00","100","","657.00","121.50","1971.00","14","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","80.00","100","","75.00","75.00","75.00","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","80.00","100","","366.00","144.00","1971.00","45","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.40","73","","667.50","667.50","667.50","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.56","44.45","","123.77","123.77","123.77","1 through 10","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.00","60.00","WELLPOINT [1015]","HB CH WELLPOINT","62.33","77.91","","483.51","229.32","1316.08","96","35.56","80","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.00","60.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.44","59.3","","439.50","225.34","1872.27","197","40","62.76","percent of total billed charges",""
"PIN SPEED 45MM RIMMED BX/3EA","SUP-ITM-10203901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.00","60.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","62.76","78.45","","385.32","55.36","1815.62","58","40","62.76","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","AETNA [1001]","HB CH AETNA HMO / PPO","83.95","58.3","","554.95","91.85","1421.75","94","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","105.12","73","","2490.03","2490.03","2490.03","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","83.95","58.3","","750.00","750.00","750.00","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.32","53","","1192.50","120.84","4149.90","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","122.40","85","","750.00","75.00","750.00","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","144.00","100","","657.00","121.50","1971.00","14","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","144.00","100","","75.00","75.00","75.00","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","144.00","100","","366.00","144.00","1971.00","45","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.12","73","","667.50","667.50","667.50","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.01","44.45","","123.77","123.77","123.77","1 through 10","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.00","108.00","WELLPOINT [1015]","HB CH WELLPOINT","112.19","77.91","","483.51","229.32","1316.08","96","64.01","144","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.00","108.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.39","59.3","","439.50","225.34","1872.27","197","72","112.97","percent of total billed charges",""
"PIN STEINMAN 1/8X12IN TROCAR POINT PL SHANK","SUP-ITM-10028033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.00","108.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.97","78.45","","385.32","55.36","1815.62","58","72","112.97","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","AETNA [1001]","HB CH AETNA HMO / PPO","156.15","58.3","","554.95","91.85","1421.75","94","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","195.52","73","","2490.03","2490.03","2490.03","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.15","58.3","","750.00","750.00","750.00","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.96","53","","1192.50","120.84","4149.90","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","227.66","85","","750.00","75.00","750.00","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","267.84","100","","657.00","121.50","1971.00","14","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","267.84","100","","75.00","75.00","75.00","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","267.84","100","","366.00","144.00","1971.00","45","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.52","73","","667.50","667.50","667.50","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.05","44.45","","123.77","123.77","123.77","1 through 10","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.84","200.88","WELLPOINT [1015]","HB CH WELLPOINT","208.67","77.91","","483.51","229.32","1316.08","96","119.05","267.84","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.84","200.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.83","59.3","","439.50","225.34","1872.27","197","133.92","210.12","percent of total billed charges",""
"PIN TRANSFIXATION 6.0X225MM BONE SS CENTRAL THREAD","SUP-ITM-10004094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.84","200.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.12","78.45","","385.32","55.36","1815.62","58","133.92","210.12","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","AETNA [1001]","HB CH AETNA HMO / PPO","507.21","58.3","","554.95","91.85","1421.75","94","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","2490.03","2490.03","2490.03","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","507.21","58.3","","750.00","750.00","750.00","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","461.10","53","","1192.50","120.84","4149.90","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","739.50","85","","750.00","75.00","750.00","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","870.00","100","","657.00","121.50","1971.00","14","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","870.00","100","","75.00","75.00","75.00","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","870.00","100","","366.00","144.00","1971.00","45","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","635.10","73","","667.50","667.50","667.50","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","386.72","44.45","","123.77","123.77","123.77","1 through 10","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","both","","","870.00","652.50","WELLPOINT [1015]","HB CH WELLPOINT","677.82","77.91","","483.51","229.32","1316.08","96","386.72","870","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","515.91","59.3","","439.50","225.34","1872.27","197","435","682.52","percent of total billed charges",""
"PIN WRIST 27MM TRIMED BUTTRESS","SUP-ITM-10005624","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","870.00","652.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","682.52","78.45","","385.32","55.36","1815.62","58","435","682.52","percent of total billed charges",""
"Place Cath Abd/Pel/Lwr Ext 1st","PX-76001049","CDM","36245","CPT","0361","RC","","","","both","","","4760.00","3570.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2775.08","58.3","","2624.64","2624.64","2624.64","1 through 10","2042.04","3708.52","percent of total billed charges",""
"Place Cath Thor/Brachio 1st Order","PX-76001045","CDM","36215","CPT","0361","RC","","","","both","","","5925.00","4443.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3140.25","53","","3053.33","3053.33","3053.33","1 through 10","3140.25","4616.17","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","both","","","3708.00","2781.00","AETNA [1001]","HB CH AETNA HMO / PPO","2161.76","58.3","","2343.98","2343.98","2343.98","1 through 10","1590.73","2888.9","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3708.00","2781.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1819.52","49.07","","3775.00","3775.00","3775.00","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3708.00","2781.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1857.71","50.1","","3860.43","3780.34","3860.43","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Placement of Seton","PX-36000475","CDM","46020","CPT","0361","RC","","","","outpatient","","","3708.00","2781.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2198.84","59.3","","4845.05","4845.05","4845.05","1 through 10","1483.2","2908.93","percent of total billed charges",""
"Plasma Frozen 8 to 24","PX-39000032","CDM","P9059","HCPCS","0390","RC","","","","both","","","510.00","382.50","MEDICARE [2001]","HB BWF MEDICARE","71.09","","APC Price ($71.09). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","71.09","71.09","71.09","1 through 10","67.54","485.01","other","OPPS APC"
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","AETNA [1001]","HB CH AETNA HMO / PPO","1215.56","58.3","","554.95","91.85","1421.75","94","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1522.05","73","","2490.03","2490.03","2490.03","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1215.56","58.3","","750.00","750.00","750.00","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1105.05","53","","1192.50","120.84","4149.90","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1772.25","85","","750.00","75.00","750.00","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2085.00","100","","657.00","121.50","1971.00","14","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2085.00","100","","75.00","75.00","75.00","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2085.00","100","","366.00","144.00","1971.00","45","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1522.05","73","","667.50","667.50","667.50","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.78","44.45","","123.77","123.77","123.77","1 through 10","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","WELLPOINT [1015]","HB CH WELLPOINT","1624.42","77.91","","483.51","229.32","1316.08","96","926.78","2085","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1236.41","59.3","","439.50","225.34","1872.27","197","1042.5","1635.68","percent of total billed charges",""
"PLATE 2.4MM SM 4 HOLE FOOT TITANIUMXSHAPE","SUP-ITM-10115917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1635.68","78.45","","385.32","55.36","1815.62","58","1042.5","1635.68","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","AETNA [1001]","HB CH AETNA HMO / PPO","2131.59","58.3","","554.95","91.85","1421.75","94","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","2490.03","2490.03","2490.03","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.59","58.3","","750.00","750.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1937.81","53","","1192.50","120.84","4149.90","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3107.81","85","","750.00","75.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3656.25","100","","657.00","121.50","1971.00","14","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3656.25","100","","75.00","75.00","75.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3656.25","100","","366.00","144.00","1971.00","45","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","667.50","667.50","667.50","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.20","44.45","","123.77","123.77","123.77","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","WELLPOINT [1015]","HB CH WELLPOINT","2848.58","77.91","","483.51","229.32","1316.08","96","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.16","59.3","","439.50","225.34","1872.27","197","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.1MM","SUP-ITM-10241564","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","385.32","55.36","1815.62","58","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","AETNA [1001]","HB CH AETNA HMO / PPO","2131.59","58.3","","554.95","91.85","1421.75","94","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","2490.03","2490.03","2490.03","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.59","58.3","","750.00","750.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1937.81","53","","1192.50","120.84","4149.90","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3107.81","85","","750.00","75.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3656.25","100","","657.00","121.50","1971.00","14","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3656.25","100","","75.00","75.00","75.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3656.25","100","","366.00","144.00","1971.00","45","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","667.50","667.50","667.50","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.20","44.45","","123.77","123.77","123.77","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","WELLPOINT [1015]","HB CH WELLPOINT","2848.58","77.91","","483.51","229.32","1316.08","96","1625.2","3656.25","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.16","59.3","","439.50","225.34","1872.27","197","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 15MM 2-HOLE LOCKING 1.5MM","SUP-ITM-10241561","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","385.32","55.36","1815.62","58","1828.13","2868.33","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","AETNA [1001]","HB CH AETNA HMO / PPO","2245.28","58.3","","554.95","91.85","1421.75","94","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2811.41","73","","2490.03","2490.03","2490.03","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2245.28","58.3","","750.00","750.00","750.00","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2041.16","53","","1192.50","120.84","4149.90","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3273.56","85","","750.00","75.00","750.00","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3851.25","100","","657.00","121.50","1971.00","14","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3851.25","100","","75.00","75.00","75.00","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3851.25","100","","366.00","144.00","1971.00","45","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2811.41","73","","667.50","667.50","667.50","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1711.88","44.45","","123.77","123.77","123.77","1 through 10","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","both","","","3851.25","2888.44","WELLPOINT [1015]","HB CH WELLPOINT","3000.51","77.91","","483.51","229.32","1316.08","96","1711.88","3851.25","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.25","2888.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2283.79","59.3","","439.50","225.34","1872.27","197","1925.63","3021.31","percent of total billed charges",""
"PLATE 28 STRAIGHT 4-HOLE LOCKING 1.5MM","SUP-ITM-10241552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3851.25","2888.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3021.31","78.45","","385.32","55.36","1815.62","58","1925.63","3021.31","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","554.95","91.85","1421.75","94","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2490.03","2490.03","2490.03","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","750.00","750.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","1192.50","120.84","4149.90","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","750.00","75.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","657.00","121.50","1971.00","14","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","75.00","75.00","75.00","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","366.00","144.00","1971.00","45","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","667.50","667.50","667.50","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","123.77","123.77","123.77","1 through 10","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","483.51","229.32","1316.08","96","1066.8","2400","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","439.50","225.34","1872.27","197","1200","1882.8","percent of total billed charges",""
"PLATE 3.0MM 5 HOLE FOOT TITANIUM STRAIGHT LOW PROFILE","SUP-ITM-10154379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","385.32","55.36","1815.62","58","1200","1882.8","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","AETNA [1001]","HB CH AETNA HMO / PPO","209.88","58.3","","554.95","91.85","1421.75","94","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","262.80","73","","2490.03","2490.03","2490.03","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.88","58.3","","750.00","750.00","750.00","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.80","53","","1192.50","120.84","4149.90","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","306.00","85","","750.00","75.00","750.00","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","360.00","100","","657.00","121.50","1971.00","14","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","360.00","100","","75.00","75.00","75.00","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","360.00","100","","366.00","144.00","1971.00","45","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.80","73","","667.50","667.50","667.50","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.02","44.45","","123.77","123.77","123.77","1 through 10","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.00","270.00","WELLPOINT [1015]","HB CH WELLPOINT","280.48","77.91","","483.51","229.32","1316.08","96","160.02","360","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.00","270.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","213.48","59.3","","439.50","225.34","1872.27","197","180","282.42","percent of total billed charges",""
"PLATE 7 HOLE FOOT THIRD SS STRAIGHT TUBULAR NONLOCKING","SUP-ITM-10154267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.00","270.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","282.42","78.45","","385.32","55.36","1815.62","58","180","282.42","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","AETNA [1001]","HB CH AETNA HMO / PPO","1421.06","58.3","","554.95","91.85","1421.75","94","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1779.38","73","","2490.03","2490.03","2490.03","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1421.06","58.3","","750.00","750.00","750.00","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1291.88","53","","1192.50","120.84","4149.90","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2071.88","85","","750.00","75.00","750.00","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2437.50","100","","657.00","121.50","1971.00","14","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2437.50","100","","75.00","75.00","75.00","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2437.50","100","","366.00","144.00","1971.00","45","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1779.38","73","","667.50","667.50","667.50","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1083.47","44.45","","123.77","123.77","123.77","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","WELLPOINT [1015]","HB CH WELLPOINT","1899.06","77.91","","483.51","229.32","1316.08","96","1083.47","2437.5","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1445.44","59.3","","439.50","225.34","1872.27","197","1218.75","1912.22","percent of total billed charges",""
"PLATE AKIN MEDIAL ANATOMIC 10MM","SUP-ITM-10241633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1912.22","78.45","","385.32","55.36","1815.62","58","1218.75","1912.22","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","AETNA [1001]","HB CH AETNA HMO / PPO","2264.48","58.3","","554.95","91.85","1421.75","94","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2835.46","73","","2490.03","2490.03","2490.03","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2264.48","58.3","","750.00","750.00","750.00","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2058.62","53","","1192.50","120.84","4149.90","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3301.56","85","","750.00","75.00","750.00","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3884.19","100","","657.00","121.50","1971.00","14","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3884.19","100","","75.00","75.00","75.00","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3884.19","100","","366.00","144.00","1971.00","45","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2835.46","73","","667.50","667.50","667.50","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.52","44.45","","123.77","123.77","123.77","1 through 10","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","both","","","3884.19","2913.14","WELLPOINT [1015]","HB CH WELLPOINT","3026.17","77.91","","483.51","229.32","1316.08","96","1726.52","3884.19","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3884.19","2913.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","2303.32","59.3","","439.50","225.34","1872.27","197","1942.1","3047.15","percent of total billed charges",""
"PLATE ANKLE 112MM 4 HOLE 2.7/3.5MM VA LCP SS MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3884.19","2913.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3047.15","78.45","","385.32","55.36","1815.62","58","1942.1","3047.15","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","AETNA [1001]","HB CH AETNA HMO / PPO","1946.61","58.3","","554.95","91.85","1421.75","94","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2437.43","73","","2490.03","2490.03","2490.03","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1946.61","58.3","","750.00","750.00","750.00","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1769.64","53","","1192.50","120.84","4149.90","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2838.11","85","","750.00","75.00","750.00","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3338.95","100","","657.00","121.50","1971.00","14","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3338.95","100","","75.00","75.00","75.00","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3338.95","100","","366.00","144.00","1971.00","45","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2437.43","73","","667.50","667.50","667.50","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1484.16","44.45","","123.77","123.77","123.77","1 through 10","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3338.95","2504.21","WELLPOINT [1015]","HB CH WELLPOINT","2601.38","77.91","","483.51","229.32","1316.08","96","1484.16","3338.95","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3338.95","2504.21","CIGNA [1006]","HB CH CIGNA HMO / PPO","1980.00","59.3","","439.50","225.34","1872.27","197","1669.48","2619.41","percent of total billed charges",""
"PLATE ANKLE 202MM 10 HOLE 2.7/3.5MM VA LCP SS 2.7/3.5MM VARIABLE ANGLE MEDIAL DISTAL TIBA RIGHT","SUP-ITM-10124937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3338.95","2504.21","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2619.41","78.45","","385.32","55.36","1815.62","58","1669.48","2619.41","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","AETNA [1001]","HB CH AETNA HMO / PPO","322.27","58.3","","554.95","91.85","1421.75","94","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","403.53","73","","2490.03","2490.03","2490.03","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","322.27","58.3","","750.00","750.00","750.00","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","292.97","53","","1192.50","120.84","4149.90","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","469.86","85","","750.00","75.00","750.00","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","552.78","100","","657.00","121.50","1971.00","14","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","552.78","100","","75.00","75.00","75.00","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","552.78","100","","366.00","144.00","1971.00","45","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","403.53","73","","667.50","667.50","667.50","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","245.71","44.45","","123.77","123.77","123.77","1 through 10","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","both","","","552.78","414.58","WELLPOINT [1015]","HB CH WELLPOINT","430.67","77.91","","483.51","229.32","1316.08","96","245.71","552.78","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.78","414.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","327.80","59.3","","439.50","225.34","1872.27","197","276.39","433.66","percent of total billed charges",""
"PLATE ANKLE 2X31MM 4 HOLE LCP SS STRAIGHT","SUP-ITM-10022820","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","552.78","414.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","433.66","78.45","","385.32","55.36","1815.62","58","276.39","433.66","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","AETNA [1001]","HB CH AETNA HMO / PPO","6102.84","58.3","","554.95","91.85","1421.75","94","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","7641.64","73","","2490.03","2490.03","2490.03","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6102.84","58.3","","750.00","750.00","750.00","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5548.04","53","","1192.50","120.84","4149.90","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","8897.80","85","","750.00","75.00","750.00","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10468.00","100","","657.00","121.50","1971.00","14","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","10468.00","100","","75.00","75.00","75.00","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","10468.00","100","","366.00","144.00","1971.00","45","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","7641.64","73","","667.50","667.50","667.50","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4653.03","44.45","","123.77","123.77","123.77","1 through 10","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","both","","","10468.00","7851.00","WELLPOINT [1015]","HB CH WELLPOINT","8155.62","77.91","","483.51","229.32","1316.08","96","4653.03","10468","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10468.00","7851.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","6207.52","59.3","","439.50","225.34","1872.27","197","5234","8212.15","percent of total billed charges",""
"PLATE ASSEMBLY 13MM SZ 10 EM DISTAL RADIO ULNAR JOINT LOCKING","SUP-ITM-10188479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","10468.00","7851.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8212.15","78.45","","385.32","55.36","1815.62","58","5234","8212.15","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","AETNA [1001]","HB CH AETNA HMO / PPO","631.60","58.3","","554.95","91.85","1421.75","94","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","790.85","73","","2490.03","2490.03","2490.03","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","631.60","58.3","","750.00","750.00","750.00","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","574.18","53","","1192.50","120.84","4149.90","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","920.86","85","","750.00","75.00","750.00","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1083.36","100","","657.00","121.50","1971.00","14","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1083.36","100","","75.00","75.00","75.00","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1083.36","100","","366.00","144.00","1971.00","45","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","790.85","73","","667.50","667.50","667.50","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","481.55","44.45","","123.77","123.77","123.77","1 through 10","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","both","","","1083.36","812.52","WELLPOINT [1015]","HB CH WELLPOINT","844.05","77.91","","483.51","229.32","1316.08","96","481.55","1083.36","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.36","812.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","642.43","59.3","","439.50","225.34","1872.27","197","541.68","849.9","percent of total billed charges",""
"PLATE BONE 1.5MM 2 HOLE HEAD 6 HOLE SHAFT VAL CONDYLAR","SUP-ITM-10164622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1083.36","812.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.90","78.45","","385.32","55.36","1815.62","58","541.68","849.9","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","AETNA [1001]","HB CH AETNA HMO / PPO","335.86","58.3","","554.95","91.85","1421.75","94","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","420.55","73","","2490.03","2490.03","2490.03","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","335.86","58.3","","750.00","750.00","750.00","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","305.33","53","","1192.50","120.84","4149.90","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","489.68","85","","750.00","75.00","750.00","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","576.09","100","","657.00","121.50","1971.00","14","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","576.09","100","","75.00","75.00","75.00","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","576.09","100","","366.00","144.00","1971.00","45","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","420.55","73","","667.50","667.50","667.50","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.07","44.45","","123.77","123.77","123.77","1 through 10","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","both","","","576.09","432.07","WELLPOINT [1015]","HB CH WELLPOINT","448.83","77.91","","483.51","229.32","1316.08","96","256.07","576.09","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","576.09","432.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","341.62","59.3","","439.50","225.34","1872.27","197","288.05","451.94","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE LCP SS GUIDE","SUP-ITM-10095122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","576.09","432.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","451.94","78.45","","385.32","55.36","1815.62","58","288.05","451.94","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","AETNA [1001]","HB CH AETNA HMO / PPO","553.94","58.3","","554.95","91.85","1421.75","94","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","693.62","73","","2490.03","2490.03","2490.03","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","553.94","58.3","","750.00","750.00","750.00","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","503.58","53","","1192.50","120.84","4149.90","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","807.64","85","","750.00","75.00","750.00","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","950.16","100","","657.00","121.50","1971.00","14","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","950.16","100","","75.00","75.00","75.00","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","950.16","100","","366.00","144.00","1971.00","45","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","693.62","73","","667.50","667.50","667.50","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","422.35","44.45","","123.77","123.77","123.77","1 through 10","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","both","","","950.16","712.62","WELLPOINT [1015]","HB CH WELLPOINT","740.27","77.91","","483.51","229.32","1316.08","96","422.35","950.16","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.16","712.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","563.44","59.3","","439.50","225.34","1872.27","197","475.08","745.4","percent of total billed charges",""
"PLATE BONE 1.5MM 6 HOLE VARIABLE ANGLE LOCKING SS STRAIGHT","SUP-ITM-10164627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","950.16","712.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","745.40","78.45","","385.32","55.36","1815.62","58","475.08","745.4","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","AETNA [1001]","HB CH AETNA HMO / PPO","598.60","58.3","","554.95","91.85","1421.75","94","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","749.53","73","","2490.03","2490.03","2490.03","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","598.60","58.3","","750.00","750.00","750.00","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","544.18","53","","1192.50","120.84","4149.90","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","872.74","85","","750.00","75.00","750.00","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1026.75","100","","657.00","121.50","1971.00","14","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1026.75","100","","75.00","75.00","75.00","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1026.75","100","","366.00","144.00","1971.00","45","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","749.53","73","","667.50","667.50","667.50","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","456.39","44.45","","123.77","123.77","123.77","1 through 10","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","both","","","1026.75","770.06","WELLPOINT [1015]","HB CH WELLPOINT","799.94","77.91","","483.51","229.32","1316.08","96","456.39","1026.75","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.75","770.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","608.86","59.3","","439.50","225.34","1872.27","197","513.38","805.49","percent of total billed charges",""
"PLATE BONE 1.5X22MM 8 HOLE SS H SHAPE EXTENDED RIGHT","SUP-ITM-10038133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1026.75","770.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","805.49","78.45","","385.32","55.36","1815.62","58","513.38","805.49","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","AETNA [1001]","HB CH AETNA HMO / PPO","557.83","58.3","","554.95","91.85","1421.75","94","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","698.48","73","","2490.03","2490.03","2490.03","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","557.83","58.3","","750.00","750.00","750.00","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","507.11","53","","1192.50","120.84","4149.90","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","813.30","85","","750.00","75.00","750.00","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","956.82","100","","657.00","121.50","1971.00","14","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","956.82","100","","75.00","75.00","75.00","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","956.82","100","","366.00","144.00","1971.00","45","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","698.48","73","","667.50","667.50","667.50","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","425.31","44.45","","123.77","123.77","123.77","1 through 10","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","both","","","956.82","717.61","WELLPOINT [1015]","HB CH WELLPOINT","745.46","77.91","","483.51","229.32","1316.08","96","425.31","956.82","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.82","717.61","CIGNA [1006]","HB CH CIGNA HMO / PPO","567.39","59.3","","439.50","225.34","1872.27","197","478.41","750.63","percent of total billed charges",""
"PLATE BONE 1.5X29MM 6 HOLE SS STRAIGHT","SUP-ITM-10038128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","956.82","717.61","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","750.63","78.45","","385.32","55.36","1815.62","58","478.41","750.63","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","AETNA [1001]","HB CH AETNA HMO / PPO","601.18","58.3","","554.95","91.85","1421.75","94","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","752.77","73","","2490.03","2490.03","2490.03","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","601.18","58.3","","750.00","750.00","750.00","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","546.53","53","","1192.50","120.84","4149.90","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","876.51","85","","750.00","75.00","750.00","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1031.19","100","","657.00","121.50","1971.00","14","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1031.19","100","","75.00","75.00","75.00","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1031.19","100","","366.00","144.00","1971.00","45","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","752.77","73","","667.50","667.50","667.50","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","458.36","44.45","","123.77","123.77","123.77","1 through 10","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","both","","","1031.19","773.39","WELLPOINT [1015]","HB CH WELLPOINT","803.40","77.91","","483.51","229.32","1316.08","96","458.36","1031.19","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.19","773.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","611.50","59.3","","439.50","225.34","1872.27","197","515.6","808.97","percent of total billed charges",""
"PLATE BONE 1.5X40MM 3 HOLE HD 8 SHAFT T SHAPE MODULAR HAND SYSTEM TITANIUM","SUP-ITM-10006088","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1031.19","773.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","808.97","78.45","","385.32","55.36","1815.62","58","515.6","808.97","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","AETNA [1001]","HB CH AETNA HMO / PPO","547.47","58.3","","554.95","91.85","1421.75","94","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","685.51","73","","2490.03","2490.03","2490.03","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","547.47","58.3","","750.00","750.00","750.00","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","497.70","53","","1192.50","120.84","4149.90","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","798.20","85","","750.00","75.00","750.00","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","939.06","100","","657.00","121.50","1971.00","14","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","939.06","100","","75.00","75.00","75.00","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","939.06","100","","366.00","144.00","1971.00","45","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","685.51","73","","667.50","667.50","667.50","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","417.41","44.45","","123.77","123.77","123.77","1 through 10","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","both","","","939.06","704.29","WELLPOINT [1015]","HB CH WELLPOINT","731.62","77.91","","483.51","229.32","1316.08","96","417.41","939.06","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.06","704.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","556.86","59.3","","439.50","225.34","1872.27","197","469.53","736.69","percent of total billed charges",""
"PLATE BONE 1.5X44MM 4 8 HOLE SS T SHAPE","SUP-ITM-10038131","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","939.06","704.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","736.69","78.45","","385.32","55.36","1815.62","58","469.53","736.69","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","AETNA [1001]","HB CH AETNA HMO / PPO","2363.70","58.3","","554.95","91.85","1421.75","94","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","2490.03","2490.03","2490.03","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2363.70","58.3","","750.00","750.00","750.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2148.82","53","","1192.50","120.84","4149.90","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3446.22","85","","750.00","75.00","750.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4054.38","100","","657.00","121.50","1971.00","14","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4054.38","100","","75.00","75.00","75.00","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4054.38","100","","366.00","144.00","1971.00","45","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2959.70","73","","667.50","667.50","667.50","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1802.17","44.45","","123.77","123.77","123.77","1 through 10","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","both","","","4054.38","3040.78","WELLPOINT [1015]","HB CH WELLPOINT","3158.77","77.91","","483.51","229.32","1316.08","96","1802.17","4054.38","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2404.25","59.3","","439.50","225.34","1872.27","197","2027.19","3180.66","percent of total billed charges",""
"PLATE BONE 11 HOLE RT FIBULAR CLUSTER ANATOMICAL","SUP-ITM-10232315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4054.38","3040.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3180.66","78.45","","385.32","55.36","1815.62","58","2027.19","3180.66","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","AETNA [1001]","HB CH AETNA HMO / PPO","427.75","58.3","","554.95","91.85","1421.75","94","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","535.61","73","","2490.03","2490.03","2490.03","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","427.75","58.3","","750.00","750.00","750.00","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","388.87","53","","1192.50","120.84","4149.90","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","623.65","85","","750.00","75.00","750.00","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","733.71","100","","657.00","121.50","1971.00","14","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","733.71","100","","75.00","75.00","75.00","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","733.71","100","","366.00","144.00","1971.00","45","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","535.61","73","","667.50","667.50","667.50","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","326.13","44.45","","123.77","123.77","123.77","1 through 10","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","both","","","733.71","550.28","WELLPOINT [1015]","HB CH WELLPOINT","571.63","77.91","","483.51","229.32","1316.08","96","326.13","733.71","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.71","550.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","435.09","59.3","","439.50","225.34","1872.27","197","366.86","575.6","percent of total billed charges",""
"PLATE BONE 111X3.5MM 8 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","733.71","550.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","575.60","78.45","","385.32","55.36","1815.62","58","366.86","575.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","AETNA [1001]","HB CH AETNA HMO / PPO","685.96","58.3","","554.95","91.85","1421.75","94","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","858.92","73","","2490.03","2490.03","2490.03","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","685.96","58.3","","750.00","750.00","750.00","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","623.60","53","","1192.50","120.84","4149.90","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1000.11","85","","750.00","75.00","750.00","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1176.60","100","","657.00","121.50","1971.00","14","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1176.60","100","","75.00","75.00","75.00","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1176.60","100","","366.00","144.00","1971.00","45","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","858.92","73","","667.50","667.50","667.50","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","523.00","44.45","","123.77","123.77","123.77","1 through 10","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","both","","","1176.60","882.45","WELLPOINT [1015]","HB CH WELLPOINT","916.69","77.91","","483.51","229.32","1316.08","96","523","1176.6","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1176.60","882.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","697.72","59.3","","439.50","225.34","1872.27","197","588.3","923.04","percent of total billed charges",""
"PLATE BONE 112X3.5MM 8 HOLE LCP SS RECONSTRUCTION","SUP-ITM-10008263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1176.60","882.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","923.04","78.45","","385.32","55.36","1815.62","58","588.3","923.04","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","AETNA [1001]","HB CH AETNA HMO / PPO","236.85","58.3","","554.95","91.85","1421.75","94","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","296.57","73","","2490.03","2490.03","2490.03","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","236.85","58.3","","750.00","750.00","750.00","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","215.32","53","","1192.50","120.84","4149.90","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","345.32","85","","750.00","75.00","750.00","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","406.26","100","","657.00","121.50","1971.00","14","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","406.26","100","","75.00","75.00","75.00","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","406.26","100","","366.00","144.00","1971.00","45","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","296.57","73","","667.50","667.50","667.50","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.58","44.45","","123.77","123.77","123.77","1 through 10","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","both","","","406.26","304.69","WELLPOINT [1015]","HB CH WELLPOINT","316.52","77.91","","483.51","229.32","1316.08","96","180.58","406.26","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.26","304.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.91","59.3","","439.50","225.34","1872.27","197","203.13","318.71","percent of total billed charges",""
"PLATE BONE 117X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR LCP SS","SUP-ITM-10008399","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","406.26","304.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","318.71","78.45","","385.32","55.36","1815.62","58","203.13","318.71","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","AETNA [1001]","HB CH AETNA HMO / PPO","238.14","58.3","","554.95","91.85","1421.75","94","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","298.19","73","","2490.03","2490.03","2490.03","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","238.14","58.3","","750.00","750.00","750.00","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","216.49","53","","1192.50","120.84","4149.90","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","347.21","85","","750.00","75.00","750.00","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","408.48","100","","657.00","121.50","1971.00","14","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","408.48","100","","75.00","75.00","75.00","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","408.48","100","","366.00","144.00","1971.00","45","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","298.19","73","","667.50","667.50","667.50","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","181.57","44.45","","123.77","123.77","123.77","1 through 10","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","both","","","408.48","306.36","WELLPOINT [1015]","HB CH WELLPOINT","318.25","77.91","","483.51","229.32","1316.08","96","181.57","408.48","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.48","306.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","242.23","59.3","","439.50","225.34","1872.27","197","204.24","320.45","percent of total billed charges",""
"PLATE BONE 121X3.5MM 10 HOLE TUBULAR ONE THIRD WITH COLLAR SS","SUP-ITM-10012409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","408.48","306.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","320.45","78.45","","385.32","55.36","1815.62","58","204.24","320.45","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","AETNA [1001]","HB CH AETNA HMO / PPO","454.93","58.3","","554.95","91.85","1421.75","94","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","569.64","73","","2490.03","2490.03","2490.03","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","454.93","58.3","","750.00","750.00","750.00","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.57","53","","1192.50","120.84","4149.90","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","663.28","85","","750.00","75.00","750.00","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","780.33","100","","657.00","121.50","1971.00","14","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","780.33","100","","75.00","75.00","75.00","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","780.33","100","","366.00","144.00","1971.00","45","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","569.64","73","","667.50","667.50","667.50","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","346.86","44.45","","123.77","123.77","123.77","1 through 10","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","both","","","780.33","585.25","WELLPOINT [1015]","HB CH WELLPOINT","607.96","77.91","","483.51","229.32","1316.08","96","346.86","780.33","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.33","585.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.74","59.3","","439.50","225.34","1872.27","197","390.17","612.17","percent of total billed charges",""
"PLATE BONE 124X3.5MM 9 HOLE LCP SS LOCKING STRAIGHT BX/2EA","SUP-ITM-10008259","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","780.33","585.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","612.17","78.45","","385.32","55.36","1815.62","58","390.17","612.17","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","AETNA [1001]","HB CH AETNA HMO / PPO","570.12","58.3","","554.95","91.85","1421.75","94","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","713.87","73","","2490.03","2490.03","2490.03","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","570.12","58.3","","750.00","750.00","750.00","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.29","53","","1192.50","120.84","4149.90","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","831.22","85","","750.00","75.00","750.00","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","977.91","100","","657.00","121.50","1971.00","14","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","977.91","100","","75.00","75.00","75.00","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","977.91","100","","366.00","144.00","1971.00","45","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.87","73","","667.50","667.50","667.50","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.68","44.45","","123.77","123.77","123.77","1 through 10","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","both","","","977.91","733.43","WELLPOINT [1015]","HB CH WELLPOINT","761.89","77.91","","483.51","229.32","1316.08","96","434.68","977.91","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","977.91","733.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.90","59.3","","439.50","225.34","1872.27","197","488.96","767.17","percent of total billed charges",""
"PLATE BONE 134X4.5MM 7 HOLE LCP SS NARROW CS/1EA","SUP-ITM-10010847","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","977.91","733.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.17","78.45","","385.32","55.36","1815.62","58","488.96","767.17","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","AETNA [1001]","HB CH AETNA HMO / PPO","242.67","58.3","","554.95","91.85","1421.75","94","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","303.86","73","","2490.03","2490.03","2490.03","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","242.67","58.3","","750.00","750.00","750.00","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","220.61","53","","1192.50","120.84","4149.90","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","353.81","85","","750.00","75.00","750.00","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","416.25","100","","657.00","121.50","1971.00","14","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","416.25","100","","75.00","75.00","75.00","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","416.25","100","","366.00","144.00","1971.00","45","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","303.86","73","","667.50","667.50","667.50","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","185.02","44.45","","123.77","123.77","123.77","1 through 10","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","both","","","416.25","312.19","WELLPOINT [1015]","HB CH WELLPOINT","324.30","77.91","","483.51","229.32","1316.08","96","185.02","416.25","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.25","312.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","246.84","59.3","","439.50","225.34","1872.27","197","208.13","326.55","percent of total billed charges",""
"PLATE BONE 141X3.5MM 12 HOLE TUBULAR ONE THIRD COLLAR LCP SS","SUP-ITM-10009795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","416.25","312.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","326.55","78.45","","385.32","55.36","1815.62","58","208.13","326.55","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","AETNA [1001]","HB CH AETNA HMO / PPO","2161.59","58.3","","554.95","91.85","1421.75","94","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2706.62","73","","2490.03","2490.03","2490.03","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2161.59","58.3","","750.00","750.00","750.00","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1965.08","53","","1192.50","120.84","4149.90","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3151.55","85","","750.00","75.00","750.00","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3707.70","100","","657.00","121.50","1971.00","14","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3707.70","100","","75.00","75.00","75.00","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3707.70","100","","366.00","144.00","1971.00","45","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2706.62","73","","667.50","667.50","667.50","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1648.07","44.45","","123.77","123.77","123.77","1 through 10","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","both","","","3707.70","2780.77","WELLPOINT [1015]","HB CH WELLPOINT","2888.67","77.91","","483.51","229.32","1316.08","96","1648.07","3707.7","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3707.70","2780.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2198.67","59.3","","439.50","225.34","1872.27","197","1853.85","2908.69","percent of total billed charges",""
"PLATE BONE 194MM 21HOLE OLECRANON LEFT","SUP-ITM-10230230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3707.70","2780.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2908.69","78.45","","385.32","55.36","1815.62","58","1853.85","2908.69","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","554.95","91.85","1421.75","94","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","2490.03","2490.03","2490.03","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","750.00","750.00","750.00","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","1192.50","120.84","4149.90","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3570.00","85","","750.00","75.00","750.00","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4200.00","100","","657.00","121.50","1971.00","14","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4200.00","100","","75.00","75.00","75.00","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4200.00","100","","366.00","144.00","1971.00","45","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","667.50","667.50","667.50","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","123.77","123.77","123.77","1 through 10","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","483.51","229.32","1316.08","96","1866.9","4200","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","439.50","225.34","1872.27","197","2100","3294.9","percent of total billed charges",""
"PLATE BONE 2-HOLE LG","SUP-ITM-10232307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","385.32","55.36","1815.62","58","2100","3294.9","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","AETNA [1001]","HB CH AETNA HMO / PPO","1480.81","58.3","","554.95","91.85","1421.75","94","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1854.19","73","","2490.03","2490.03","2490.03","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1480.81","58.3","","750.00","750.00","750.00","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1346.19","53","","1192.50","120.84","4149.90","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2158.98","85","","750.00","75.00","750.00","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2539.98","100","","657.00","121.50","1971.00","14","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2539.98","100","","75.00","75.00","75.00","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2539.98","100","","366.00","144.00","1971.00","45","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1854.19","73","","667.50","667.50","667.50","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1129.02","44.45","","123.77","123.77","123.77","1 through 10","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2539.98","1904.98","WELLPOINT [1015]","HB CH WELLPOINT","1978.90","77.91","","483.51","229.32","1316.08","96","1129.02","2539.98","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2539.98","1904.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","1506.21","59.3","","439.50","225.34","1872.27","197","1269.99","1992.61","percent of total billed charges",""
"PLATE BONE 4.5MM 137MM 6HOLE BUTTRESS DISTAL MEDIAL FEMORAL CONDYLE NONSTERILE RIGHT","SUP-ITM-10237573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2539.98","1904.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1992.61","78.45","","385.32","55.36","1815.62","58","1269.99","1992.61","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","AETNA [1001]","HB CH AETNA HMO / PPO","491.82","58.3","","554.95","91.85","1421.75","94","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","615.83","73","","2490.03","2490.03","2490.03","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","491.82","58.3","","750.00","750.00","750.00","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","447.11","53","","1192.50","120.84","4149.90","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","717.06","85","","750.00","75.00","750.00","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","843.60","100","","657.00","121.50","1971.00","14","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","843.60","100","","75.00","75.00","75.00","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","843.60","100","","366.00","144.00","1971.00","45","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","615.83","73","","667.50","667.50","667.50","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","374.98","44.45","","123.77","123.77","123.77","1 through 10","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","both","","","843.60","632.70","WELLPOINT [1015]","HB CH WELLPOINT","657.25","77.91","","483.51","229.32","1316.08","96","374.98","843.6","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.60","632.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","500.25","59.3","","439.50","225.34","1872.27","197","421.8","661.8","percent of total billed charges",""
"PLATE BONE 60X2.4MM 7 HOLE LCP SS STRAIGHT","SUP-ITM-10021678","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","843.60","632.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","661.80","78.45","","385.32","55.36","1815.62","58","421.8","661.8","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","AETNA [1001]","HB CH AETNA HMO / PPO","2131.44","58.3","","554.95","91.85","1421.75","94","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2668.87","73","","2490.03","2490.03","2490.03","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.44","58.3","","750.00","750.00","750.00","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1937.67","53","","1192.50","120.84","4149.90","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3107.58","85","","750.00","75.00","750.00","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3655.98","100","","657.00","121.50","1971.00","14","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3655.98","100","","75.00","75.00","75.00","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3655.98","100","","366.00","144.00","1971.00","45","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2668.87","73","","667.50","667.50","667.50","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.08","44.45","","123.77","123.77","123.77","1 through 10","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","both","","","3655.98","2741.98","WELLPOINT [1015]","HB CH WELLPOINT","2848.37","77.91","","483.51","229.32","1316.08","96","1625.08","3655.98","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3655.98","2741.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.00","59.3","","439.50","225.34","1872.27","197","1827.99","2868.12","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA EXTRA LONG LEFT STERILE","SUP-ITM-10230254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3655.98","2741.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.12","78.45","","385.32","55.36","1815.62","58","1827.99","2868.12","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","AETNA [1001]","HB CH AETNA HMO / PPO","1935.99","58.3","","554.95","91.85","1421.75","94","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2424.13","73","","2490.03","2490.03","2490.03","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1935.99","58.3","","750.00","750.00","750.00","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1759.99","53","","1192.50","120.84","4149.90","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2822.62","85","","750.00","75.00","750.00","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3320.73","100","","657.00","121.50","1971.00","14","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3320.73","100","","75.00","75.00","75.00","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3320.73","100","","366.00","144.00","1971.00","45","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2424.13","73","","667.50","667.50","667.50","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1476.06","44.45","","123.77","123.77","123.77","1 through 10","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","both","","","3320.73","2490.55","WELLPOINT [1015]","HB CH WELLPOINT","2587.18","77.91","","483.51","229.32","1316.08","96","1476.06","3320.73","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.73","2490.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","1969.19","59.3","","439.50","225.34","1872.27","197","1660.37","2605.11","percent of total billed charges",""
"PLATE BONE DVR LOCK EXTRA LONG LEFT STERILE","SUP-ITM-10230256","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3320.73","2490.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2605.11","78.45","","385.32","55.36","1815.62","58","1660.37","2605.11","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","AETNA [1001]","HB CH AETNA HMO / PPO","2011.35","58.3","","554.95","91.85","1421.75","94","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2518.50","73","","2490.03","2490.03","2490.03","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2011.35","58.3","","750.00","750.00","750.00","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1828.50","53","","1192.50","120.84","4149.90","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2932.50","85","","750.00","75.00","750.00","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3450.00","100","","657.00","121.50","1971.00","14","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3450.00","100","","75.00","75.00","75.00","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3450.00","100","","366.00","144.00","1971.00","45","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2518.50","73","","667.50","667.50","667.50","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1533.53","44.45","","123.77","123.77","123.77","1 through 10","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","both","","","3450.00","2587.50","WELLPOINT [1015]","HB CH WELLPOINT","2687.90","77.91","","483.51","229.32","1316.08","96","1533.53","3450","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3450.00","2587.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2045.85","59.3","","439.50","225.34","1872.27","197","1725","2706.53","percent of total billed charges",""
"PLATE BONE IMPLANT RIGHT ASSEMBLED PROTEAN COR ONOID","SUP-ITM-10266658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3450.00","2587.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2706.53","78.45","","385.32","55.36","1815.62","58","1725","2706.53","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","AETNA [1001]","HB CH AETNA HMO / PPO","2269.91","58.3","","554.95","91.85","1421.75","94","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2842.26","73","","2490.03","2490.03","2490.03","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2269.91","58.3","","750.00","750.00","750.00","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2063.56","53","","1192.50","120.84","4149.90","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3309.48","85","","750.00","75.00","750.00","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3893.50","100","","657.00","121.50","1971.00","14","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3893.50","100","","75.00","75.00","75.00","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3893.50","100","","366.00","144.00","1971.00","45","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2842.26","73","","667.50","667.50","667.50","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1730.66","44.45","","123.77","123.77","123.77","1 through 10","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","both","","","3893.50","2920.12","WELLPOINT [1015]","HB CH WELLPOINT","3033.43","77.91","","483.51","229.32","1316.08","96","1730.66","3893.5","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3893.50","2920.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2308.85","59.3","","439.50","225.34","1872.27","197","1946.75","3054.45","percent of total billed charges",""
"PLATE BONE RT LATERAL TT STD","SUP-ITM-10238057","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3893.50","2920.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3054.45","78.45","","385.32","55.36","1815.62","58","1946.75","3054.45","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","AETNA [1001]","HB CH AETNA HMO / PPO","2365.65","58.3","","554.95","91.85","1421.75","94","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2962.14","73","","2490.03","2490.03","2490.03","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2365.65","58.3","","750.00","750.00","750.00","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2150.59","53","","1192.50","120.84","4149.90","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3449.06","85","","750.00","75.00","750.00","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4057.72","100","","657.00","121.50","1971.00","14","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4057.72","100","","75.00","75.00","75.00","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4057.72","100","","366.00","144.00","1971.00","45","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2962.14","73","","667.50","667.50","667.50","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1803.66","44.45","","123.77","123.77","123.77","1 through 10","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","both","","","4057.72","3043.29","WELLPOINT [1015]","HB CH WELLPOINT","3161.37","77.91","","483.51","229.32","1316.08","96","1803.66","4057.72","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.72","3043.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","2406.23","59.3","","439.50","225.34","1872.27","197","2028.86","3183.28","percent of total billed charges",""
"PLATE BONE SM 7 HOLE TTC RT NHPL PERI OP","SUP-ITM-10091879","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4057.72","3043.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3183.28","78.45","","385.32","55.36","1815.62","58","2028.86","3183.28","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","554.95","91.85","1421.75","94","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2490.03","2490.03","2490.03","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","750.00","750.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","1192.50","120.84","4149.90","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","750.00","75.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","657.00","121.50","1971.00","14","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","75.00","75.00","75.00","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","366.00","144.00","1971.00","45","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","667.50","667.50","667.50","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","123.77","123.77","123.77","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","483.51","229.32","1316.08","96","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","439.50","225.34","1872.27","197","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 10MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","385.32","55.36","1815.62","58","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","554.95","91.85","1421.75","94","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2490.03","2490.03","2490.03","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","750.00","750.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","1192.50","120.84","4149.90","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","750.00","75.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","657.00","121.50","1971.00","14","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","75.00","75.00","75.00","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","366.00","144.00","1971.00","45","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","667.50","667.50","667.50","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","123.77","123.77","123.77","1 through 10","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","483.51","229.32","1316.08","96","666.75","1500","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","439.50","225.34","1872.27","197","750","1176.75","percent of total billed charges",""
"PLATE CERVICAL 20MM LEVEL 1 MAXAN TITANIUM","SUP-ITM-10108072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","385.32","55.36","1815.62","58","750","1176.75","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","AETNA [1001]","HB CH AETNA HMO / PPO","1447.73","58.3","","554.95","91.85","1421.75","94","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1812.77","73","","2490.03","2490.03","2490.03","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1447.73","58.3","","750.00","750.00","750.00","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1316.12","53","","1192.50","120.84","4149.90","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2110.76","85","","750.00","75.00","750.00","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2483.25","100","","657.00","121.50","1971.00","14","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2483.25","100","","75.00","75.00","75.00","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2483.25","100","","366.00","144.00","1971.00","45","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1812.77","73","","667.50","667.50","667.50","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1103.80","44.45","","123.77","123.77","123.77","1 through 10","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","both","","","2483.25","1862.44","WELLPOINT [1015]","HB CH WELLPOINT","1934.70","77.91","","483.51","229.32","1316.08","96","1103.8","2483.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2483.25","1862.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1472.57","59.3","","439.50","225.34","1872.27","197","1241.63","1948.11","percent of total billed charges",""
"PLATE CLAVICLE 2.7 VA LCP SHAFT/ CS3/ LEFT","SUP-ITM-10286302","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2483.25","1862.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1948.11","78.45","","385.32","55.36","1815.62","58","1241.63","1948.11","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","AETNA [1001]","HB CH AETNA HMO / PPO","1400.39","58.3","","554.95","91.85","1421.75","94","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1753.49","73","","2490.03","2490.03","2490.03","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1400.39","58.3","","750.00","750.00","750.00","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1273.08","53","","1192.50","120.84","4149.90","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2041.73","85","","750.00","75.00","750.00","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2402.04","100","","657.00","121.50","1971.00","14","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2402.04","100","","75.00","75.00","75.00","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2402.04","100","","366.00","144.00","1971.00","45","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1753.49","73","","667.50","667.50","667.50","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1067.71","44.45","","123.77","123.77","123.77","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","WELLPOINT [1015]","HB CH WELLPOINT","1871.43","77.91","","483.51","229.32","1316.08","96","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","1424.41","59.3","","439.50","225.34","1872.27","197","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 2.7/3.5X113MM 11 HOLE VA STAINLESS STEEL LATERAL ANTERIOR","SUP-ITM-10095083","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1884.40","78.45","","385.32","55.36","1815.62","58","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","AETNA [1001]","HB CH AETNA HMO / PPO","1541.74","58.3","","554.95","91.85","1421.75","94","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1930.49","73","","2490.03","2490.03","2490.03","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1541.74","58.3","","750.00","750.00","750.00","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1401.59","53","","1192.50","120.84","4149.90","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2247.83","85","","750.00","75.00","750.00","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2644.50","100","","657.00","121.50","1971.00","14","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2644.50","100","","75.00","75.00","75.00","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2644.50","100","","366.00","144.00","1971.00","45","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1930.49","73","","667.50","667.50","667.50","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1175.48","44.45","","123.77","123.77","123.77","1 through 10","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","both","","","2644.50","1983.37","WELLPOINT [1015]","HB CH WELLPOINT","2060.33","77.91","","483.51","229.32","1316.08","96","1175.48","2644.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2644.50","1983.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1568.19","59.3","","439.50","225.34","1872.27","197","1322.25","2074.61","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS1 LEFT","SUP-ITM-10286294","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2644.50","1983.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2074.61","78.45","","385.32","55.36","1815.62","58","1322.25","2074.61","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","AETNA [1001]","HB CH AETNA HMO / PPO","1516.93","58.3","","554.95","91.85","1421.75","94","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1899.41","73","","2490.03","2490.03","2490.03","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1516.93","58.3","","750.00","750.00","750.00","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1379.02","53","","1192.50","120.84","4149.90","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2211.64","85","","750.00","75.00","750.00","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2601.93","100","","657.00","121.50","1971.00","14","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2601.93","100","","75.00","75.00","75.00","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2601.93","100","","366.00","144.00","1971.00","45","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1899.41","73","","667.50","667.50","667.50","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1156.56","44.45","","123.77","123.77","123.77","1 through 10","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2601.93","1951.45","WELLPOINT [1015]","HB CH WELLPOINT","2027.16","77.91","","483.51","229.32","1316.08","96","1156.56","2601.93","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2601.93","1951.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1542.94","59.3","","439.50","225.34","1872.27","197","1300.97","2041.21","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS2 RIGHT","SUP-ITM-10285838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2601.93","1951.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2041.21","78.45","","385.32","55.36","1815.62","58","1300.97","2041.21","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","AETNA [1001]","HB CH AETNA HMO / PPO","1519.18","58.3","","554.95","91.85","1421.75","94","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1902.23","73","","2490.03","2490.03","2490.03","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1519.18","58.3","","750.00","750.00","750.00","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1381.07","53","","1192.50","120.84","4149.90","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2214.93","85","","750.00","75.00","750.00","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2605.80","100","","657.00","121.50","1971.00","14","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2605.80","100","","75.00","75.00","75.00","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2605.80","100","","366.00","144.00","1971.00","45","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1902.23","73","","667.50","667.50","667.50","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1158.28","44.45","","123.77","123.77","123.77","1 through 10","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","both","","","2605.80","1954.35","WELLPOINT [1015]","HB CH WELLPOINT","2030.18","77.91","","483.51","229.32","1316.08","96","1158.28","2605.8","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.80","1954.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","1545.24","59.3","","439.50","225.34","1872.27","197","1302.9","2044.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL LATERAL CS3 LEFT","SUP-ITM-10286297","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2605.80","1954.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2044.25","78.45","","385.32","55.36","1815.62","58","1302.9","2044.25","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","AETNA [1001]","HB CH AETNA HMO / PPO","1827.53","58.3","","554.95","91.85","1421.75","94","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2288.33","73","","2490.03","2490.03","2490.03","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1827.53","58.3","","750.00","750.00","750.00","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1661.39","53","","1192.50","120.84","4149.90","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2664.50","85","","750.00","75.00","750.00","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3134.70","100","","657.00","121.50","1971.00","14","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3134.70","100","","75.00","75.00","75.00","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3134.70","100","","366.00","144.00","1971.00","45","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2288.33","73","","667.50","667.50","667.50","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1393.37","44.45","","123.77","123.77","123.77","1 through 10","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","both","","","3134.70","2351.02","WELLPOINT [1015]","HB CH WELLPOINT","2442.24","77.91","","483.51","229.32","1316.08","96","1393.37","3134.7","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.70","2351.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","1858.88","59.3","","439.50","225.34","1872.27","197","1567.35","2459.17","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL MEDIAL LEFT","SUP-ITM-10286304","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3134.70","2351.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2459.17","78.45","","385.32","55.36","1815.62","58","1567.35","2459.17","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","AETNA [1001]","HB CH AETNA HMO / PPO","1466.54","58.3","","554.95","91.85","1421.75","94","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1836.32","73","","2490.03","2490.03","2490.03","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1466.54","58.3","","750.00","750.00","750.00","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1333.22","53","","1192.50","120.84","4149.90","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2138.18","85","","750.00","75.00","750.00","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2515.50","100","","657.00","121.50","1971.00","14","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2515.50","100","","75.00","75.00","75.00","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2515.50","100","","366.00","144.00","1971.00","45","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1836.32","73","","667.50","667.50","667.50","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1118.14","44.45","","123.77","123.77","123.77","1 through 10","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","both","","","2515.50","1886.62","WELLPOINT [1015]","HB CH WELLPOINT","1959.83","77.91","","483.51","229.32","1316.08","96","1118.14","2515.5","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2515.50","1886.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1491.69","59.3","","439.50","225.34","1872.27","197","1257.75","1973.41","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS1 RIGHT","SUP-ITM-10285837","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2515.50","1886.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1973.41","78.45","","385.32","55.36","1815.62","58","1257.75","1973.41","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","AETNA [1001]","HB CH AETNA HMO / PPO","1422.92","58.3","","554.95","91.85","1421.75","94","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1781.70","73","","2490.03","2490.03","2490.03","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1422.92","58.3","","750.00","750.00","750.00","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1293.56","53","","1192.50","120.84","4149.90","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2074.58","85","","750.00","75.00","750.00","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2440.68","100","","657.00","121.50","1971.00","14","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2440.68","100","","75.00","75.00","75.00","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2440.68","100","","366.00","144.00","1971.00","45","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1781.70","73","","667.50","667.50","667.50","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1084.88","44.45","","123.77","123.77","123.77","1 through 10","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","both","","","2440.68","1830.51","WELLPOINT [1015]","HB CH WELLPOINT","1901.53","77.91","","483.51","229.32","1316.08","96","1084.88","2440.68","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2440.68","1830.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","1447.32","59.3","","439.50","225.34","1872.27","197","1220.34","1914.71","percent of total billed charges",""
"PLATE CLAVICLE 2.7MM VA LCP STAINLESS STEEL SHAFT CS2 LEFT","SUP-ITM-10286300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2440.68","1830.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1914.71","78.45","","385.32","55.36","1815.62","58","1220.34","1914.71","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","AETNA [1001]","HB CH AETNA HMO / PPO","1329.85","58.3","","1830.28","315.58","1830.28","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1665.17","73","","4170.85","4170.85","4170.85","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.93","44.45","","649.55","649.55","649.55","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","WELLPOINT [1015]","HB CH WELLPOINT","1777.17","77.91","","8998.38","2542.37","8998.38","20","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","1352.66","59.3","","1891.61","1609.14","3664.18","25","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X105MM 6 HOLE LCP STAINLESS STEEL SUPERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10095085","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1789.48","78.45","","1470.68","1310.06","2481.69","19","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","AETNA [1001]","HB CH AETNA HMO / PPO","1329.85","58.3","","554.95","91.85","1421.75","94","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1665.17","73","","2490.03","2490.03","2490.03","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1329.85","58.3","","750.00","750.00","750.00","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1208.96","53","","1192.50","120.84","4149.90","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1938.89","85","","750.00","75.00","750.00","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2281.05","100","","657.00","121.50","1971.00","14","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2281.05","100","","75.00","75.00","75.00","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2281.05","100","","366.00","144.00","1971.00","45","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1665.17","73","","667.50","667.50","667.50","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.93","44.45","","123.77","123.77","123.77","1 through 10","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","both","","","2281.05","1710.79","WELLPOINT [1015]","HB CH WELLPOINT","1777.17","77.91","","483.51","229.32","1316.08","96","1013.93","2281.05","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","1352.66","59.3","","439.50","225.34","1872.27","197","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X108MM 6 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10036318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2281.05","1710.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1789.48","78.45","","385.32","55.36","1815.62","58","1140.53","1789.48","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","AETNA [1001]","HB CH AETNA HMO / PPO","1364.15","58.3","","554.95","91.85","1421.75","94","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1708.11","73","","2490.03","2490.03","2490.03","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1364.15","58.3","","750.00","750.00","750.00","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1240.14","53","","1192.50","120.84","4149.90","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1988.90","85","","750.00","75.00","750.00","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2339.88","100","","657.00","121.50","1971.00","14","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2339.88","100","","75.00","75.00","75.00","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2339.88","100","","366.00","144.00","1971.00","45","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1708.11","73","","667.50","667.50","667.50","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1040.08","44.45","","123.77","123.77","123.77","1 through 10","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","both","","","2339.88","1754.91","WELLPOINT [1015]","HB CH WELLPOINT","1823.00","77.91","","483.51","229.32","1316.08","96","1040.08","2339.88","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2339.88","1754.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1387.55","59.3","","439.50","225.34","1872.27","197","1169.94","1835.64","percent of total billed charges",""
"PLATE CLAVICLE 3.5X110MM 7 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LEFT","SUP-ITM-10036319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2339.88","1754.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1835.64","78.45","","385.32","55.36","1815.62","58","1169.94","1835.64","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","AETNA [1001]","HB CH AETNA HMO / PPO","1400.39","58.3","","554.95","91.85","1421.75","94","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1753.49","73","","2490.03","2490.03","2490.03","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1400.39","58.3","","750.00","750.00","750.00","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1273.08","53","","1192.50","120.84","4149.90","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2041.73","85","","750.00","75.00","750.00","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2402.04","100","","657.00","121.50","1971.00","14","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2402.04","100","","75.00","75.00","75.00","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2402.04","100","","366.00","144.00","1971.00","45","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1753.49","73","","667.50","667.50","667.50","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1067.71","44.45","","123.77","123.77","123.77","1 through 10","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","both","","","2402.04","1801.53","WELLPOINT [1015]","HB CH WELLPOINT","1871.43","77.91","","483.51","229.32","1316.08","96","1067.71","2402.04","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","1424.41","59.3","","439.50","225.34","1872.27","197","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 3.5X115MM 8 HOLE LCP STAINLESS STEEL SUPERIOR LEFT","SUP-ITM-10073223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2402.04","1801.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1884.40","78.45","","385.32","55.36","1815.62","58","1201.02","1884.4","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","AETNA [1001]","HB CH AETNA HMO / PPO","1272.90","58.3","","554.95","91.85","1421.75","94","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1593.86","73","","2490.03","2490.03","2490.03","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1272.90","58.3","","750.00","750.00","750.00","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1157.19","53","","1192.50","120.84","4149.90","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1855.86","85","","750.00","75.00","750.00","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2183.37","100","","657.00","121.50","1971.00","14","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2183.37","100","","75.00","75.00","75.00","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2183.37","100","","366.00","144.00","1971.00","45","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1593.86","73","","667.50","667.50","667.50","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","970.51","44.45","","123.77","123.77","123.77","1 through 10","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","both","","","2183.37","1637.53","WELLPOINT [1015]","HB CH WELLPOINT","1701.06","77.91","","483.51","229.32","1316.08","96","970.51","2183.37","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2183.37","1637.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","1294.74","59.3","","439.50","225.34","1872.27","197","1091.69","1712.85","percent of total billed charges",""
"PLATE CLAVICLE 3.5X69MM 3 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10029985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2183.37","1637.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1712.85","78.45","","385.32","55.36","1815.62","58","1091.69","1712.85","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","AETNA [1001]","HB CH AETNA HMO / PPO","1292.97","58.3","","554.95","91.85","1421.75","94","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1618.98","73","","2490.03","2490.03","2490.03","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1292.97","58.3","","750.00","750.00","750.00","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1175.42","53","","1192.50","120.84","4149.90","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1885.11","85","","750.00","75.00","750.00","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2217.78","100","","657.00","121.50","1971.00","14","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2217.78","100","","75.00","75.00","75.00","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2217.78","100","","366.00","144.00","1971.00","45","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1618.98","73","","667.50","667.50","667.50","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","985.80","44.45","","123.77","123.77","123.77","1 through 10","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","both","","","2217.78","1663.33","WELLPOINT [1015]","HB CH WELLPOINT","1727.87","77.91","","483.51","229.32","1316.08","96","985.8","2217.78","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2217.78","1663.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1315.14","59.3","","439.50","225.34","1872.27","197","1108.89","1739.85","percent of total billed charges",""
"PLATE CLAVICLE 3.5X81MM 4 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION LEFT","SUP-ITM-10079556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2217.78","1663.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1739.85","78.45","","385.32","55.36","1815.62","58","1108.89","1739.85","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","AETNA [1001]","HB CH AETNA HMO / PPO","1315.62","58.3","","554.95","91.85","1421.75","94","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1647.34","73","","2490.03","2490.03","2490.03","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1315.62","58.3","","750.00","750.00","750.00","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1196.01","53","","1192.50","120.84","4149.90","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1918.14","85","","750.00","75.00","750.00","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2256.63","100","","657.00","121.50","1971.00","14","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2256.63","100","","75.00","75.00","75.00","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2256.63","100","","366.00","144.00","1971.00","45","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1647.34","73","","667.50","667.50","667.50","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1003.07","44.45","","123.77","123.77","123.77","1 through 10","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","both","","","2256.63","1692.47","WELLPOINT [1015]","HB CH WELLPOINT","1758.14","77.91","","483.51","229.32","1316.08","96","1003.07","2256.63","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.63","1692.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","1338.18","59.3","","439.50","225.34","1872.27","197","1128.32","1770.33","percent of total billed charges",""
"PLATE CLAVICLE 3.5X94MM 5 HOLE LCP STAINLESS STEEL SUPERIOR ANTERIOR LATERAL EXTENSION RIGHT","SUP-ITM-10072420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2256.63","1692.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1770.33","78.45","","385.32","55.36","1815.62","58","1128.32","1770.33","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","554.95","91.85","1421.75","94","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","2490.03","2490.03","2490.03","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","750.00","750.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","1192.50","120.84","4149.90","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","892.50","85","","750.00","75.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1050.00","100","","657.00","121.50","1971.00","14","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1050.00","100","","75.00","75.00","75.00","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1050.00","100","","366.00","144.00","1971.00","45","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","667.50","667.50","667.50","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","123.77","123.77","123.77","1 through 10","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","483.51","229.32","1316.08","96","466.73","1050","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","439.50","225.34","1872.27","197","525","823.73","percent of total billed charges",""
"PLATE CLAVICLE BUTTON TRACTION FIXATION DISTAL","SUP-ITM-10118276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","385.32","55.36","1815.62","58","525","823.73","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","AETNA [1001]","HB CH AETNA HMO / PPO","2131.59","58.3","","554.95","91.85","1421.75","94","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","2490.03","2490.03","2490.03","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.59","58.3","","750.00","750.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1937.81","53","","1192.50","120.84","4149.90","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3107.81","85","","750.00","75.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3656.25","100","","657.00","121.50","1971.00","14","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3656.25","100","","75.00","75.00","75.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3656.25","100","","366.00","144.00","1971.00","45","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","667.50","667.50","667.50","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.20","44.45","","123.77","123.77","123.77","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","WELLPOINT [1015]","HB CH WELLPOINT","2848.58","77.91","","483.51","229.32","1316.08","96","1625.2","3656.25","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.16","59.3","","439.50","225.34","1872.27","197","1828.13","2868.33","percent of total billed charges",""
"PLATE CLOVER LISFRANC 6-HOLE RIGHT COMPRESSION","SUP-ITM-10241376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","385.32","55.36","1815.62","58","1828.13","2868.33","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","AETNA [1001]","HB CH AETNA HMO / PPO","2321.07","58.3","","554.95","91.85","1421.75","94","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2906.31","73","","2490.03","2490.03","2490.03","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2321.07","58.3","","750.00","750.00","750.00","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2110.06","53","","1192.50","120.84","4149.90","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3384.06","85","","750.00","75.00","750.00","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3981.25","100","","657.00","121.50","1971.00","14","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3981.25","100","","75.00","75.00","75.00","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3981.25","100","","366.00","144.00","1971.00","45","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2906.31","73","","667.50","667.50","667.50","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1769.67","44.45","","123.77","123.77","123.77","1 through 10","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","both","","","3981.25","2985.94","WELLPOINT [1015]","HB CH WELLPOINT","3101.79","77.91","","483.51","229.32","1316.08","96","1769.67","3981.25","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3981.25","2985.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2360.88","59.3","","439.50","225.34","1872.27","197","1990.63","3123.29","percent of total billed charges",""
"PLATE COMPRESSION PLAPIDUS 3-HOLE STANDARD NO ARM RT PRECISION GUIDE","SUP-ITM-10241464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3981.25","2985.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3123.29","78.45","","385.32","55.36","1815.62","58","1990.63","3123.29","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","AETNA [1001]","HB CH AETNA HMO / PPO","1705.28","58.3","","554.95","91.85","1421.75","94","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","2490.03","2490.03","2490.03","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1705.28","58.3","","750.00","750.00","750.00","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1550.25","53","","1192.50","120.84","4149.90","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2486.25","85","","750.00","75.00","750.00","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2925.00","100","","657.00","121.50","1971.00","14","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2925.00","100","","75.00","75.00","75.00","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2925.00","100","","366.00","144.00","1971.00","45","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2135.25","73","","667.50","667.50","667.50","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1300.16","44.45","","123.77","123.77","123.77","1 through 10","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","both","","","2925.00","2193.75","WELLPOINT [1015]","HB CH WELLPOINT","2278.87","77.91","","483.51","229.32","1316.08","96","1300.16","2925","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1734.53","59.3","","439.50","225.34","1872.27","197","1462.5","2294.66","percent of total billed charges",""
"PLATE COMPRESSSION JMF8 HOLE RIGHT","SUP-ITM-10241589","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2925.00","2193.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2294.66","78.45","","385.32","55.36","1815.62","58","1462.5","2294.66","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","AETNA [1001]","HB CH AETNA HMO / PPO","747.44","58.3","","554.95","91.85","1421.75","94","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","935.90","73","","2490.03","2490.03","2490.03","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","747.44","58.3","","750.00","750.00","750.00","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","679.49","53","","1192.50","120.84","4149.90","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1089.74","85","","750.00","75.00","750.00","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1282.05","100","","657.00","121.50","1971.00","14","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1282.05","100","","75.00","75.00","75.00","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1282.05","100","","366.00","144.00","1971.00","45","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","935.90","73","","667.50","667.50","667.50","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","569.87","44.45","","123.77","123.77","123.77","1 through 10","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","both","","","1282.05","961.54","WELLPOINT [1015]","HB CH WELLPOINT","998.85","77.91","","483.51","229.32","1316.08","96","569.87","1282.05","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1282.05","961.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","760.26","59.3","","439.50","225.34","1872.27","197","641.03","1005.77","percent of total billed charges",""
"PLATE CRANIOMAXILLOFACIAL 2X48MM 3 HOLE 8 SHAFT BONE Y SHAPE DCP TITANIUM","SUP-ITM-10002242","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1282.05","961.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1005.77","78.45","","385.32","55.36","1815.62","58","641.03","1005.77","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","AETNA [1001]","HB CH AETNA HMO / PPO","2268.02","58.3","","554.95","91.85","1421.75","94","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2839.88","73","","2490.03","2490.03","2490.03","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2268.02","58.3","","750.00","750.00","750.00","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2061.83","53","","1192.50","120.84","4149.90","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3306.71","85","","750.00","75.00","750.00","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3890.25","100","","657.00","121.50","1971.00","14","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3890.25","100","","75.00","75.00","75.00","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3890.25","100","","366.00","144.00","1971.00","45","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2839.88","73","","667.50","667.50","667.50","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1729.22","44.45","","123.77","123.77","123.77","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","WELLPOINT [1015]","HB CH WELLPOINT","3030.89","77.91","","483.51","229.32","1316.08","96","1729.22","3890.25","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2306.92","59.3","","439.50","225.34","1872.27","197","1945.13","3051.9","percent of total billed charges",""
"PLATE DOGBONE 15MM","SUP-ITM-10241370","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3051.90","78.45","","385.32","55.36","1815.62","58","1945.13","3051.9","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","AETNA [1001]","HB CH AETNA HMO / PPO","1414.63","58.3","","554.95","91.85","1421.75","94","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1771.32","73","","2490.03","2490.03","2490.03","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1414.63","58.3","","750.00","750.00","750.00","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1286.02","53","","1192.50","120.84","4149.90","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2062.49","85","","750.00","75.00","750.00","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2426.46","100","","657.00","121.50","1971.00","14","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2426.46","100","","75.00","75.00","75.00","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2426.46","100","","366.00","144.00","1971.00","45","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1771.32","73","","667.50","667.50","667.50","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1078.56","44.45","","123.77","123.77","123.77","1 through 10","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","both","","","2426.46","1819.84","WELLPOINT [1015]","HB CH WELLPOINT","1890.45","77.91","","483.51","229.32","1316.08","96","1078.56","2426.46","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2426.46","1819.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","1438.89","59.3","","439.50","225.34","1872.27","197","1213.23","1903.56","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X142MM 6 HOLE LCP SS OLECRANON VARIABLE ANGLE RIGHT","SUP-ITM-10114053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2426.46","1819.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1903.56","78.45","","385.32","55.36","1815.62","58","1213.23","1903.56","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","AETNA [1001]","HB CH AETNA HMO / PPO","1514.28","58.3","","554.95","91.85","1421.75","94","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","2490.03","2490.03","2490.03","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1514.28","58.3","","750.00","750.00","750.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1376.62","53","","1192.50","120.84","4149.90","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2207.79","85","","750.00","75.00","750.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2597.40","100","","657.00","121.50","1971.00","14","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2597.40","100","","75.00","75.00","75.00","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2597.40","100","","366.00","144.00","1971.00","45","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1896.10","73","","667.50","667.50","667.50","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1154.54","44.45","","123.77","123.77","123.77","1 through 10","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","both","","","2597.40","1948.05","WELLPOINT [1015]","HB CH WELLPOINT","2023.63","77.91","","483.51","229.32","1316.08","96","1154.54","2597.4","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1540.26","59.3","","439.50","225.34","1872.27","197","1298.7","2037.66","percent of total billed charges",""
"PLATE ELBOW 2.7/3.5X69MM SHORT 1 HOLE HUMERUS VA LCP SS DISTAL LATERAL RIGHT","SUP-ITM-10103950","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2597.40","1948.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2037.66","78.45","","385.32","55.36","1815.62","58","1298.7","2037.66","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","AETNA [1001]","HB CH AETNA HMO / PPO","1750.49","58.3","","554.95","91.85","1421.75","94","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2191.86","73","","2490.03","2490.03","2490.03","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1750.49","58.3","","750.00","750.00","750.00","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1591.35","53","","1192.50","120.84","4149.90","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2552.17","85","","750.00","75.00","750.00","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3002.55","100","","657.00","121.50","1971.00","14","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3002.55","100","","75.00","75.00","75.00","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3002.55","100","","366.00","144.00","1971.00","45","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2191.86","73","","667.50","667.50","667.50","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.63","44.45","","123.77","123.77","123.77","1 through 10","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","WELLPOINT [1015]","HB CH WELLPOINT","2339.29","77.91","","483.51","229.32","1316.08","96","1334.63","3002.55","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3002.55","2251.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1780.51","59.3","","439.50","225.34","1872.27","197","1501.28","2355.5","percent of total billed charges",""
"PLATE FEMORAL 3-5.5X14MM 4 HOLE LATERAL DISTAL TOMOFIX TITANIUM RIGHT","SUP-ITM-10017937","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3002.55","2251.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2355.50","78.45","","385.32","55.36","1815.62","58","1501.28","2355.5","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","AETNA [1001]","HB CH AETNA HMO / PPO","1120.83","58.3","","1634.24","1004.95","1718.99","42","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1403.44","73","","2123.89","1900.92","2123.89","1 through 10","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1120.83","58.3","","3729.00","1254.19","3729.00","1 through 10","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1018.94","53","","939.37","939.37","5593.65","1 through 10","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1634.14","85","","2323.25","1864.50","2882.25","16","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1922.52","100","","2909.44","1772.40","10952.08","45","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1922.52","100","","2323.25","2323.25","2323.25","1 through 10","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1922.52","100","","2882.25","1772.40","10169.17","187","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1403.44","73","","1659.41","1659.41","1659.41","1 through 10","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","both","","","1922.52","1441.89","WELLPOINT [1015]","HB CH WELLPOINT","1497.84","77.91","","2050.91","1468.48","2902.83","52","854.56","1922.52","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1922.52","1441.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","1140.05","59.3","","1548.60","1092.60","3613.79","82","961.26","1508.22","percent of total billed charges",""
"PLATE FIBULA 2.7X118MM 6 HOLE DISTAL VA LCP SS LEFT","SUP-ITM-10125028","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1922.52","1441.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1508.22","78.45","","2085.51","998.68","6202.11","56","961.26","1508.22","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","AETNA [1001]","HB CH AETNA HMO / PPO","1421.06","58.3","","554.95","91.85","1421.75","94","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1779.38","73","","2490.03","2490.03","2490.03","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1421.06","58.3","","750.00","750.00","750.00","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1291.88","53","","1192.50","120.84","4149.90","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2071.88","85","","750.00","75.00","750.00","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2437.50","100","","657.00","121.50","1971.00","14","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2437.50","100","","75.00","75.00","75.00","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2437.50","100","","366.00","144.00","1971.00","45","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1779.38","73","","667.50","667.50","667.50","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1083.47","44.45","","123.77","123.77","123.77","1 through 10","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","both","","","2437.50","1828.12","WELLPOINT [1015]","HB CH WELLPOINT","1899.06","77.91","","483.51","229.32","1316.08","96","1083.47","2437.5","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1445.44","59.3","","439.50","225.34","1872.27","197","1218.75","1912.22","percent of total billed charges",""
"PLATE FIBULAR STRAIGHT 12 HOLE","SUP-ITM-10241341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2437.50","1828.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1912.22","78.45","","385.32","55.36","1815.62","58","1218.75","1912.22","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","AETNA [1001]","HB CH AETNA HMO / PPO","2068.23","58.3","","554.95","91.85","1421.75","94","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2589.72","73","","2490.03","2490.03","2490.03","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2068.23","58.3","","750.00","750.00","750.00","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1880.21","53","","1192.50","120.84","4149.90","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3015.43","85","","750.00","75.00","750.00","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3547.56","100","","657.00","121.50","1971.00","14","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3547.56","100","","75.00","75.00","75.00","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3547.56","100","","366.00","144.00","1971.00","45","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2589.72","73","","667.50","667.50","667.50","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.89","44.45","","123.77","123.77","123.77","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","WELLPOINT [1015]","HB CH WELLPOINT","2763.90","77.91","","483.51","229.32","1316.08","96","1576.89","3547.56","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.56","2660.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","2103.70","59.3","","439.50","225.34","1872.27","197","1773.78","2783.06","percent of total billed charges",""
"PLATE FUSION SHORT 9 HOLE WRIST STRAIGHT","SUP-ITM-10038056","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.56","2660.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2783.06","78.45","","385.32","55.36","1815.62","58","1773.78","2783.06","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","AETNA [1001]","HB CH AETNA HMO / PPO","484.05","58.3","","554.95","91.85","1421.75","94","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","606.10","73","","2490.03","2490.03","2490.03","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","484.05","58.3","","750.00","750.00","750.00","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","440.05","53","","1192.50","120.84","4149.90","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","705.74","85","","750.00","75.00","750.00","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","830.28","100","","657.00","121.50","1971.00","14","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","830.28","100","","75.00","75.00","75.00","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","830.28","100","","366.00","144.00","1971.00","45","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","606.10","73","","667.50","667.50","667.50","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","369.06","44.45","","123.77","123.77","123.77","1 through 10","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","both","","","830.28","622.71","WELLPOINT [1015]","HB CH WELLPOINT","646.87","77.91","","483.51","229.32","1316.08","96","369.06","830.28","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.28","622.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","492.36","59.3","","439.50","225.34","1872.27","197","415.14","651.35","percent of total billed charges",""
"PLATE HAND 1.3MM 12 HOLE SS STRAIGHT","SUP-ITM-10037593","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","830.28","622.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","651.35","78.45","","385.32","55.36","1815.62","58","415.14","651.35","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","AETNA [1001]","HB CH AETNA HMO / PPO","569.47","58.3","","554.95","91.85","1421.75","94","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","713.06","73","","2490.03","2490.03","2490.03","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","569.47","58.3","","750.00","750.00","750.00","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","517.70","53","","1192.50","120.84","4149.90","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","830.28","85","","750.00","75.00","750.00","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","976.80","100","","657.00","121.50","1971.00","14","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","976.80","100","","75.00","75.00","75.00","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","976.80","100","","366.00","144.00","1971.00","45","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.06","73","","667.50","667.50","667.50","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.19","44.45","","123.77","123.77","123.77","1 through 10","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","both","","","976.80","732.60","WELLPOINT [1015]","HB CH WELLPOINT","761.02","77.91","","483.51","229.32","1316.08","96","434.19","976.8","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.80","732.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.24","59.3","","439.50","225.34","1872.27","197","488.4","766.3","percent of total billed charges",""
"PLATE HAND 1.3MM 14 HOLE LOCKING WEB","SUP-ITM-10164645","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","976.80","732.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","766.30","78.45","","385.32","55.36","1815.62","58","488.4","766.3","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","AETNA [1001]","HB CH AETNA HMO / PPO","489.23","58.3","","554.95","91.85","1421.75","94","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","612.59","73","","2490.03","2490.03","2490.03","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.23","58.3","","750.00","750.00","750.00","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","444.75","53","","1192.50","120.84","4149.90","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","713.29","85","","750.00","75.00","750.00","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","839.16","100","","657.00","121.50","1971.00","14","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","839.16","100","","75.00","75.00","75.00","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","839.16","100","","366.00","144.00","1971.00","45","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","612.59","73","","667.50","667.50","667.50","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.01","44.45","","123.77","123.77","123.77","1 through 10","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","both","","","839.16","629.37","WELLPOINT [1015]","HB CH WELLPOINT","653.79","77.91","","483.51","229.32","1316.08","96","373.01","839.16","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","839.16","629.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","497.62","59.3","","439.50","225.34","1872.27","197","419.58","658.32","percent of total billed charges",""
"PLATE HAND 1.3MM 4X8 HOLE SS T SHAPE","SUP-ITM-10037597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","839.16","629.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.32","78.45","","385.32","55.36","1815.62","58","419.58","658.32","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","AETNA [1001]","HB CH AETNA HMO / PPO","492.47","58.3","","554.95","91.85","1421.75","94","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","616.64","73","","2490.03","2490.03","2490.03","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","492.47","58.3","","750.00","750.00","750.00","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","447.70","53","","1192.50","120.84","4149.90","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","718.00","85","","750.00","75.00","750.00","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","844.71","100","","657.00","121.50","1971.00","14","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","844.71","100","","75.00","75.00","75.00","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","844.71","100","","366.00","144.00","1971.00","45","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","616.64","73","","667.50","667.50","667.50","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","375.47","44.45","","123.77","123.77","123.77","1 through 10","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","both","","","844.71","633.53","WELLPOINT [1015]","HB CH WELLPOINT","658.11","77.91","","483.51","229.32","1316.08","96","375.47","844.71","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.71","633.53","CIGNA [1006]","HB CH CIGNA HMO / PPO","500.91","59.3","","439.50","225.34","1872.27","197","422.36","662.67","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE LOCKING STRAIGHT","SUP-ITM-10164654","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","844.71","633.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","662.67","78.45","","385.32","55.36","1815.62","58","422.36","662.67","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","AETNA [1001]","HB CH AETNA HMO / PPO","440.70","58.3","","554.95","91.85","1421.75","94","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","551.81","73","","2490.03","2490.03","2490.03","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","440.70","58.3","","750.00","750.00","750.00","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","400.63","53","","1192.50","120.84","4149.90","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","642.52","85","","750.00","75.00","750.00","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","755.91","100","","657.00","121.50","1971.00","14","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","755.91","100","","75.00","75.00","75.00","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","755.91","100","","366.00","144.00","1971.00","45","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","551.81","73","","667.50","667.50","667.50","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","336.00","44.45","","123.77","123.77","123.77","1 through 10","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","both","","","755.91","566.93","WELLPOINT [1015]","HB CH WELLPOINT","588.93","77.91","","483.51","229.32","1316.08","96","336","755.91","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.91","566.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","448.25","59.3","","439.50","225.34","1872.27","197","377.96","593.01","percent of total billed charges",""
"PLATE HAND 1.3MM 6 HOLE SS STRAIGHT","SUP-ITM-10037592","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","755.91","566.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","593.01","78.45","","385.32","55.36","1815.62","58","377.96","593.01","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","AETNA [1001]","HB CH AETNA HMO / PPO","537.77","58.3","","554.95","91.85","1421.75","94","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","673.36","73","","2490.03","2490.03","2490.03","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","537.77","58.3","","750.00","750.00","750.00","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","488.88","53","","1192.50","120.84","4149.90","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","784.05","85","","750.00","75.00","750.00","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","922.41","100","","657.00","121.50","1971.00","14","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","922.41","100","","75.00","75.00","75.00","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","922.41","100","","366.00","144.00","1971.00","45","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","673.36","73","","667.50","667.50","667.50","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","410.01","44.45","","123.77","123.77","123.77","1 through 10","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","both","","","922.41","691.81","WELLPOINT [1015]","HB CH WELLPOINT","718.65","77.91","","483.51","229.32","1316.08","96","410.01","922.41","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.41","691.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","546.99","59.3","","439.50","225.34","1872.27","197","461.21","723.63","percent of total billed charges",""
"PLATE HAND 1.3MM SS H SHAPE EXTENDED RIGHT","SUP-ITM-10037594","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","922.41","691.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","723.63","78.45","","385.32","55.36","1815.62","58","461.21","723.63","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","AETNA [1001]","HB CH AETNA HMO / PPO","645.19","58.3","","554.95","91.85","1421.75","94","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","807.87","73","","2490.03","2490.03","2490.03","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","645.19","58.3","","750.00","750.00","750.00","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","586.54","53","","1192.50","120.84","4149.90","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","940.67","85","","750.00","75.00","750.00","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1106.67","100","","657.00","121.50","1971.00","14","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1106.67","100","","75.00","75.00","75.00","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1106.67","100","","366.00","144.00","1971.00","45","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","807.87","73","","667.50","667.50","667.50","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","491.91","44.45","","123.77","123.77","123.77","1 through 10","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","both","","","1106.67","830.00","WELLPOINT [1015]","HB CH WELLPOINT","862.21","77.91","","483.51","229.32","1316.08","96","491.91","1106.67","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1106.67","830.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","656.26","59.3","","439.50","225.34","1872.27","197","553.34","868.18","percent of total billed charges",""
"PLATE HAND 1.5MM 6 HOLE SHAFT LCP SS LOCKING CONDYLE","SUP-ITM-10083682","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1106.67","830.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","868.18","78.45","","385.32","55.36","1815.62","58","553.34","868.18","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","AETNA [1001]","HB CH AETNA HMO / PPO","688.55","58.3","","554.95","91.85","1421.75","94","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","862.16","73","","2490.03","2490.03","2490.03","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","688.55","58.3","","750.00","750.00","750.00","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","625.95","53","","1192.50","120.84","4149.90","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1003.88","85","","750.00","75.00","750.00","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1181.04","100","","657.00","121.50","1971.00","14","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1181.04","100","","75.00","75.00","75.00","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1181.04","100","","366.00","144.00","1971.00","45","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","862.16","73","","667.50","667.50","667.50","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","524.97","44.45","","123.77","123.77","123.77","1 through 10","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","both","","","1181.04","885.78","WELLPOINT [1015]","HB CH WELLPOINT","920.15","77.91","","483.51","229.32","1316.08","96","524.97","1181.04","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1181.04","885.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","700.36","59.3","","439.50","225.34","1872.27","197","590.52","926.53","percent of total billed charges",""
"PLATE HAND 2MM 12 HOLE SS STRAIGHT MINI","SUP-ITM-10038068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1181.04","885.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","926.53","78.45","","385.32","55.36","1815.62","58","590.52","926.53","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","AETNA [1001]","HB CH AETNA HMO / PPO","280.85","58.3","","554.95","91.85","1421.75","94","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","351.67","73","","2490.03","2490.03","2490.03","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","280.85","58.3","","750.00","750.00","750.00","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","255.32","53","","1192.50","120.84","4149.90","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","409.48","85","","750.00","75.00","750.00","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","481.74","100","","657.00","121.50","1971.00","14","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","481.74","100","","75.00","75.00","75.00","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","481.74","100","","366.00","144.00","1971.00","45","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","351.67","73","","667.50","667.50","667.50","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","214.13","44.45","","123.77","123.77","123.77","1 through 10","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","both","","","481.74","361.30","WELLPOINT [1015]","HB CH WELLPOINT","375.32","77.91","","483.51","229.32","1316.08","96","214.13","481.74","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","285.67","59.3","","439.50","225.34","1872.27","197","240.87","377.93","percent of total billed charges",""
"PLATE HAND 36X1.5MM 6 HOLE LCP SS","SUP-ITM-10083676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","481.74","361.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","377.93","78.45","","385.32","55.36","1815.62","58","240.87","377.93","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","AETNA [1001]","HB CH AETNA HMO / PPO","563.00","58.3","","554.95","91.85","1421.75","94","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","704.96","73","","2490.03","2490.03","2490.03","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","563.00","58.3","","750.00","750.00","750.00","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","511.82","53","","1192.50","120.84","4149.90","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","820.85","85","","750.00","75.00","750.00","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","965.70","100","","657.00","121.50","1971.00","14","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","965.70","100","","75.00","75.00","75.00","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","965.70","100","","366.00","144.00","1971.00","45","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","704.96","73","","667.50","667.50","667.50","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","429.25","44.45","","123.77","123.77","123.77","1 through 10","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","both","","","965.70","724.27","WELLPOINT [1015]","HB CH WELLPOINT","752.38","77.91","","483.51","229.32","1316.08","96","429.25","965.7","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","965.70","724.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","572.66","59.3","","439.50","225.34","1872.27","197","482.85","757.59","percent of total billed charges",""
"PLATE HAND 36X2MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002280","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","965.70","724.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","757.59","78.45","","385.32","55.36","1815.62","58","482.85","757.59","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","AETNA [1001]","HB CH AETNA HMO / PPO","866.51","58.3","","554.95","91.85","1421.75","94","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1084.99","73","","2490.03","2490.03","2490.03","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","866.51","58.3","","750.00","750.00","750.00","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","787.73","53","","1192.50","120.84","4149.90","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1263.35","85","","750.00","75.00","750.00","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1486.29","100","","657.00","121.50","1971.00","14","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1486.29","100","","75.00","75.00","75.00","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1486.29","100","","366.00","144.00","1971.00","45","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1084.99","73","","667.50","667.50","667.50","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","660.66","44.45","","123.77","123.77","123.77","1 through 10","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1486.29","1114.72","WELLPOINT [1015]","HB CH WELLPOINT","1157.97","77.91","","483.51","229.32","1316.08","96","660.66","1486.29","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1486.29","1114.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","881.37","59.3","","439.50","225.34","1872.27","197","743.15","1165.99","percent of total billed charges",""
"PLATE HAND 47X2.4MM 6 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1486.29","1114.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1165.99","78.45","","385.32","55.36","1815.62","58","743.15","1165.99","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","AETNA [1001]","HB CH AETNA HMO / PPO","637.42","58.3","","554.95","91.85","1421.75","94","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","798.15","73","","2490.03","2490.03","2490.03","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","637.42","58.3","","750.00","750.00","750.00","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","579.48","53","","1192.50","120.84","4149.90","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","929.35","85","","750.00","75.00","750.00","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1093.35","100","","657.00","121.50","1971.00","14","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1093.35","100","","75.00","75.00","75.00","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1093.35","100","","366.00","144.00","1971.00","45","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","798.15","73","","667.50","667.50","667.50","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","485.99","44.45","","123.77","123.77","123.77","1 through 10","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","both","","","1093.35","820.01","WELLPOINT [1015]","HB CH WELLPOINT","851.83","77.91","","483.51","229.32","1316.08","96","485.99","1093.35","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1093.35","820.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","648.36","59.3","","439.50","225.34","1872.27","197","546.68","857.73","percent of total billed charges",""
"PLATE HAND 48X2MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1093.35","820.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","857.73","78.45","","385.32","55.36","1815.62","58","546.68","857.73","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","AETNA [1001]","HB CH AETNA HMO / PPO","936.40","58.3","","554.95","91.85","1421.75","94","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1172.50","73","","2490.03","2490.03","2490.03","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","936.40","58.3","","750.00","750.00","750.00","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","851.27","53","","1192.50","120.84","4149.90","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1365.24","85","","750.00","75.00","750.00","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1606.17","100","","657.00","121.50","1971.00","14","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1606.17","100","","75.00","75.00","75.00","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1606.17","100","","366.00","144.00","1971.00","45","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1172.50","73","","667.50","667.50","667.50","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","713.94","44.45","","123.77","123.77","123.77","1 through 10","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","both","","","1606.17","1204.63","WELLPOINT [1015]","HB CH WELLPOINT","1251.37","77.91","","483.51","229.32","1316.08","96","713.94","1606.17","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1606.17","1204.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","952.46","59.3","","439.50","225.34","1872.27","197","803.09","1260.04","percent of total billed charges",""
"PLATE HAND 63X2.4MM 8 HOLE STRAIGHT LC DCP MODULAR SYSTEM TITANIUM","SUP-ITM-10002255","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1606.17","1204.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1260.04","78.45","","385.32","55.36","1815.62","58","803.09","1260.04","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","AETNA [1001]","HB CH AETNA HMO / PPO","2084.23","58.3","","554.95","91.85","1421.75","94","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2609.75","73","","2490.03","2490.03","2490.03","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2084.23","58.3","","750.00","750.00","750.00","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1894.75","53","","1192.50","120.84","4149.90","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3038.75","85","","750.00","75.00","750.00","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3575.00","100","","657.00","121.50","1971.00","14","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3575.00","100","","75.00","75.00","75.00","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3575.00","100","","366.00","144.00","1971.00","45","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2609.75","73","","667.50","667.50","667.50","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1589.09","44.45","","123.77","123.77","123.77","1 through 10","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","both","","","3575.00","2681.25","WELLPOINT [1015]","HB CH WELLPOINT","2785.28","77.91","","483.51","229.32","1316.08","96","1589.09","3575","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3575.00","2681.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2119.98","59.3","","439.50","225.34","1872.27","197","1787.5","2804.59","percent of total billed charges",""
"PLATE HEVANS MED LEFT 20MM","SUP-ITM-10241483","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3575.00","2681.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2804.59","78.45","","385.32","55.36","1815.62","58","1787.5","2804.59","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","AETNA [1001]","HB CH AETNA HMO / PPO","2311.89","58.3","","554.95","91.85","1421.75","94","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2894.82","73","","2490.03","2490.03","2490.03","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2311.89","58.3","","750.00","750.00","750.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2101.72","53","","1192.50","120.84","4149.90","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3370.68","85","","750.00","75.00","750.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3965.50","100","","657.00","121.50","1971.00","14","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3965.50","100","","75.00","75.00","75.00","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3965.50","100","","366.00","144.00","1971.00","45","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2894.82","73","","667.50","667.50","667.50","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1762.66","44.45","","123.77","123.77","123.77","1 through 10","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","both","","","3965.50","2974.12","WELLPOINT [1015]","HB CH WELLPOINT","3089.52","77.91","","483.51","229.32","1316.08","96","1762.66","3965.5","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3965.50","2974.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2351.54","59.3","","439.50","225.34","1872.27","197","1982.75","3110.93","percent of total billed charges",""
"PLATE HIGH STRENGTH 2.7MM 20H","SUP-ITM-10334744","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3965.50","2974.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3110.93","78.45","","385.32","55.36","1815.62","58","1982.75","3110.93","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","AETNA [1001]","HB CH AETNA HMO / PPO","830.91","58.3","","554.95","91.85","1421.75","94","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.43","73","","2490.03","2490.03","2490.03","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.91","58.3","","750.00","750.00","750.00","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.38","53","","1192.50","120.84","4149.90","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.45","85","","750.00","75.00","750.00","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.24","100","","657.00","121.50","1971.00","14","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.24","100","","75.00","75.00","75.00","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.24","100","","366.00","144.00","1971.00","45","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.43","73","","667.50","667.50","667.50","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.52","44.45","","123.77","123.77","123.77","1 through 10","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.24","1068.93","WELLPOINT [1015]","HB CH WELLPOINT","1110.40","77.91","","483.51","229.32","1316.08","96","633.52","1425.24","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.17","59.3","","439.50","225.34","1872.27","197","712.62","1118.1","percent of total billed charges",""
"PLATE HIP 46MM 2 HOLE 135DEG DHS SS COMPRESSION STANDARD BARREL","SUP-ITM-10025369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.24","1068.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1118.10","78.45","","385.32","55.36","1815.62","58","712.62","1118.1","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","AETNA [1001]","HB CH AETNA HMO / PPO","2160.02","58.3","","554.95","91.85","1421.75","94","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2704.65","73","","2490.03","2490.03","2490.03","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2160.02","58.3","","750.00","750.00","750.00","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1963.65","53","","1192.50","120.84","4149.90","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3149.25","85","","750.00","75.00","750.00","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3705.00","100","","657.00","121.50","1971.00","14","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3705.00","100","","75.00","75.00","75.00","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3705.00","100","","366.00","144.00","1971.00","45","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2704.65","73","","667.50","667.50","667.50","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1646.87","44.45","","123.77","123.77","123.77","1 through 10","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","both","","","3705.00","2778.75","WELLPOINT [1015]","HB CH WELLPOINT","2886.57","77.91","","483.51","229.32","1316.08","96","1646.87","3705","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3705.00","2778.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2197.07","59.3","","439.50","225.34","1872.27","197","1852.5","2906.57","percent of total billed charges",""
"PLATE HOOK COMPRESSION JMF 5 HOLE RIGHT","SUP-ITM-10241586","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3705.00","2778.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2906.57","78.45","","385.32","55.36","1815.62","58","1852.5","2906.57","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","AETNA [1001]","HB CH AETNA HMO / PPO","2458.44","58.3","","554.95","91.85","1421.75","94","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3078.32","73","","2490.03","2490.03","2490.03","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2458.44","58.3","","750.00","750.00","750.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2234.95","53","","1192.50","120.84","4149.90","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3584.35","85","","750.00","75.00","750.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4216.88","100","","657.00","121.50","1971.00","14","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4216.88","100","","75.00","75.00","75.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4216.88","100","","366.00","144.00","1971.00","45","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3078.32","73","","667.50","667.50","667.50","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1874.40","44.45","","123.77","123.77","123.77","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","WELLPOINT [1015]","HB CH WELLPOINT","3285.37","77.91","","483.51","229.32","1316.08","96","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4216.88","3162.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2500.61","59.3","","439.50","225.34","1872.27","197","2108.44","3308.14","percent of total billed charges",""
"PLATE HOOK LATERAL MALLEOLUS 6-HOLE ANATOMICAL RIGHT","SUP-ITM-10241325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4216.88","3162.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3308.14","78.45","","385.32","55.36","1815.62","58","2108.44","3308.14","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","AETNA [1001]","HB CH AETNA HMO / PPO","2458.44","58.3","","554.95","91.85","1421.75","94","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3078.32","73","","2490.03","2490.03","2490.03","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2458.44","58.3","","750.00","750.00","750.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2234.95","53","","1192.50","120.84","4149.90","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3584.35","85","","750.00","75.00","750.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4216.88","100","","657.00","121.50","1971.00","14","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4216.88","100","","75.00","75.00","75.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4216.88","100","","366.00","144.00","1971.00","45","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3078.32","73","","667.50","667.50","667.50","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1874.40","44.45","","123.77","123.77","123.77","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","WELLPOINT [1015]","HB CH WELLPOINT","3285.37","77.91","","483.51","229.32","1316.08","96","1874.4","4216.88","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4216.88","3162.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2500.61","59.3","","439.50","225.34","1872.27","197","2108.44","3308.14","percent of total billed charges",""
"PLATE HOOK MEDIAL MALLEOLUS 2-HOLE ANATOMICAL","SUP-ITM-10241324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4216.88","3162.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3308.14","78.45","","385.32","55.36","1815.62","58","2108.44","3308.14","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","AETNA [1001]","HB CH AETNA HMO / PPO","1562.82","58.3","","554.95","91.85","1421.75","94","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1956.87","73","","2490.03","2490.03","2490.03","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1562.82","58.3","","750.00","750.00","750.00","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1420.74","53","","1192.50","120.84","4149.90","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2278.55","85","","750.00","75.00","750.00","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2680.65","100","","657.00","121.50","1971.00","14","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2680.65","100","","75.00","75.00","75.00","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2680.65","100","","366.00","144.00","1971.00","45","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1956.87","73","","667.50","667.50","667.50","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1191.55","44.45","","123.77","123.77","123.77","1 through 10","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","both","","","2680.65","2010.49","WELLPOINT [1015]","HB CH WELLPOINT","2088.49","77.91","","483.51","229.32","1316.08","96","1191.55","2680.65","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1589.63","59.3","","439.50","225.34","1872.27","197","1340.33","2102.97","percent of total billed charges",""
"PLATE HUMERUS 2.7/3.5X72MM SHORT 1 HOLE LCP SS EXTENDED DISTAL MEDIAL RIGHT","SUP-ITM-10114078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2680.65","2010.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2102.97","78.45","","385.32","55.36","1815.62","58","1340.33","2102.97","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","AETNA [1001]","HB CH AETNA HMO / PPO","2206.78","58.3","","554.95","91.85","1421.75","94","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2763.21","73","","2490.03","2490.03","2490.03","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2206.78","58.3","","750.00","750.00","750.00","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2006.17","53","","1192.50","120.84","4149.90","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3217.44","85","","750.00","75.00","750.00","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3785.22","100","","657.00","121.50","1971.00","14","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3785.22","100","","75.00","75.00","75.00","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3785.22","100","","366.00","144.00","1971.00","45","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2763.21","73","","667.50","667.50","667.50","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1682.53","44.45","","123.77","123.77","123.77","1 through 10","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","both","","","3785.22","2838.91","WELLPOINT [1015]","HB CH WELLPOINT","2949.06","77.91","","483.51","229.32","1316.08","96","1682.53","3785.22","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.22","2838.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","2244.64","59.3","","439.50","225.34","1872.27","197","1892.61","2969.51","percent of total billed charges",""
"PLATE HUMERUS 3.5X114MM 6X5 HOLE PROXIMAL LCP STANDARD","SUP-ITM-10009796","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3785.22","2838.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2969.51","78.45","","385.32","55.36","1815.62","58","1892.61","2969.51","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","AETNA [1001]","HB CH AETNA HMO / PPO","1699.59","58.3","","554.95","91.85","1421.75","94","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","2490.03","2490.03","2490.03","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1699.59","58.3","","750.00","750.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1545.08","53","","1192.50","120.84","4149.90","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2477.96","85","","750.00","75.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2915.25","100","","657.00","121.50","1971.00","14","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2915.25","100","","75.00","75.00","75.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2915.25","100","","366.00","144.00","1971.00","45","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","667.50","667.50","667.50","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.83","44.45","","123.77","123.77","123.77","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","WELLPOINT [1015]","HB CH WELLPOINT","2271.27","77.91","","483.51","229.32","1316.08","96","1295.83","2915.25","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.74","59.3","","439.50","225.34","1872.27","197","1457.63","2287.01","percent of total billed charges",""
"PLATE L OBLIQUE 7 HOLE LEFT","SUP-ITM-10241630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2287.01","78.45","","385.32","55.36","1815.62","58","1457.63","2287.01","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","AETNA [1001]","HB CH AETNA HMO / PPO","2458.44","58.3","","554.95","91.85","1421.75","94","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3078.32","73","","2490.03","2490.03","2490.03","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2458.44","58.3","","750.00","750.00","750.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2234.95","53","","1192.50","120.84","4149.90","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3584.35","85","","750.00","75.00","750.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4216.88","100","","657.00","121.50","1971.00","14","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4216.88","100","","75.00","75.00","75.00","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4216.88","100","","366.00","144.00","1971.00","45","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3078.32","73","","667.50","667.50","667.50","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1874.40","44.45","","123.77","123.77","123.77","1 through 10","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","both","","","4216.88","3162.66","WELLPOINT [1015]","HB CH WELLPOINT","3285.37","77.91","","483.51","229.32","1316.08","96","1874.4","4216.88","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4216.88","3162.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2500.61","59.3","","439.50","225.34","1872.27","197","2108.44","3308.14","percent of total billed charges",""
"PLATE MEDIAL MALLEOLUS 7 HOLE ANATOMICAL","SUP-ITM-10241305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4216.88","3162.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3308.14","78.45","","385.32","55.36","1815.62","58","2108.44","3308.14","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","AETNA [1001]","HB CH AETNA HMO / PPO","2538.97","58.3","","554.95","91.85","1421.75","94","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3179.15","73","","2490.03","2490.03","2490.03","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2538.97","58.3","","750.00","750.00","750.00","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2308.15","53","","1192.50","120.84","4149.90","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3701.75","85","","750.00","75.00","750.00","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4355.00","100","","657.00","121.50","1971.00","14","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4355.00","100","","75.00","75.00","75.00","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4355.00","100","","366.00","144.00","1971.00","45","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3179.15","73","","667.50","667.50","667.50","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1935.80","44.45","","123.77","123.77","123.77","1 through 10","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","both","","","4355.00","3266.25","WELLPOINT [1015]","HB CH WELLPOINT","3392.98","77.91","","483.51","229.32","1316.08","96","1935.8","4355","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4355.00","3266.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2582.52","59.3","","439.50","225.34","1872.27","197","2177.5","3416.5","percent of total billed charges",""
"PLATE MESH 6X14 RIGHT 84 HOLE","SUP-ITM-10241576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4355.00","3266.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3416.50","78.45","","385.32","55.36","1815.62","58","2177.5","3416.5","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","AETNA [1001]","HB CH AETNA HMO / PPO","841.27","58.3","","554.95","91.85","1421.75","94","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1053.39","73","","2490.03","2490.03","2490.03","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","841.27","58.3","","750.00","750.00","750.00","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","764.79","53","","1192.50","120.84","4149.90","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1226.55","85","","750.00","75.00","750.00","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1443.00","100","","657.00","121.50","1971.00","14","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1443.00","100","","75.00","75.00","75.00","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1443.00","100","","366.00","144.00","1971.00","45","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1053.39","73","","667.50","667.50","667.50","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","641.41","44.45","","123.77","123.77","123.77","1 through 10","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","both","","","1443.00","1082.25","WELLPOINT [1015]","HB CH WELLPOINT","1124.24","77.91","","483.51","229.32","1316.08","96","641.41","1443","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1443.00","1082.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","855.70","59.3","","439.50","225.34","1872.27","197","721.5","1132.03","percent of total billed charges",""
"PLATE METACARPAL 1.5MM NECK VARIABLE ANGLE LOCKING SS","SUP-ITM-10164609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1443.00","1082.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1132.03","78.45","","385.32","55.36","1815.62","58","721.5","1132.03","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","AETNA [1001]","HB CH AETNA HMO / PPO","951.28","58.3","","554.95","91.85","1421.75","94","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1191.14","73","","2490.03","2490.03","2490.03","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","951.28","58.3","","750.00","750.00","750.00","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","864.80","53","","1192.50","120.84","4149.90","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1386.95","85","","750.00","75.00","750.00","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1631.70","100","","657.00","121.50","1971.00","14","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1631.70","100","","75.00","75.00","75.00","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1631.70","100","","366.00","144.00","1971.00","45","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1191.14","73","","667.50","667.50","667.50","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","725.29","44.45","","123.77","123.77","123.77","1 through 10","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","both","","","1631.70","1223.77","WELLPOINT [1015]","HB CH WELLPOINT","1271.26","77.91","","483.51","229.32","1316.08","96","725.29","1631.7","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","967.60","59.3","","439.50","225.34","1872.27","197","815.85","1280.07","percent of total billed charges",""
"PLATE METACARPAL 2MM LOCKING FIRST DORSAL VARIABLE ANGLE","SUP-ITM-10164585","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1631.70","1223.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1280.07","78.45","","385.32","55.36","1815.62","58","815.85","1280.07","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","AETNA [1001]","HB CH AETNA HMO / PPO","1176.48","58.3","","554.95","91.85","1421.75","94","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1473.13","73","","2490.03","2490.03","2490.03","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1176.48","58.3","","750.00","750.00","750.00","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1069.53","53","","1192.50","120.84","4149.90","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1715.28","85","","750.00","75.00","750.00","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2017.98","100","","657.00","121.50","1971.00","14","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2017.98","100","","75.00","75.00","75.00","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2017.98","100","","366.00","144.00","1971.00","45","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1473.13","73","","667.50","667.50","667.50","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.99","44.45","","123.77","123.77","123.77","1 through 10","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","both","","","2017.98","1513.48","WELLPOINT [1015]","HB CH WELLPOINT","1572.21","77.91","","483.51","229.32","1316.08","96","896.99","2017.98","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2017.98","1513.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","1196.66","59.3","","439.50","225.34","1872.27","197","1008.99","1583.11","percent of total billed charges",""
"PLATE METAPHYSEAL 3.5X125MM 9 HOLE METAPHYSL LCP SS","SUP-ITM-10029055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2017.98","1513.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1583.11","78.45","","385.32","55.36","1815.62","58","1008.99","1583.11","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","AETNA [1001]","HB CH AETNA HMO / PPO","1034.11","58.3","","554.95","91.85","1421.75","94","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1294.86","73","","2490.03","2490.03","2490.03","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1034.11","58.3","","750.00","750.00","750.00","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","940.10","53","","1192.50","120.84","4149.90","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1507.71","85","","750.00","75.00","750.00","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1773.78","100","","657.00","121.50","1971.00","14","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1773.78","100","","75.00","75.00","75.00","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1773.78","100","","366.00","144.00","1971.00","45","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1294.86","73","","667.50","667.50","667.50","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","788.45","44.45","","123.77","123.77","123.77","1 through 10","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","both","","","1773.78","1330.33","WELLPOINT [1015]","HB CH WELLPOINT","1381.95","77.91","","483.51","229.32","1316.08","96","788.45","1773.78","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1773.78","1330.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1051.85","59.3","","439.50","225.34","1872.27","197","886.89","1391.53","percent of total billed charges",""
"PLATE METAPHYSEAL 4.5X3.5MM 8 HOLE LCP TITANIUM","SUP-ITM-10040489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1773.78","1330.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1391.53","78.45","","385.32","55.36","1815.62","58","886.89","1391.53","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","AETNA [1001]","HB CH AETNA HMO / PPO","2240.54","58.3","","554.95","91.85","1421.75","94","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2805.48","73","","2490.03","2490.03","2490.03","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2240.54","58.3","","750.00","750.00","750.00","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2036.86","53","","1192.50","120.84","4149.90","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3266.66","85","","750.00","75.00","750.00","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3843.13","100","","657.00","121.50","1971.00","14","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3843.13","100","","75.00","75.00","75.00","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3843.13","100","","366.00","144.00","1971.00","45","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2805.48","73","","667.50","667.50","667.50","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.27","44.45","","123.77","123.77","123.77","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","WELLPOINT [1015]","HB CH WELLPOINT","2994.18","77.91","","483.51","229.32","1316.08","96","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","2278.98","59.3","","439.50","225.34","1872.27","197","1921.57","3014.94","percent of total billed charges",""
"PLATE MTP 0 DEGREE MED RIGHT","SUP-ITM-10241513","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3014.94","78.45","","385.32","55.36","1815.62","58","1921.57","3014.94","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","AETNA [1001]","HB CH AETNA HMO / PPO","2240.54","58.3","","554.95","91.85","1421.75","94","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2805.48","73","","2490.03","2490.03","2490.03","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2240.54","58.3","","750.00","750.00","750.00","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2036.86","53","","1192.50","120.84","4149.90","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3266.66","85","","750.00","75.00","750.00","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3843.13","100","","657.00","121.50","1971.00","14","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3843.13","100","","75.00","75.00","75.00","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3843.13","100","","366.00","144.00","1971.00","45","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2805.48","73","","667.50","667.50","667.50","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1708.27","44.45","","123.77","123.77","123.77","1 through 10","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","both","","","3843.13","2882.35","WELLPOINT [1015]","HB CH WELLPOINT","2994.18","77.91","","483.51","229.32","1316.08","96","1708.27","3843.13","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","2278.98","59.3","","439.50","225.34","1872.27","197","1921.57","3014.94","percent of total billed charges",""
"PLATE MTP 0 DEGREE SHORT LEFT","SUP-ITM-10241530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3843.13","2882.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3014.94","78.45","","385.32","55.36","1815.62","58","1921.57","3014.94","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","AETNA [1001]","HB CH AETNA HMO / PPO","2154.33","58.3","","554.95","91.85","1421.75","94","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2697.53","73","","2490.03","2490.03","2490.03","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2154.33","58.3","","750.00","750.00","750.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1958.48","53","","1192.50","120.84","4149.90","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3140.96","85","","750.00","75.00","750.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3695.25","100","","657.00","121.50","1971.00","14","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3695.25","100","","75.00","75.00","75.00","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3695.25","100","","366.00","144.00","1971.00","45","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2697.53","73","","667.50","667.50","667.50","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1642.54","44.45","","123.77","123.77","123.77","1 through 10","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","both","","","3695.25","2771.44","WELLPOINT [1015]","HB CH WELLPOINT","2878.97","77.91","","483.51","229.32","1316.08","96","1642.54","3695.25","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3695.25","2771.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","2191.28","59.3","","439.50","225.34","1872.27","197","1847.63","2898.92","percent of total billed charges",""
"PLATE NAVICULAR 9 HOLE MED LEFT","SUP-ITM-10241584","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3695.25","2771.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2898.92","78.45","","385.32","55.36","1815.62","58","1847.63","2898.92","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","AETNA [1001]","HB CH AETNA HMO / PPO","1394.57","58.3","","554.95","91.85","1421.75","94","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1746.20","73","","2490.03","2490.03","2490.03","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1394.57","58.3","","750.00","750.00","750.00","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1267.79","53","","1192.50","120.84","4149.90","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2033.24","85","","750.00","75.00","750.00","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2392.05","100","","657.00","121.50","1971.00","14","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2392.05","100","","75.00","75.00","75.00","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2392.05","100","","366.00","144.00","1971.00","45","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1746.20","73","","667.50","667.50","667.50","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1063.27","44.45","","123.77","123.77","123.77","1 through 10","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","both","","","2392.05","1794.04","WELLPOINT [1015]","HB CH WELLPOINT","1863.65","77.91","","483.51","229.32","1316.08","96","1063.27","2392.05","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2392.05","1794.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1418.49","59.3","","439.50","225.34","1872.27","197","1196.03","1876.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X116MM 4 HOLE ELBOW LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10114052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2392.05","1794.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1876.56","78.45","","385.32","55.36","1815.62","58","1196.03","1876.56","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","AETNA [1001]","HB CH AETNA HMO / PPO","1215.31","58.3","","554.95","91.85","1421.75","94","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1521.74","73","","2490.03","2490.03","2490.03","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1215.31","58.3","","750.00","750.00","750.00","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1104.83","53","","1192.50","120.84","4149.90","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1771.89","85","","750.00","75.00","750.00","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2084.58","100","","657.00","121.50","1971.00","14","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2084.58","100","","75.00","75.00","75.00","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2084.58","100","","366.00","144.00","1971.00","45","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1521.74","73","","667.50","667.50","667.50","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.60","44.45","","123.77","123.77","123.77","1 through 10","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","both","","","2084.58","1563.43","WELLPOINT [1015]","HB CH WELLPOINT","1624.10","77.91","","483.51","229.32","1316.08","96","926.6","2084.58","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.58","1563.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","1236.16","59.3","","439.50","225.34","1872.27","197","1042.29","1635.35","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE LCP SS PROXIMAL VARIABLE ANGLE RIGHT","SUP-ITM-10114050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2084.58","1563.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1635.35","78.45","","385.32","55.36","1815.62","58","1042.29","1635.35","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","AETNA [1001]","HB CH AETNA HMO / PPO","1336.32","58.3","","1634.24","1004.95","1718.99","42","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1673.27","73","","2123.89","1900.92","2123.89","1 through 10","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1336.32","58.3","","3729.00","1254.19","3729.00","1 through 10","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1214.84","53","","939.37","939.37","5593.65","1 through 10","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1948.33","85","","2323.25","1864.50","2882.25","16","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2292.15","100","","2909.44","1772.40","10952.08","45","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2292.15","100","","2323.25","2323.25","2323.25","1 through 10","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2292.15","100","","2882.25","1772.40","10169.17","187","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1673.27","73","","1659.41","1659.41","1659.41","1 through 10","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","both","","","2292.15","1719.11","WELLPOINT [1015]","HB CH WELLPOINT","1785.81","77.91","","2050.91","1468.48","2902.83","52","1018.86","2292.15","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2292.15","1719.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","1359.24","59.3","","1548.60","1092.60","3613.79","82","1146.08","1798.19","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X73MM 2 HOLE BONE VA LCP SS PROXIMAL VARIABLE ANGLE LEFT","SUP-ITM-10124804","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2292.15","1719.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1798.19","78.45","","2085.51","998.68","6202.11","56","1146.08","1798.19","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","AETNA [1001]","HB CH AETNA HMO / PPO","1358.33","58.3","","554.95","91.85","1421.75","94","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1700.82","73","","2490.03","2490.03","2490.03","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1358.33","58.3","","750.00","750.00","750.00","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1234.84","53","","1192.50","120.84","4149.90","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1980.41","85","","750.00","75.00","750.00","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2329.89","100","","657.00","121.50","1971.00","14","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2329.89","100","","75.00","75.00","75.00","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2329.89","100","","366.00","144.00","1971.00","45","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1700.82","73","","667.50","667.50","667.50","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1035.64","44.45","","123.77","123.77","123.77","1 through 10","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","both","","","2329.89","1747.42","WELLPOINT [1015]","HB CH WELLPOINT","1815.22","77.91","","483.51","229.32","1316.08","96","1035.64","2329.89","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.89","1747.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","1381.62","59.3","","439.50","225.34","1872.27","197","1164.95","1827.8","percent of total billed charges",""
"PLATE OLECRANON 2.7-3.5X90MM 2 HOLE LCP SS VARIABLE ANGLE RIGHT","SUP-ITM-10113433","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2329.89","1747.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1827.80","78.45","","385.32","55.36","1815.62","58","1164.95","1827.8","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","AETNA [1001]","HB CH AETNA HMO / PPO","1216.18","58.3","","554.95","91.85","1421.75","94","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1522.84","73","","2490.03","2490.03","2490.03","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1216.18","58.3","","750.00","750.00","750.00","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1105.62","53","","1192.50","120.84","4149.90","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1773.17","85","","750.00","75.00","750.00","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2086.08","100","","657.00","121.50","1971.00","14","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2086.08","100","","75.00","75.00","75.00","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2086.08","100","","366.00","144.00","1971.00","45","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1522.84","73","","667.50","667.50","667.50","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","927.26","44.45","","123.77","123.77","123.77","1 through 10","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","both","","","2086.08","1564.56","WELLPOINT [1015]","HB CH WELLPOINT","1625.26","77.91","","483.51","229.32","1316.08","96","927.26","2086.08","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2086.08","1564.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1237.05","59.3","","439.50","225.34","1872.27","197","1043.04","1636.53","percent of total billed charges",""
"PLATE OLECRANON 3.5X112MM 4 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10019763","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2086.08","1564.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1636.53","78.45","","385.32","55.36","1815.62","58","1043.04","1636.53","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","AETNA [1001]","HB CH AETNA HMO / PPO","1253.68","58.3","","554.95","91.85","1421.75","94","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1569.79","73","","2490.03","2490.03","2490.03","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1253.68","58.3","","750.00","750.00","750.00","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1139.71","53","","1192.50","120.84","4149.90","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1827.84","85","","750.00","75.00","750.00","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2150.40","100","","657.00","121.50","1971.00","14","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2150.40","100","","75.00","75.00","75.00","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2150.40","100","","366.00","144.00","1971.00","45","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1569.79","73","","667.50","667.50","667.50","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","955.85","44.45","","123.77","123.77","123.77","1 through 10","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","both","","","2150.40","1612.80","WELLPOINT [1015]","HB CH WELLPOINT","1675.38","77.91","","483.51","229.32","1316.08","96","955.85","2150.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2150.40","1612.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","1275.19","59.3","","439.50","225.34","1872.27","197","1075.2","1686.99","percent of total billed charges",""
"PLATE OLECRANON 3.5X138MM 6 HOLE COMPRESSION LCP SS RIGHT","SUP-ITM-10021721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2150.40","1612.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1686.99","78.45","","385.32","55.36","1815.62","58","1075.2","1686.99","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","AETNA [1001]","HB CH AETNA HMO / PPO","1292.30","58.3","","554.95","91.85","1421.75","94","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1618.15","73","","2490.03","2490.03","2490.03","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1292.30","58.3","","750.00","750.00","750.00","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1174.82","53","","1192.50","120.84","4149.90","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1884.14","85","","750.00","75.00","750.00","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2216.64","100","","657.00","121.50","1971.00","14","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2216.64","100","","75.00","75.00","75.00","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2216.64","100","","366.00","144.00","1971.00","45","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1618.15","73","","667.50","667.50","667.50","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","985.30","44.45","","123.77","123.77","123.77","1 through 10","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","both","","","2216.64","1662.48","WELLPOINT [1015]","HB CH WELLPOINT","1726.98","77.91","","483.51","229.32","1316.08","96","985.3","2216.64","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2216.64","1662.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","1314.47","59.3","","439.50","225.34","1872.27","197","1108.32","1738.95","percent of total billed charges",""
"PLATE OLECRANON 3.5X164MM 8 HOLE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022290","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2216.64","1662.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1738.95","78.45","","385.32","55.36","1815.62","58","1108.32","1738.95","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","AETNA [1001]","HB CH AETNA HMO / PPO","1329.80","58.3","","554.95","91.85","1421.75","94","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1665.10","73","","2490.03","2490.03","2490.03","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1329.80","58.3","","750.00","750.00","750.00","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1208.91","53","","1192.50","120.84","4149.90","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1938.82","85","","750.00","75.00","750.00","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2280.96","100","","657.00","121.50","1971.00","14","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2280.96","100","","75.00","75.00","75.00","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2280.96","100","","366.00","144.00","1971.00","45","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1665.10","73","","667.50","667.50","667.50","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1013.89","44.45","","123.77","123.77","123.77","1 through 10","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","both","","","2280.96","1710.72","WELLPOINT [1015]","HB CH WELLPOINT","1777.10","77.91","","483.51","229.32","1316.08","96","1013.89","2280.96","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2280.96","1710.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","1352.61","59.3","","439.50","225.34","1872.27","197","1140.48","1789.41","percent of total billed charges",""
"PLATE OLECRANON 3.5X190MM 10 HOLE COMPRESSION LCP SS LEFT","SUP-ITM-10022094","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2280.96","1710.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1789.41","78.45","","385.32","55.36","1815.62","58","1140.48","1789.41","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","AETNA [1001]","HB CH AETNA HMO / PPO","1351.63","58.3","","554.95","91.85","1421.75","94","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1692.43","73","","2490.03","2490.03","2490.03","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1351.63","58.3","","750.00","750.00","750.00","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1228.75","53","","1192.50","120.84","4149.90","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1970.64","85","","750.00","75.00","750.00","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2318.40","100","","657.00","121.50","1971.00","14","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2318.40","100","","75.00","75.00","75.00","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2318.40","100","","366.00","144.00","1971.00","45","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1692.43","73","","667.50","667.50","667.50","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1030.53","44.45","","123.77","123.77","123.77","1 through 10","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","both","","","2318.40","1738.80","WELLPOINT [1015]","HB CH WELLPOINT","1806.27","77.91","","483.51","229.32","1316.08","96","1030.53","2318.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2318.40","1738.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","1374.81","59.3","","439.50","225.34","1872.27","197","1159.2","1818.78","percent of total billed charges",""
"PLATE OLECRANON 3.5X216MM 10 HOLE BONE COMPRESSION LOCKING LCP SS RIGHT","SUP-ITM-10022293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2318.40","1738.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1818.78","78.45","","385.32","55.36","1815.62","58","1159.2","1818.78","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","AETNA [1001]","HB CH AETNA HMO / PPO","721.99","58.3","","554.95","91.85","1421.75","94","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","904.03","73","","2490.03","2490.03","2490.03","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","721.99","58.3","","750.00","750.00","750.00","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","656.35","53","","1192.50","120.84","4149.90","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1052.64","85","","750.00","75.00","750.00","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1238.40","100","","657.00","121.50","1971.00","14","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1238.40","100","","75.00","75.00","75.00","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1238.40","100","","366.00","144.00","1971.00","45","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","904.03","73","","667.50","667.50","667.50","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","550.47","44.45","","123.77","123.77","123.77","1 through 10","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","both","","","1238.40","928.80","WELLPOINT [1015]","HB CH WELLPOINT","964.84","77.91","","483.51","229.32","1316.08","96","550.47","1238.4","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1238.40","928.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","734.37","59.3","","439.50","225.34","1872.27","197","619.2","971.52","percent of total billed charges",""
"PLATE OLECRANON 3.5X62MM 3 HOLE LCP SS HOOK","SUP-ITM-10073329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1238.40","928.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","971.52","78.45","","385.32","55.36","1815.62","58","619.2","971.52","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","AETNA [1001]","HB CH AETNA HMO / PPO","1165.25","58.3","","554.95","91.85","1421.75","94","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1459.07","73","","2490.03","2490.03","2490.03","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1165.25","58.3","","750.00","750.00","750.00","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1059.32","53","","1192.50","120.84","4149.90","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1698.91","85","","750.00","75.00","750.00","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1998.72","100","","657.00","121.50","1971.00","14","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1998.72","100","","75.00","75.00","75.00","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1998.72","100","","366.00","144.00","1971.00","45","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1459.07","73","","667.50","667.50","667.50","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","888.43","44.45","","123.77","123.77","123.77","1 through 10","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","both","","","1998.72","1499.04","WELLPOINT [1015]","HB CH WELLPOINT","1557.20","77.91","","483.51","229.32","1316.08","96","888.43","1998.72","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1998.72","1499.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","1185.24","59.3","","439.50","225.34","1872.27","197","999.36","1568","percent of total billed charges",""
"PLATE OLECRANON 3.5X86MM 2 HOLE COMPRESSION LOCKING LCP SS LEFT","SUP-ITM-10021719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1998.72","1499.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1568.00","78.45","","385.32","55.36","1815.62","58","999.36","1568","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","AETNA [1001]","HB CH AETNA HMO / PPO","1047.06","58.3","","554.95","91.85","1421.75","94","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1311.07","73","","2490.03","2490.03","2490.03","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1047.06","58.3","","750.00","750.00","750.00","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","951.87","53","","1192.50","120.84","4149.90","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1526.58","85","","750.00","75.00","750.00","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1795.98","100","","657.00","121.50","1971.00","14","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1795.98","100","","75.00","75.00","75.00","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1795.98","100","","366.00","144.00","1971.00","45","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1311.07","73","","667.50","667.50","667.50","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","798.31","44.45","","123.77","123.77","123.77","1 through 10","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","both","","","1795.98","1346.98","WELLPOINT [1015]","HB CH WELLPOINT","1399.25","77.91","","483.51","229.32","1316.08","96","798.31","1795.98","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.98","1346.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","1065.02","59.3","","439.50","225.34","1872.27","197","897.99","1408.95","percent of total billed charges",""
"PLATE PELVIC 4.5X221MM 14 HOLE LCP RECONSTRUCTION SS BROAD STRAIGHT","SUP-ITM-10004229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1795.98","1346.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1408.95","78.45","","385.32","55.36","1815.62","58","897.99","1408.95","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","AETNA [1001]","HB CH AETNA HMO / PPO","2259.22","58.3","","554.95","91.85","1421.75","94","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2828.87","73","","2490.03","2490.03","2490.03","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2259.22","58.3","","750.00","750.00","750.00","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2053.83","53","","1192.50","120.84","4149.90","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3293.89","85","","750.00","75.00","750.00","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3875.16","100","","657.00","121.50","1971.00","14","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3875.16","100","","75.00","75.00","75.00","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3875.16","100","","366.00","144.00","1971.00","45","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2828.87","73","","667.50","667.50","667.50","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1722.51","44.45","","123.77","123.77","123.77","1 through 10","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","both","","","3875.16","2906.37","WELLPOINT [1015]","HB CH WELLPOINT","3019.14","77.91","","483.51","229.32","1316.08","96","1722.51","3875.16","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3875.16","2906.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2297.97","59.3","","439.50","225.34","1872.27","197","1937.58","3040.06","percent of total billed charges",""
"PLATE RADIUS 125MM 7 HOLE SHAFT LCP SS META VOLAR EXTRA ACTICULAR RIGHT DISTAL","SUP-ITM-10023170","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3875.16","2906.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3040.06","78.45","","385.32","55.36","1815.62","58","1937.58","3040.06","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","AETNA [1001]","HB CH AETNA HMO / PPO","1310.16","58.3","","554.95","91.85","1421.75","94","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1640.51","73","","2490.03","2490.03","2490.03","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1310.16","58.3","","750.00","750.00","750.00","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1191.05","53","","1192.50","120.84","4149.90","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1910.18","85","","750.00","75.00","750.00","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2247.27","100","","657.00","121.50","1971.00","14","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2247.27","100","","75.00","75.00","75.00","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2247.27","100","","366.00","144.00","1971.00","45","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1640.51","73","","667.50","667.50","667.50","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","998.91","44.45","","123.77","123.77","123.77","1 through 10","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","both","","","2247.27","1685.45","WELLPOINT [1015]","HB CH WELLPOINT","1750.85","77.91","","483.51","229.32","1316.08","96","998.91","2247.27","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2247.27","1685.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1332.63","59.3","","439.50","225.34","1872.27","197","1123.64","1762.98","percent of total billed charges",""
"PLATE RADIUS 2.4MM DISTAL 6 HOLE HEAD 4 SHAFT BONE LCP SS 2 COLUMN VARIABLE ANGLE RIGHT","SUP-ITM-10056611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2247.27","1685.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1762.98","78.45","","385.32","55.36","1815.62","58","1123.64","1762.98","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","AETNA [1001]","HB CH AETNA HMO / PPO","1359.13","58.3","","554.95","91.85","1421.75","94","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1701.83","73","","2490.03","2490.03","2490.03","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1359.13","58.3","","750.00","750.00","750.00","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1235.57","53","","1192.50","120.84","4149.90","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1981.58","85","","750.00","75.00","750.00","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2331.27","100","","657.00","121.50","1971.00","14","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2331.27","100","","75.00","75.00","75.00","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2331.27","100","","366.00","144.00","1971.00","45","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1701.83","73","","667.50","667.50","667.50","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1036.25","44.45","","123.77","123.77","123.77","1 through 10","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","both","","","2331.27","1748.45","WELLPOINT [1015]","HB CH WELLPOINT","1816.29","77.91","","483.51","229.32","1316.08","96","1036.25","2331.27","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.27","1748.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1382.44","59.3","","439.50","225.34","1872.27","197","1165.64","1828.88","percent of total billed charges",""
"PLATE RADIUS 2.4X19.5X72MM DISTAL 6 HEAD HOLE 5 SHAFT HOLE VA LCP SS 2 COLUMN NARROW VOLAR LEFT","SUP-ITM-10093974","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2331.27","1748.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1828.88","78.45","","385.32","55.36","1815.62","58","1165.64","1828.88","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","AETNA [1001]","HB CH AETNA HMO / PPO","880.10","58.3","","554.95","91.85","1421.75","94","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1102.01","73","","2490.03","2490.03","2490.03","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","880.10","58.3","","750.00","750.00","750.00","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","800.09","53","","1192.50","120.84","4149.90","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1283.16","85","","750.00","75.00","750.00","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1509.60","100","","657.00","121.50","1971.00","14","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1509.60","100","","75.00","75.00","75.00","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1509.60","100","","366.00","144.00","1971.00","45","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1102.01","73","","667.50","667.50","667.50","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","671.02","44.45","","123.77","123.77","123.77","1 through 10","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","both","","","1509.60","1132.20","WELLPOINT [1015]","HB CH WELLPOINT","1176.13","77.91","","483.51","229.32","1316.08","96","671.02","1509.6","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1509.60","1132.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","895.19","59.3","","439.50","225.34","1872.27","197","754.8","1184.28","percent of total billed charges",""
"PLATE RADIUS 2.4X28MM 2 HOLE LCP RADIAL HEAD NECK","SUP-ITM-10019035","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1509.60","1132.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1184.28","78.45","","385.32","55.36","1815.62","58","754.8","1184.28","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","AETNA [1001]","HB CH AETNA HMO / PPO","956.63","58.3","","554.95","91.85","1421.75","94","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1197.84","73","","2490.03","2490.03","2490.03","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","956.63","58.3","","750.00","750.00","750.00","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","869.67","53","","1192.50","120.84","4149.90","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1394.75","85","","750.00","75.00","750.00","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1640.88","100","","657.00","121.50","1971.00","14","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1640.88","100","","75.00","75.00","75.00","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1640.88","100","","366.00","144.00","1971.00","45","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1197.84","73","","667.50","667.50","667.50","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","729.37","44.45","","123.77","123.77","123.77","1 through 10","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","both","","","1640.88","1230.66","WELLPOINT [1015]","HB CH WELLPOINT","1278.41","77.91","","483.51","229.32","1316.08","96","729.37","1640.88","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1640.88","1230.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","973.04","59.3","","439.50","225.34","1872.27","197","820.44","1287.27","percent of total billed charges",""
"PLATE RADIUS 2.4X40MM 2 HOLE HEAD 3 SHAFT 90DEG HUMERAL LCP L SS SHAPE RIGHT ANGLE LEFT MINUS","SUP-ITM-10016912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1640.88","1230.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1287.27","78.45","","385.32","55.36","1815.62","58","820.44","1287.27","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","AETNA [1001]","HB CH AETNA HMO / PPO","1031.09","58.3","","554.95","91.85","1421.75","94","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1291.07","73","","2490.03","2490.03","2490.03","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.09","58.3","","750.00","750.00","750.00","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","937.35","53","","1192.50","120.84","4149.90","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1503.30","85","","750.00","75.00","750.00","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1768.59","100","","657.00","121.50","1971.00","14","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1768.59","100","","75.00","75.00","75.00","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1768.59","100","","366.00","144.00","1971.00","45","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1291.07","73","","667.50","667.50","667.50","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.14","44.45","","123.77","123.77","123.77","1 through 10","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","both","","","1768.59","1326.44","WELLPOINT [1015]","HB CH WELLPOINT","1377.91","77.91","","483.51","229.32","1316.08","96","786.14","1768.59","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1768.59","1326.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1048.77","59.3","","439.50","225.34","1872.27","197","884.3","1387.46","percent of total billed charges",""
"PLATE RADIUS 2.4X49MM DISTAL 3 HOLE HD 4 SHAFT BONE LCP T SHAPE","SUP-ITM-10016925","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1768.59","1326.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1387.46","78.45","","385.32","55.36","1815.62","58","884.3","1387.46","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","AETNA [1001]","HB CH AETNA HMO / PPO","2057.38","58.3","","554.95","91.85","1421.75","94","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2576.14","73","","2490.03","2490.03","2490.03","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2057.38","58.3","","750.00","750.00","750.00","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1870.35","53","","1192.50","120.84","4149.90","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2999.62","85","","750.00","75.00","750.00","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3528.96","100","","657.00","121.50","1971.00","14","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3528.96","100","","75.00","75.00","75.00","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3528.96","100","","366.00","144.00","1971.00","45","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2576.14","73","","667.50","667.50","667.50","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1568.62","44.45","","123.77","123.77","123.77","1 through 10","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","both","","","3528.96","2646.72","WELLPOINT [1015]","HB CH WELLPOINT","2749.41","77.91","","483.51","229.32","1316.08","96","1568.62","3528.96","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.96","2646.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","2092.67","59.3","","439.50","225.34","1872.27","197","1764.48","2768.47","percent of total billed charges",""
"PLATE RADIUS 22X109MM DISTAL 6 HEAD HOLE 7 SHAFT HOLE SS VA LCP 2 COLUMN VOLAR STANDARD LEFT","SUP-ITM-10212954","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3528.96","2646.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2768.47","78.45","","385.32","55.36","1815.62","58","1764.48","2768.47","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","AETNA [1001]","HB CH AETNA HMO / PPO","2261.02","58.3","","554.95","91.85","1421.75","94","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2831.12","73","","2490.03","2490.03","2490.03","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2261.02","58.3","","750.00","750.00","750.00","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2055.47","53","","1192.50","120.84","4149.90","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3296.51","85","","750.00","75.00","750.00","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3878.25","100","","657.00","121.50","1971.00","14","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3878.25","100","","75.00","75.00","75.00","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3878.25","100","","366.00","144.00","1971.00","45","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2831.12","73","","667.50","667.50","667.50","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1723.88","44.45","","123.77","123.77","123.77","1 through 10","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","both","","","3878.25","2908.69","WELLPOINT [1015]","HB CH WELLPOINT","3021.54","77.91","","483.51","229.32","1316.08","96","1723.88","3878.25","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2299.80","59.3","","439.50","225.34","1872.27","197","1939.13","3042.49","percent of total billed charges",""
"PLATE RADIUS 56MM SHORT 4 HOLE VARIAX INTERMEDIATE LEFT","SUP-ITM-10174736","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3878.25","2908.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3042.49","78.45","","385.32","55.36","1815.62","58","1939.13","3042.49","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","AETNA [1001]","HB CH AETNA HMO / PPO","1630.70","58.3","","554.95","91.85","1421.75","94","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2041.87","73","","2490.03","2490.03","2490.03","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1630.70","58.3","","750.00","750.00","750.00","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1482.45","53","","1192.50","120.84","4149.90","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2377.52","85","","750.00","75.00","750.00","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2797.08","100","","657.00","121.50","1971.00","14","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2797.08","100","","75.00","75.00","75.00","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2797.08","100","","366.00","144.00","1971.00","45","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2041.87","73","","667.50","667.50","667.50","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1243.30","44.45","","123.77","123.77","123.77","1 through 10","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","both","","","2797.08","2097.81","WELLPOINT [1015]","HB CH WELLPOINT","2179.21","77.91","","483.51","229.32","1316.08","96","1243.3","2797.08","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.08","2097.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1658.67","59.3","","439.50","225.34","1872.27","197","1398.54","2194.31","percent of total billed charges",""
"PLATE RADIUS VOLAR DVR RIM LEFT STANDARD","SUP-ITM-10188740","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2797.08","2097.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2194.31","78.45","","385.32","55.36","1815.62","58","1398.54","2194.31","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","554.95","91.85","1421.75","94","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","2490.03","2490.03","2490.03","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","682.11","58.3","","750.00","750.00","750.00","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","620.10","53","","1192.50","120.84","4149.90","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","994.50","85","","750.00","75.00","750.00","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1170.00","100","","657.00","121.50","1971.00","14","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1170.00","100","","75.00","75.00","75.00","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1170.00","100","","366.00","144.00","1971.00","45","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","667.50","667.50","667.50","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","123.77","123.77","123.77","1 through 10","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","483.51","229.32","1316.08","96","520.07","1170","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","439.50","225.34","1872.27","197","585","917.87","percent of total billed charges",""
"PLATE SCREW SPINE MODULAR POLYAXIAL TULIP","SUP-ITM-10272776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","385.32","55.36","1815.62","58","585","917.87","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","AETNA [1001]","HB CH AETNA HMO / PPO","2060.54","58.3","","554.95","91.85","1421.75","94","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2580.10","73","","2490.03","2490.03","2490.03","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2060.54","58.3","","750.00","750.00","750.00","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1873.22","53","","1192.50","120.84","4149.90","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3004.22","85","","750.00","75.00","750.00","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3534.38","100","","657.00","121.50","1971.00","14","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3534.38","100","","75.00","75.00","75.00","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3534.38","100","","366.00","144.00","1971.00","45","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2580.10","73","","667.50","667.50","667.50","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1571.03","44.45","","123.77","123.77","123.77","1 through 10","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","both","","","3534.38","2650.78","WELLPOINT [1015]","HB CH WELLPOINT","2753.64","77.91","","483.51","229.32","1316.08","96","1571.03","3534.38","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.38","2650.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","2095.89","59.3","","439.50","225.34","1872.27","197","1767.19","2772.72","percent of total billed charges",""
"PLATE SINUS SUPPORT TARSI RIGHT SM","SUP-ITM-10241536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3534.38","2650.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2772.72","78.45","","385.32","55.36","1815.62","58","1767.19","2772.72","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","AETNA [1001]","HB CH AETNA HMO / PPO","2131.59","58.3","","554.95","91.85","1421.75","94","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","2490.03","2490.03","2490.03","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2131.59","58.3","","750.00","750.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1937.81","53","","1192.50","120.84","4149.90","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3107.81","85","","750.00","75.00","750.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3656.25","100","","657.00","121.50","1971.00","14","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3656.25","100","","75.00","75.00","75.00","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3656.25","100","","366.00","144.00","1971.00","45","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2669.06","73","","667.50","667.50","667.50","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1625.20","44.45","","123.77","123.77","123.77","1 through 10","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","both","","","3656.25","2742.19","WELLPOINT [1015]","HB CH WELLPOINT","2848.58","77.91","","483.51","229.32","1316.08","96","1625.2","3656.25","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","2168.16","59.3","","439.50","225.34","1872.27","197","1828.13","2868.33","percent of total billed charges",""
"PLATE SLANTED LISFRANC T 4-HOLE W/ COMPRESSION RIGHT","SUP-ITM-10241388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3656.25","2742.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2868.33","78.45","","385.32","55.36","1815.62","58","1828.13","2868.33","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","AETNA [1001]","HB CH AETNA HMO / PPO","3434.80","58.3","","554.95","91.85","1421.75","94","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4300.87","73","","2490.03","2490.03","2490.03","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3434.80","58.3","","750.00","750.00","750.00","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3122.55","53","","1192.50","120.84","4149.90","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5007.86","85","","750.00","75.00","750.00","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5891.60","100","","657.00","121.50","1971.00","14","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5891.60","100","","75.00","75.00","75.00","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5891.60","100","","366.00","144.00","1971.00","45","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4300.87","73","","667.50","667.50","667.50","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2618.82","44.45","","123.77","123.77","123.77","1 through 10","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","both","","","5891.60","4418.70","WELLPOINT [1015]","HB CH WELLPOINT","4590.15","77.91","","483.51","229.32","1316.08","96","2618.82","5891.6","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5891.60","4418.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","3493.72","59.3","","439.50","225.34","1872.27","197","2945.8","4621.96","percent of total billed charges",""
"PLATE SPANNING DORSAL","SUP-ITM-10319612","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5891.60","4418.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4621.96","78.45","","385.32","55.36","1815.62","58","2945.8","4621.96","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","AETNA [1001]","HB CH AETNA HMO / PPO","1288.05","58.3","","554.95","91.85","1421.75","94","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1612.83","73","","2490.03","2490.03","2490.03","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1288.05","58.3","","750.00","750.00","750.00","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1170.96","53","","1192.50","120.84","4149.90","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1877.95","85","","750.00","75.00","750.00","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2209.35","100","","657.00","121.50","1971.00","14","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2209.35","100","","75.00","75.00","75.00","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2209.35","100","","366.00","144.00","1971.00","45","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1612.83","73","","667.50","667.50","667.50","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","982.06","44.45","","123.77","123.77","123.77","1 through 10","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","both","","","2209.35","1657.01","WELLPOINT [1015]","HB CH WELLPOINT","1721.30","77.91","","483.51","229.32","1316.08","96","982.06","2209.35","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2209.35","1657.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","1310.14","59.3","","439.50","225.34","1872.27","197","1104.68","1733.24","percent of total billed charges",""
"PLATE STRAIGHT 1.5MM/2.0MM 10H","SUP-ITM-10334838","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2209.35","1657.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1733.24","78.45","","385.32","55.36","1815.62","58","1104.68","1733.24","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","AETNA [1001]","HB CH AETNA HMO / PPO","2268.02","58.3","","554.95","91.85","1421.75","94","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2839.88","73","","2490.03","2490.03","2490.03","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2268.02","58.3","","750.00","750.00","750.00","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2061.83","53","","1192.50","120.84","4149.90","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3306.71","85","","750.00","75.00","750.00","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3890.25","100","","657.00","121.50","1971.00","14","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3890.25","100","","75.00","75.00","75.00","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3890.25","100","","366.00","144.00","1971.00","45","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2839.88","73","","667.50","667.50","667.50","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1729.22","44.45","","123.77","123.77","123.77","1 through 10","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","both","","","3890.25","2917.69","WELLPOINT [1015]","HB CH WELLPOINT","3030.89","77.91","","483.51","229.32","1316.08","96","1729.22","3890.25","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","2306.92","59.3","","439.50","225.34","1872.27","197","1945.13","3051.9","percent of total billed charges",""
"PLATE STRAIGHT T20 HOLE 1.4MM THICK","SUP-ITM-10241632","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3890.25","2917.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3051.90","78.45","","385.32","55.36","1815.62","58","1945.13","3051.9","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","AETNA [1001]","HB CH AETNA HMO / PPO","1699.59","58.3","","554.95","91.85","1421.75","94","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","2490.03","2490.03","2490.03","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1699.59","58.3","","750.00","750.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1545.08","53","","1192.50","120.84","4149.90","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2477.96","85","","750.00","75.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2915.25","100","","657.00","121.50","1971.00","14","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2915.25","100","","75.00","75.00","75.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2915.25","100","","366.00","144.00","1971.00","45","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","667.50","667.50","667.50","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.83","44.45","","123.77","123.77","123.77","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","WELLPOINT [1015]","HB CH WELLPOINT","2271.27","77.91","","483.51","229.32","1316.08","96","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.74","59.3","","439.50","225.34","1872.27","197","1457.63","2287.01","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE","SUP-ITM-10241641","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2287.01","78.45","","385.32","55.36","1815.62","58","1457.63","2287.01","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","AETNA [1001]","HB CH AETNA HMO / PPO","1699.59","58.3","","554.95","91.85","1421.75","94","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","2490.03","2490.03","2490.03","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1699.59","58.3","","750.00","750.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1545.08","53","","1192.50","120.84","4149.90","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2477.96","85","","750.00","75.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2915.25","100","","657.00","121.50","1971.00","14","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2915.25","100","","75.00","75.00","75.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2915.25","100","","366.00","144.00","1971.00","45","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","667.50","667.50","667.50","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.83","44.45","","123.77","123.77","123.77","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","WELLPOINT [1015]","HB CH WELLPOINT","2271.27","77.91","","483.51","229.32","1316.08","96","1295.83","2915.25","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.74","59.3","","439.50","225.34","1872.27","197","1457.63","2287.01","percent of total billed charges",""
"PLATE STRAIGHT T6 HOLE W/ COMPRESSION","SUP-ITM-10241637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2287.01","78.45","","385.32","55.36","1815.62","58","1457.63","2287.01","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","AETNA [1001]","HB CH AETNA HMO / PPO","1699.59","58.3","","554.95","91.85","1421.75","94","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","2490.03","2490.03","2490.03","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1699.59","58.3","","750.00","750.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1545.08","53","","1192.50","120.84","4149.90","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2477.96","85","","750.00","75.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2915.25","100","","657.00","121.50","1971.00","14","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2915.25","100","","75.00","75.00","75.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2915.25","100","","366.00","144.00","1971.00","45","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","667.50","667.50","667.50","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.83","44.45","","123.77","123.77","123.77","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","WELLPOINT [1015]","HB CH WELLPOINT","2271.27","77.91","","483.51","229.32","1316.08","96","1295.83","2915.25","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.74","59.3","","439.50","225.34","1872.27","197","1457.63","2287.01","percent of total billed charges",""
"PLATE T10 HOLE T5","SUP-ITM-10241598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2287.01","78.45","","385.32","55.36","1815.62","58","1457.63","2287.01","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","AETNA [1001]","HB CH AETNA HMO / PPO","1699.59","58.3","","554.95","91.85","1421.75","94","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","2490.03","2490.03","2490.03","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1699.59","58.3","","750.00","750.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1545.08","53","","1192.50","120.84","4149.90","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2477.96","85","","750.00","75.00","750.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2915.25","100","","657.00","121.50","1971.00","14","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2915.25","100","","75.00","75.00","75.00","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2915.25","100","","366.00","144.00","1971.00","45","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2128.13","73","","667.50","667.50","667.50","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1295.83","44.45","","123.77","123.77","123.77","1 through 10","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","both","","","2915.25","2186.44","WELLPOINT [1015]","HB CH WELLPOINT","2271.27","77.91","","483.51","229.32","1316.08","96","1295.83","2915.25","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1728.74","59.3","","439.50","225.34","1872.27","197","1457.63","2287.01","percent of total billed charges",""
"PLATE T9 HOLE T3","SUP-ITM-10241600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2915.25","2186.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2287.01","78.45","","385.32","55.36","1815.62","58","1457.63","2287.01","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","AETNA [1001]","HB CH AETNA HMO / PPO","1979.07","58.3","","554.95","91.85","1421.75","94","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2478.08","73","","2490.03","2490.03","2490.03","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1979.07","58.3","","750.00","750.00","750.00","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1799.15","53","","1192.50","120.84","4149.90","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2885.44","85","","750.00","75.00","750.00","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3394.63","100","","657.00","121.50","1971.00","14","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3394.63","100","","75.00","75.00","75.00","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3394.63","100","","366.00","144.00","1971.00","45","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2478.08","73","","667.50","667.50","667.50","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1508.91","44.45","","123.77","123.77","123.77","1 through 10","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","both","","","3394.63","2545.97","WELLPOINT [1015]","HB CH WELLPOINT","2644.76","77.91","","483.51","229.32","1316.08","96","1508.91","3394.63","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3394.63","2545.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","2013.02","59.3","","439.50","225.34","1872.27","197","1697.32","2663.09","percent of total billed charges",""
"PLATE TEDDY BEAR SM","SUP-ITM-10241350","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3394.63","2545.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2663.09","78.45","","385.32","55.36","1815.62","58","1697.32","2663.09","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","AETNA [1001]","HB CH AETNA HMO / PPO","1454.75","58.3","","554.95","91.85","1421.75","94","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1821.55","73","","2490.03","2490.03","2490.03","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1454.75","58.3","","750.00","750.00","750.00","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1322.50","53","","1192.50","120.84","4149.90","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2120.99","85","","750.00","75.00","750.00","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2495.28","100","","657.00","121.50","1971.00","14","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2495.28","100","","75.00","75.00","75.00","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2495.28","100","","366.00","144.00","1971.00","45","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1821.55","73","","667.50","667.50","667.50","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1109.15","44.45","","123.77","123.77","123.77","1 through 10","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","both","","","2495.28","1871.46","WELLPOINT [1015]","HB CH WELLPOINT","1944.07","77.91","","483.51","229.32","1316.08","96","1109.15","2495.28","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2495.28","1871.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","1479.70","59.3","","439.50","225.34","1872.27","197","1247.64","1957.55","percent of total billed charges",""
"PLATE TI 2.4MM //15 6 HOLE VA LCP INTERCARPAL FUSION","SUP-ITM-10095957","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2495.28","1871.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1957.55","78.45","","385.32","55.36","1815.62","58","1247.64","1957.55","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","AETNA [1001]","HB CH AETNA HMO / PPO","2194.12","58.3","","554.95","91.85","1421.75","94","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2747.36","73","","2490.03","2490.03","2490.03","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2194.12","58.3","","750.00","750.00","750.00","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1994.66","53","","1192.50","120.84","4149.90","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3198.98","85","","750.00","75.00","750.00","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3763.50","100","","657.00","121.50","1971.00","14","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3763.50","100","","75.00","75.00","75.00","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3763.50","100","","366.00","144.00","1971.00","45","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2747.36","73","","667.50","667.50","667.50","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1672.88","44.45","","123.77","123.77","123.77","1 through 10","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","both","","","3763.50","2822.62","WELLPOINT [1015]","HB CH WELLPOINT","2932.14","77.91","","483.51","229.32","1316.08","96","1672.88","3763.5","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3763.50","2822.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2231.76","59.3","","439.50","225.34","1872.27","197","1881.75","2952.47","percent of total billed charges",""
"PLATE TIBIA 10 HOLE MEDIAL DISTAL","SUP-ITM-10296781","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3763.50","2822.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2952.47","78.45","","385.32","55.36","1815.62","58","1881.75","2952.47","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","AETNA [1001]","HB CH AETNA HMO / PPO","2262.33","58.3","","554.95","91.85","1421.75","94","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2832.77","73","","2490.03","2490.03","2490.03","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2262.33","58.3","","750.00","750.00","750.00","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2056.67","53","","1192.50","120.84","4149.90","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3298.43","85","","750.00","75.00","750.00","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3880.50","100","","657.00","121.50","1971.00","14","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3880.50","100","","75.00","75.00","75.00","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3880.50","100","","366.00","144.00","1971.00","45","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2832.77","73","","667.50","667.50","667.50","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1724.88","44.45","","123.77","123.77","123.77","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","WELLPOINT [1015]","HB CH WELLPOINT","3023.30","77.91","","483.51","229.32","1316.08","96","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2301.14","59.3","","439.50","225.34","1872.27","197","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 5-HOLE ANATOMICAL LEFT","SUP-ITM-10241322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3044.25","78.45","","385.32","55.36","1815.62","58","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","AETNA [1001]","HB CH AETNA HMO / PPO","2262.33","58.3","","1634.24","1004.95","1718.99","42","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2832.77","73","","2123.89","1900.92","2123.89","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2262.33","58.3","","3729.00","1254.19","3729.00","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2056.67","53","","939.37","939.37","5593.65","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3298.43","85","","2323.25","1864.50","2882.25","16","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3880.50","100","","2909.44","1772.40","10952.08","45","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3880.50","100","","2323.25","2323.25","2323.25","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3880.50","100","","2882.25","1772.40","10169.17","187","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2832.77","73","","1659.41","1659.41","1659.41","1 through 10","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","both","","","3880.50","2910.37","WELLPOINT [1015]","HB CH WELLPOINT","3023.30","77.91","","2050.91","1468.48","2902.83","52","1724.88","3880.5","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2301.14","59.3","","1548.60","1092.60","3613.79","82","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIA POSTEROMEDIAL DISTAL 6-HOLE ANATOMICAL RIGHT P53-209-R006","SUP-ITM-10241307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3880.50","2910.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3044.25","78.45","","2085.51","998.68","6202.11","56","1940.25","3044.25","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","AETNA [1001]","HB CH AETNA HMO / PPO","1752.43","58.3","","554.95","91.85","1421.75","94","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2194.29","73","","2490.03","2490.03","2490.03","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1752.43","58.3","","750.00","750.00","750.00","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1593.12","53","","1192.50","120.84","4149.90","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2555.00","85","","750.00","75.00","750.00","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3005.88","100","","657.00","121.50","1971.00","14","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3005.88","100","","75.00","75.00","75.00","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3005.88","100","","366.00","144.00","1971.00","45","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2194.29","73","","667.50","667.50","667.50","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1336.11","44.45","","123.77","123.77","123.77","1 through 10","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","both","","","3005.88","2254.41","WELLPOINT [1015]","HB CH WELLPOINT","2341.88","77.91","","483.51","229.32","1316.08","96","1336.11","3005.88","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.88","2254.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1782.49","59.3","","439.50","225.34","1872.27","197","1502.94","2358.11","percent of total billed charges",""
"PLATE TIBIAL 3.5X187MM 10 HOLE LCP SS LOW BEND DISTAL MEDIAL RIGHT","SUP-ITM-10073305","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3005.88","2254.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2358.11","78.45","","385.32","55.36","1815.62","58","1502.94","2358.11","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","AETNA [1001]","HB CH AETNA HMO / PPO","1322.73","58.3","","554.95","91.85","1421.75","94","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1656.25","73","","2490.03","2490.03","2490.03","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1322.73","58.3","","750.00","750.00","750.00","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1202.49","53","","1192.50","120.84","4149.90","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1928.51","85","","750.00","75.00","750.00","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2268.84","100","","657.00","121.50","1971.00","14","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2268.84","100","","75.00","75.00","75.00","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2268.84","100","","366.00","144.00","1971.00","45","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1656.25","73","","667.50","667.50","667.50","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1008.50","44.45","","123.77","123.77","123.77","1 through 10","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","both","","","2268.84","1701.63","WELLPOINT [1015]","HB CH WELLPOINT","1767.65","77.91","","483.51","229.32","1316.08","96","1008.5","2268.84","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2268.84","1701.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","1345.42","59.3","","439.50","225.34","1872.27","197","1134.42","1779.9","percent of total billed charges",""
"PLATE WRIST 2.4MM 15 6 HOLE VA LCP SS LOCKING FUSION INTERCARPAL","SUP-ITM-10095075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2268.84","1701.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1779.90","78.45","","385.32","55.36","1815.62","58","1134.42","1779.9","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","AETNA [1001]","HB CH AETNA HMO / PPO","2068.23","58.3","","554.95","91.85","1421.75","94","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2589.72","73","","2490.03","2490.03","2490.03","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2068.23","58.3","","750.00","750.00","750.00","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1880.21","53","","1192.50","120.84","4149.90","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3015.43","85","","750.00","75.00","750.00","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3547.56","100","","657.00","121.50","1971.00","14","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3547.56","100","","75.00","75.00","75.00","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3547.56","100","","366.00","144.00","1971.00","45","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2589.72","73","","667.50","667.50","667.50","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.89","44.45","","123.77","123.77","123.77","1 through 10","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","both","","","3547.56","2660.67","WELLPOINT [1015]","HB CH WELLPOINT","2763.90","77.91","","483.51","229.32","1316.08","96","1576.89","3547.56","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.56","2660.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","2103.70","59.3","","439.50","225.34","1872.27","197","1773.78","2783.06","percent of total billed charges",""
"PLATE WRIST MD LG 8 HOLE FUSION SS STANDARD BEND","SUP-ITM-10019116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3547.56","2660.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2783.06","78.45","","385.32","55.36","1815.62","58","1773.78","2783.06","percent of total billed charges",""
"PLATE WRIST VOLAR HOOK 6 HOLE","SUP-ITM-10192108","CDM","C1889","HCPCS","0278","RC","","","","both","","","2490.00","1867.50","AETNA [1001]","HB CH AETNA HMO / PPO","1451.67","58.3","","1830.28","315.58","1830.28","1 through 10","1106.81","2490","percent of total billed charges",""
"PLATE WRIST VOLAR HOOK 6 HOLE","SUP-ITM-10192108","CDM","C1889","HCPCS","0278","RC","","","","both","","","2490.00","1867.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1817.70","73","","4170.85","4170.85","4170.85","1 through 10","1106.81","2490","percent of total billed charges",""
"PLATE WRIST VOLAR HOOK 6 HOLE","SUP-ITM-10192108","CDM","C1889","HCPCS","0278","RC","","","","both","","","2490.00","1867.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1106.81","44.45","","649.55","649.55","649.55","1 through 10","1106.81","2490","percent of total billed charges",""
"PLATE WRIST VOLAR HOOK 6 HOLE","SUP-ITM-10192108","CDM","C1889","HCPCS","0278","RC","","","","both","","","2490.00","1867.50","WELLPOINT [1015]","HB CH WELLPOINT","1939.96","77.91","","8998.38","2542.37","8998.38","20","1106.81","2490","percent of total billed charges",""
"PLATE WRIST VOLAR HOOK 6 HOLE","SUP-ITM-10192108","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2490.00","1867.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1476.57","59.3","","1891.61","1609.14","3664.18","25","1245","1953.41","percent of total billed charges",""
"PLATE WRIST VOLAR HOOK 6 HOLE","SUP-ITM-10192108","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2490.00","1867.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1953.41","78.45","","1470.68","1310.06","2481.69","19","1245","1953.41","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","AETNA [1001]","HB CH AETNA HMO / PPO","1555.58","58.3","","554.95","91.85","1421.75","94","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1947.81","73","","2490.03","2490.03","2490.03","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1555.58","58.3","","750.00","750.00","750.00","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1414.16","53","","1192.50","120.84","4149.90","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2268.00","85","","750.00","75.00","750.00","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2668.23","100","","657.00","121.50","1971.00","14","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2668.23","100","","75.00","75.00","75.00","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2668.23","100","","366.00","144.00","1971.00","45","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1947.81","73","","667.50","667.50","667.50","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1186.03","44.45","","123.77","123.77","123.77","1 through 10","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","both","","","2668.23","2001.17","WELLPOINT [1015]","HB CH WELLPOINT","2078.82","77.91","","483.51","229.32","1316.08","96","1186.03","2668.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2668.23","2001.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","1582.26","59.3","","439.50","225.34","1872.27","197","1334.12","2093.23","percent of total billed charges",""
"PLATE Y 2.4MM 5H","SUP-ITM-10334793","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2668.23","2001.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2093.23","78.45","","385.32","55.36","1815.62","58","1334.12","2093.23","percent of total billed charges",""
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","both","","","3672.00","2754.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1592.23","","APC Price ($1,624.73). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1592.40","1592.39","1592.40","1 through 10","1543.65","4636.57","other","OPPS APC"
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","outpatient","","","3672.00","2754.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1363.03","","Case rate ($1,363.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1968.22","1968.22","1968.22","1 through 10","1363.03","4472.66","other","ASC "
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","outpatient","","","3672.00","2754.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1363.03","","Case rate ($1,363.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","985.47","985.47","985.47","1 through 10","1363.03","4472.66","other","ASC "
"Plc Dev/Mkr Rad Therapy Prost 1/1+","PX-76001328","CDM","55876","CPT","0761","RC","","","","outpatient","","","3672.00","2754.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2177.50","59.3","","1749.21","1749.21","1749.21","1 through 10","1363.03","4472.66","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","1 through 10","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","47","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.41","362.41","362.41","1 through 10","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","both","","","896.00","672.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","362.41","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.42","362.41","363.42","1 through 10","197.14","981.49","other","OPPS APC"
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","896.00","672.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","531.33","59.3","","510.41","510.41","510.41","1 through 10","191.73","702.91","percent of total billed charges",""
"Plethysmography Lung Vol Air Resist","PX-46000043","CDM","94726","CPT","0460","RC","","","","outpatient","","","896.00","672.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","702.91","78.45","","669.62","653.48","669.62","1 through 10","191.73","702.91","percent of total billed charges",""
"Pleural Effusion With McC","186","MS-DRG","","","","","","","","inpatient","","","90095.45","67571.59","MEDICARE [2001]","HB BWF MEDICARE","16061.04","","Case rate ($16,061.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,712.46, add-ons for qualifying new technology services are included. If operating cost exceeds $60,236.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,662.58, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $14,620.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,373.22 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,101.80. The transfer capital threshold is the transfer adjustment factor * $1,101.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15961.84","15961.84","15961.84","1 through 10","14395.29","16061.04","other","Inpatient DRG"
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","485.82","364.36","AETNA [1001]","HB CH AETNA HMO / PPO","283.23","58.3","","1830.28","315.58","1830.28","1 through 10","215.95","485.82","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","485.82","364.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","354.65","73","","4170.85","4170.85","4170.85","1 through 10","215.95","485.82","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","485.82","364.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.95","44.45","","649.55","649.55","649.55","1 through 10","215.95","485.82","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","both","","","485.82","364.36","WELLPOINT [1015]","HB CH WELLPOINT","378.50","77.91","","8998.38","2542.37","8998.38","20","215.95","485.82","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","485.82","364.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.09","59.3","","1891.61","1609.14","3664.18","25","242.91","381.13","percent of total billed charges",""
"PLIAFX PRIME 1.0CC FREEZE DRIED","SUP-ITM-10243414","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","485.82","364.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","381.13","78.45","","1470.68","1310.06","2481.69","19","242.91","381.13","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","2738.70","2054.02","AETNA [1001]","HB CH AETNA HMO / PPO","1596.66","58.3","","1830.28","315.58","1830.28","1 through 10","1217.35","2738.7","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","2738.70","2054.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1999.25","73","","4170.85","4170.85","4170.85","1 through 10","1217.35","2738.7","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","2738.70","2054.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1217.35","44.45","","649.55","649.55","649.55","1 through 10","1217.35","2738.7","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","both","","","2738.70","2054.02","WELLPOINT [1015]","HB CH WELLPOINT","2133.72","77.91","","8998.38","2542.37","8998.38","20","1217.35","2738.7","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2738.70","2054.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","1624.05","59.3","","1891.61","1609.14","3664.18","25","1369.35","2148.51","percent of total billed charges",""
"PLIAFX PRIME 10.0CC FREEZE DRIED","SUP-ITM-10243411","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2738.70","2054.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2148.51","78.45","","1470.68","1310.06","2481.69","19","1369.35","2148.51","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1113.99","835.49","AETNA [1001]","HB CH AETNA HMO / PPO","649.46","58.3","","1830.28","315.58","1830.28","1 through 10","495.17","1113.99","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1113.99","835.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","813.21","73","","4170.85","4170.85","4170.85","1 through 10","495.17","1113.99","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1113.99","835.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","495.17","44.45","","649.55","649.55","649.55","1 through 10","495.17","1113.99","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","both","","","1113.99","835.49","WELLPOINT [1015]","HB CH WELLPOINT","867.91","77.91","","8998.38","2542.37","8998.38","20","495.17","1113.99","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1113.99","835.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","660.60","59.3","","1891.61","1609.14","3664.18","25","557","873.93","percent of total billed charges",""
"PLIAFX PRIME 2.5CC FREEZE DRIED","SUP-ITM-10243413","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1113.99","835.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","873.93","78.45","","1470.68","1310.06","2481.69","19","557","873.93","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","AETNA [1001]","HB CH AETNA HMO / PPO","1081.09","58.3","","1830.28","315.58","1830.28","1 through 10","824.26","1854.36","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1353.68","73","","4170.85","4170.85","4170.85","1 through 10","824.26","1854.36","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","824.26","44.45","","649.55","649.55","649.55","1 through 10","824.26","1854.36","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","both","","","1854.36","1390.77","WELLPOINT [1015]","HB CH WELLPOINT","1444.73","77.91","","8998.38","2542.37","8998.38","20","824.26","1854.36","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1854.36","1390.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","1099.64","59.3","","1891.61","1609.14","3664.18","25","927.18","1454.75","percent of total billed charges",""
"PLIAFX PRIME 5.0CC FREEZE DRIED","SUP-ITM-10243412","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1854.36","1390.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1454.75","78.45","","1470.68","1310.06","2481.69","19","927.18","1454.75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"PLUG BONE 12.5MM SIZE 2 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10005428","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"PLUG BONE 14.0MM SIZE 3 CEMENT INTRAMEDULLARY TOTAL HIP","SUP-ITM-10028324","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","554.95","91.85","1421.75","94","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2490.03","2490.03","2490.03","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","750.00","750.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","1192.50","120.84","4149.90","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","750.00","75.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","657.00","121.50","1971.00","14","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","75.00","75.00","75.00","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","366.00","144.00","1971.00","45","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","667.50","667.50","667.50","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","123.77","123.77","123.77","1 through 10","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","483.51","229.32","1316.08","96","133.35","300","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","439.50","225.34","1872.27","197","150","235.35","percent of total billed charges",""
"PLUG CEMENT 8.0MM RESTRICTOR CUT GLYCEROL GELATIN RESORBABLE","SUP-ITM-10159204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","385.32","55.36","1815.62","58","150","235.35","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","both","","","15.67","11.75","AETNA [1001]","HB CH AETNA HMO / PPO","9.14","58.3","","585.96","347.85","5016.82","1 through 10","6.97","15.67","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","both","","","15.67","11.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","13.32","85","","1295.16","1295.16","1295.16","1 through 10","6.97","15.67","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","both","","","15.67","11.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","15.67","100","","2700.00","1008.69","2700.00","1 through 10","6.97","15.67","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","both","","","15.67","11.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15.67","100","","2520.00","797.10","5898.60","1 through 10","6.97","15.67","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","both","","","15.67","11.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","6.97","44.45","","1953.42","1953.42","1953.42","1 through 10","6.97","15.67","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","both","","","15.67","11.75","WELLPOINT [1015]","HB CH WELLPOINT","12.21","77.91","","1490.36","627.80","7327.37","1 through 10","6.97","15.67","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","15.67","11.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","9.29","59.3","","536.35","188.54","1772.63","17","7.84","12.29","percent of total billed charges",""
"PLUG COMFORT 40MM DIA DEVICE HERNIA REPAIR ULTRAPRO PART ABS BX/22EA - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10138807","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","15.67","11.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","12.29","78.45","","562.30","246.20","3344.28","1 through 10","7.84","12.29","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1634.24","1004.95","1718.99","42","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2123.89","1900.92","2123.89","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","3729.00","1254.19","3729.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","939.37","939.37","5593.65","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","2323.25","1864.50","2882.25","16","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","2909.44","1772.40","10952.08","45","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","2323.25","2323.25","2323.25","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","2882.25","1772.40","10169.17","187","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","1659.41","1659.41","1659.41","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","2050.91","1468.48","2902.83","52","33.34","75","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1548.60","1092.60","3613.79","82","37.5","58.84","percent of total billed charges",""
"PLUG FEMORAL 12.8MM DOME HOLE ACETABULAR TRIDENT SECURFIT HIP 16B","SUP-ITM-10005569","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","2085.51","998.68","6202.11","56","37.5","58.84","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"PLUG FEMORAL TRIDENT II HEX DOME HOLE PLUG SZ MM","SUP-ITM-10237459","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"PLUG FISTULA ANAL BIODESIGN 0.6X9.5CM AREA 5.7 SQCM STERILE LF","SUP-ITM-10104568","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3672.00","2754.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2880.68","78.45","","555.84","555.84","555.84","1 through 10","1836","2880.68","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","1634.24","1004.95","1718.99","42","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2123.89","1900.92","2123.89","1 through 10","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","3729.00","1254.19","3729.00","1 through 10","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","939.37","939.37","5593.65","1 through 10","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","2323.25","1864.50","2882.25","16","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","2909.44","1772.40","10952.08","45","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","2323.25","2323.25","2323.25","1 through 10","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","2882.25","1772.40","10169.17","187","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","1659.41","1659.41","1659.41","1 through 10","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","2050.91","1468.48","2902.83","52","72.01","162","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","1548.60","1092.60","3613.79","82","81","127.09","percent of total billed charges",""
"PLUG HIP 48 66MM IMPLANT LINER HOLE ELIMINATOR THRDED POSITIVE STOP APEX 16B","SUP-ITM-10005725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","2085.51","998.68","6202.11","56","81","127.09","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","AETNA [1001]","HB CH AETNA HMO / PPO","1661.55","58.3","","1634.24","1004.95","1718.99","42","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","2123.89","1900.92","2123.89","1 through 10","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1661.55","58.3","","3729.00","1254.19","3729.00","1 through 10","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1510.50","53","","939.37","939.37","5593.65","1 through 10","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2422.50","85","","2323.25","1864.50","2882.25","16","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2850.00","100","","2909.44","1772.40","10952.08","45","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2850.00","100","","2323.25","2323.25","2323.25","1 through 10","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2850.00","100","","2882.25","1772.40","10169.17","187","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2080.50","73","","1659.41","1659.41","1659.41","1 through 10","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","both","","","2850.00","2137.50","WELLPOINT [1015]","HB CH WELLPOINT","2220.44","77.91","","2050.91","1468.48","2902.83","52","1266.83","2850","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1690.05","59.3","","1548.60","1092.60","3613.79","82","1425","2235.83","percent of total billed charges",""
"PLUG HUMERAL 36MM SHOULDER AEQUALIS REVERSED II COBALT CEMENT POLYETHYLENE","SUP-ITM-10017347","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2850.00","2137.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2235.83","78.45","","2085.51","998.68","6202.11","56","1425","2235.83","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","450.59","337.94","AETNA [1001]","HB CH AETNA HMO / PPO","262.69","58.3","","585.96","347.85","5016.82","1 through 10","200.29","450.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","450.59","337.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","383.00","85","","1295.16","1295.16","1295.16","1 through 10","200.29","450.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","450.59","337.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.59","100","","2700.00","1008.69","2700.00","1 through 10","200.29","450.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","450.59","337.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.59","100","","2520.00","797.10","5898.60","1 through 10","200.29","450.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","450.59","337.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.29","44.45","","1953.42","1953.42","1953.42","1 through 10","200.29","450.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","both","","","450.59","337.94","WELLPOINT [1015]","HB CH WELLPOINT","351.05","77.91","","1490.36","627.80","7327.37","1 through 10","200.29","450.59","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","450.59","337.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","267.20","59.3","","536.35","188.54","1772.63","17","225.3","353.49","percent of total billed charges",""
"PLUG INGUINAL 5CMX4 MED PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028848","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","450.59","337.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.49","78.45","","562.30","246.20","3344.28","1 through 10","225.3","353.49","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","468.67","351.50","AETNA [1001]","HB CH AETNA HMO / PPO","273.23","58.3","","585.96","347.85","5016.82","1 through 10","208.32","468.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","468.67","351.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","398.37","85","","1295.16","1295.16","1295.16","1 through 10","208.32","468.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","468.67","351.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","468.67","100","","2700.00","1008.69","2700.00","1 through 10","208.32","468.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","468.67","351.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","468.67","100","","2520.00","797.10","5898.60","1 through 10","208.32","468.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","468.67","351.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.32","44.45","","1953.42","1953.42","1953.42","1 through 10","208.32","468.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","both","","","468.67","351.50","WELLPOINT [1015]","HB CH WELLPOINT","365.14","77.91","","1490.36","627.80","7327.37","1 through 10","208.32","468.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","468.67","351.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","277.92","59.3","","536.35","188.54","1772.63","17","234.34","367.67","percent of total billed charges",""
"PLUG INGUINAL 5CMXLG PRESHAPED PART ABSORB SYNTHETIC ULTRAPRO BX/6EA","SUP-ITM-10028847","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","468.67","351.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","367.67","78.45","","562.30","246.20","3344.28","1 through 10","234.34","367.67","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","512.94","384.70","AETNA [1001]","HB CH AETNA HMO / PPO","299.04","58.3","","585.96","347.85","5016.82","1 through 10","228","512.94","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","512.94","384.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","436.00","85","","1295.16","1295.16","1295.16","1 through 10","228","512.94","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","512.94","384.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","512.94","100","","2700.00","1008.69","2700.00","1 through 10","228","512.94","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","512.94","384.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","512.94","100","","2520.00","797.10","5898.60","1 through 10","228","512.94","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","512.94","384.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","228.00","44.45","","1953.42","1953.42","1953.42","1 through 10","228","512.94","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","both","","","512.94","384.70","WELLPOINT [1015]","HB CH WELLPOINT","399.63","77.91","","1490.36","627.80","7327.37","1 through 10","228","512.94","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","512.94","384.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","304.17","59.3","","536.35","188.54","1772.63","17","256.47","402.4","percent of total billed charges",""
"PLUG NONABSORBABLE 3CMX5 SM MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030237","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","512.94","384.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","402.40","78.45","","562.30","246.20","3344.28","1 through 10","256.47","402.4","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.07","388.55","AETNA [1001]","HB CH AETNA HMO / PPO","302.03","58.3","","585.96","347.85","5016.82","1 through 10","230.28","518.07","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.07","388.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","440.36","85","","1295.16","1295.16","1295.16","1 through 10","230.28","518.07","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.07","388.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","518.07","100","","2700.00","1008.69","2700.00","1 through 10","230.28","518.07","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.07","388.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","518.07","100","","2520.00","797.10","5898.60","1 through 10","230.28","518.07","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.07","388.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","230.28","44.45","","1953.42","1953.42","1953.42","1 through 10","230.28","518.07","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","both","","","518.07","388.55","WELLPOINT [1015]","HB CH WELLPOINT","403.63","77.91","","1490.36","627.80","7327.37","1 through 10","230.28","518.07","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","518.07","388.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","307.22","59.3","","536.35","188.54","1772.63","17","259.04","406.43","percent of total billed charges",""
"PLUG NONABSORBABLE 4X5CM MD MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10024544","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","518.07","388.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","406.43","78.45","","562.30","246.20","3344.28","1 through 10","259.04","406.43","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","523.17","392.38","AETNA [1001]","HB CH AETNA HMO / PPO","305.01","58.3","","585.96","347.85","5016.82","1 through 10","232.55","523.17","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","523.17","392.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","444.69","85","","1295.16","1295.16","1295.16","1 through 10","232.55","523.17","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","523.17","392.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","523.17","100","","2700.00","1008.69","2700.00","1 through 10","232.55","523.17","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","523.17","392.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","523.17","100","","2520.00","797.10","5898.60","1 through 10","232.55","523.17","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","523.17","392.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.55","44.45","","1953.42","1953.42","1953.42","1 through 10","232.55","523.17","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","both","","","523.17","392.38","WELLPOINT [1015]","HB CH WELLPOINT","407.60","77.91","","1490.36","627.80","7327.37","1 through 10","232.55","523.17","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","523.17","392.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","310.24","59.3","","536.35","188.54","1772.63","17","261.59","410.43","percent of total billed charges",""
"PLUG NONABSORBABLE 5 XCM LG MESH SURGICAL HERNIA ULTRAPRO POLYPROPYLENE BX/2EA","SUP-ITM-10030238","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","523.17","392.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","410.43","78.45","","562.30","246.20","3344.28","1 through 10","261.59","410.43","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","459.34","344.50","AETNA [1001]","HB CH AETNA HMO / PPO","267.80","58.3","","585.96","347.85","5016.82","1 through 10","204.18","459.34","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","459.34","344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","390.44","85","","1295.16","1295.16","1295.16","1 through 10","204.18","459.34","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","459.34","344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","459.34","100","","2700.00","1008.69","2700.00","1 through 10","204.18","459.34","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","459.34","344.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","459.34","100","","2520.00","797.10","5898.60","1 through 10","204.18","459.34","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","459.34","344.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.18","44.45","","1953.42","1953.42","1953.42","1 through 10","204.18","459.34","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","both","","","459.34","344.50","WELLPOINT [1015]","HB CH WELLPOINT","357.87","77.91","","1490.36","627.80","7327.37","1 through 10","204.18","459.34","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","459.34","344.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","272.39","59.3","","536.35","188.54","1772.63","17","229.67","360.35","percent of total billed charges",""
"PLUG POLYPROPYLENE 5X3CM SM MESH ULTRAPRO BX/6EA","SUP-ITM-10023459","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","459.34","344.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","360.35","78.45","","562.30","246.20","3344.28","1 through 10","229.67","360.35","percent of total billed charges",""
"Pneumothorax With Cc","200","MS-DRG","","","","","","","","inpatient","","","24239.55","18179.66","MEDICARE [2001]","HB BWF MEDICARE","10461.00","","Case rate ($10,461). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,477.50, add-ons for qualifying new technology services are included. If operating cost exceeds $56,001.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,337.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,344.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,138.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $777.16. The transfer capital threshold is the transfer adjustment factor * $777.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11189.29","11189.29","11189.29","1 through 10","10251.78","10952.0675","other","Inpatient Replacement Plans DRG"
"Pneumothorax With McC","199","MS-DRG","","","","","","","","inpatient","","","29268.71","21951.53","MEDICARE [2001]","HB BWF MEDICARE","18135.08","","Case rate ($18,135.08). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,608.60, add-ons for qualifying new technology services are included. If operating cost exceeds $62,132.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,807.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,548.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,269.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,247.15. The transfer capital threshold is the transfer adjustment factor * $1,247.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","16250.48","18135.08","other","Inpatient DRG"
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","AETNA [1001]","HB CH AETNA HMO / PPO","37.50","58.3","","554.95","91.85","1421.75","94","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","46.95","73","","2490.03","2490.03","2490.03","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","37.50","58.3","","750.00","750.00","750.00","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.09","53","","1192.50","120.84","4149.90","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","54.67","85","","750.00","75.00","750.00","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","64.32","100","","657.00","121.50","1971.00","14","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","64.32","100","","75.00","75.00","75.00","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","64.32","100","","366.00","144.00","1971.00","45","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","46.95","73","","667.50","667.50","667.50","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","28.59","44.45","","123.77","123.77","123.77","1 through 10","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","both","","","64.32","48.24","WELLPOINT [1015]","HB CH WELLPOINT","50.11","77.91","","483.51","229.32","1316.08","96","28.59","64.32","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.32","48.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.14","59.3","","439.50","225.34","1872.27","197","32.16","50.46","percent of total billed charges",""
"POINT SPADE 1.6X150MM GUIDEWIRE ORTHOPEDIC SS THREADED","SUP-ITM-10004545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","64.32","48.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","50.46","78.45","","385.32","55.36","1815.62","58","32.16","50.46","percent of total billed charges",""
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","215.47","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15660.40","15660.40","15660.40","1 through 10","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","205.21","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14107.44","14107.44","14107.44","1 through 10","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","205.21","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7953.19","7953.19","7953.19","1 through 10","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","MEDICARE [2001]","HB BWF MEDICARE","205.21","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","16445.52","0.03","16555.47","17","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","205.21","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","47988.08","47988.08","47988.08","1 through 10","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","205.21","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","23017.93","23017.93","23017.93","1 through 10","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs With McC","917","MS-DRG","","","","","","","","inpatient","","","39303.81","29477.86","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","205.21","","Case rate ($205.21) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14877.06","14877.06","14882.36","1 through 10","205.21","16099.63","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","26410.83","19808.12","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8145.49","8145.49","8145.49","1 through 10","193.14","8798.13","other","Inpatient Psych"
"Poisoning And Toxic Effects Of Drugs Without McC","918","MS-DRG","","","","","","","","inpatient","","","26410.83","19808.12","MEDICARE [2001]","HB BWF MEDICARE","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8987.82","70.54","9047.15","1 through 10","193.14","8798.13","other","Inpatient Psych"
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","43413.39","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","15188.90","","Case rate ($16,793.94). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,223.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,EXTREME","812","DRG","","","","","","","","inpatient","","","43413.39","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","15188.90","","Case rate ($16,793.94). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $59,223.94, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","16789.82","16789.82","16789.82","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","31224.11","","FALLON HEALTH [1008]","HB BWF MEDICAID","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7699.12","7699.12","7699.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","31224.11","","MASSHEALTH [3001]","HB BWF MEDICAID","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7699.12","7699.12","7699.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","31224.11","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","31224.11","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7699.12","7699.12","7699.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","31224.11","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1798.86","1798.86","1798.86","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MAJOR","812","DRG","","","","","","","","inpatient","","","31224.11","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6965.01","","Case rate ($7,701.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,131.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7699.12","7699.12","7699.12","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MINOR","812","DRG","","","","","","","","inpatient","","","19718.63","","MASSHEALTH [3001]","HB BWF MEDICAID","3767.52","","Case rate ($4,165.64). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,595.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4333.36","4333.36","4333.36","1 through 10","3572.45","79068.74","case rate",""
"Poisoning Of Medicinal Agents,MODERATE","812","DRG","","","","","","","","inpatient","","","23769.99","","MASSHEALTH [3001]","HB BWF MEDICAID","5097.24","","Case rate ($5,635.87). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,065.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5634.49","5634.49","5634.49","1 through 10","3572.45","79068.74","case rate",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","AETNA [1001]","HB CH AETNA HMO / PPO","2241.45","58.3","","1634.24","1004.95","1718.99","42","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2806.62","73","","2123.89","1900.92","2123.89","1 through 10","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2241.45","58.3","","3729.00","1254.19","3729.00","1 through 10","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2037.68","53","","939.37","939.37","5593.65","1 through 10","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3267.98","85","","2323.25","1864.50","2882.25","16","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3844.68","100","","2909.44","1772.40","10952.08","45","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3844.68","100","","2323.25","2323.25","2323.25","1 through 10","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3844.68","100","","2882.25","1772.40","10169.17","187","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2806.62","73","","1659.41","1659.41","1659.41","1 through 10","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","both","","","3844.68","2883.51","WELLPOINT [1015]","HB CH WELLPOINT","2995.39","77.91","","2050.91","1468.48","2902.83","52","1708.96","3844.68","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3844.68","2883.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","2279.90","59.3","","1548.60","1092.60","3613.79","82","1922.34","3016.15","percent of total billed charges",""
"POST MONOBLOCK 28MM BASEPLATE","SUP-ITM-10233535","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3844.68","2883.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3016.15","78.45","","2085.51","998.68","6202.11","56","1922.34","3016.15","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","AETNA [1001]","HB CH AETNA HMO / PPO","454.74","58.3","","1634.24","1004.95","1718.99","42","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","569.40","73","","2123.89","1900.92","2123.89","1 through 10","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","454.74","58.3","","3729.00","1254.19","3729.00","1 through 10","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","413.40","53","","939.37","939.37","5593.65","1 through 10","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","663.00","85","","2323.25","1864.50","2882.25","16","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","780.00","100","","2909.44","1772.40","10952.08","45","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","780.00","100","","2323.25","2323.25","2323.25","1 through 10","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","780.00","100","","2882.25","1772.40","10169.17","187","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","569.40","73","","1659.41","1659.41","1659.41","1 through 10","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","both","","","780.00","585.00","WELLPOINT [1015]","HB CH WELLPOINT","607.70","77.91","","2050.91","1468.48","2902.83","52","346.71","780","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","462.54","59.3","","1548.60","1092.60","3613.79","82","390","611.91","percent of total billed charges",""
"POST PRESS FIT LONG 15MM PERFORM REVERSED","SUP-ITM-10215267","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","780.00","585.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","611.91","78.45","","2085.51","998.68","6202.11","56","390","611.91","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB CH AETNA HMO / PPO","570.17","58.3","","1634.24","1004.95","1718.99","42","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","2123.89","1900.92","2123.89","1 through 10","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","570.17","58.3","","3729.00","1254.19","3729.00","1 through 10","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.34","53","","939.37","939.37","5593.65","1 through 10","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","831.30","85","","2323.25","1864.50","2882.25","16","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","978.00","100","","2909.44","1772.40","10952.08","45","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","978.00","100","","2323.25","2323.25","2323.25","1 through 10","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","978.00","100","","2882.25","1772.40","10169.17","187","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","1659.41","1659.41","1659.41","1 through 10","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","both","","","978.00","733.50","WELLPOINT [1015]","HB CH WELLPOINT","761.96","77.91","","2050.91","1468.48","2902.83","52","434.72","978","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.95","59.3","","1548.60","1092.60","3613.79","82","489","767.24","percent of total billed charges",""
"POST THREADED 6.5X30MM REVERSE CENTRAL PERFORM","SUP-ITM-10211837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.24","78.45","","2085.51","998.68","6202.11","56","489","767.24","percent of total billed charges",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","158185.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","55402.47","","Case rate ($61,256.95). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $103,686.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","61241.92","61241.92","61241.92","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,EXTREME","711","DRG","","","","","","","","inpatient","","","158185.85","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","55402.47","","Case rate ($61,256.95). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $103,686.95, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","56816.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","35577.00","","Fee schedule rate ($35,577.00). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34540.31","34540.31","34540.31","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","56816.13","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","25303.41","","Case rate ($27,977.27). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,407.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","27970.40","27970.40","27970.40","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MAJOR","711","DRG","","","","","","","","inpatient","","","56816.13","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","25303.41","","Case rate ($27,977.27). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,407.27, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","14322.36","14322.36","14322.36","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","34643.64","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23342.919","","Fee schedule rate ($23,342.92). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23342.919","33987.44","33987.44","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MINOR","711","DRG","","","","","","","","inpatient","","","34643.64","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","33861.06","","Fee schedule rate ($33,861.06). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","33861.06","33861.06","33861.06","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","23190.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32553.47","","Fee schedule rate ($32,553.47). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($3,765.92) multiplied by length of stay and the outlier percent (100%).","32553.46","32553.46","32553.46","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","23190.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","34968.92","","Fee schedule rate ($34,968.92). Expected reimbursement is the lesser of the normal pricing or the DRG per diem rate ($4,046.11) multiplied by length of stay and the outlier percent (100%).","34968.91","34968.91","34968.91","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure,MODERATE","711","DRG","","","","","","","","inpatient","","","23190.37","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","14404.09","","Case rate ($15,926.20). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,356.20, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15922.29","15922.29","15922.29","1 through 10","10477.78","223902.34","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","132904.14","","MASSHEALTH [3001]","HB BWF MEDICAID","25710.09","","Case rate ($28,426.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,856.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,393.65 and the sum of the standard inlier and any outlier amount.","28419.95","28419.95","28419.95","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,EXTREME","721","DRG","","","","","","","","inpatient","","","132904.14","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","25710.09","","Case rate ($28,426.92). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $70,856.92, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $4,393.65 and the sum of the standard inlier and any outlier amount.","28419.95","28419.95","28419.95","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MAJOR","721","DRG","","","","","","","","inpatient","","","29045.77","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29617.85","","Standard inlier is a Case rate ($29,617.85). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,933, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,204.13) for the length of stay and the standard reimbursement.","29617.84","29617.84","29617.84","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","17724.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12839.094","","Fee schedule rate ($12,839.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12839.094","12839.10","12839.10","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MINOR","721","DRG","","","","","","","","inpatient","","","17724.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","23342.919","","Fee schedule rate ($12,839.09). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23342.919","12839.10","12839.10","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18833.36","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18781.41","","Standard inlier is a Case rate ($18,781.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,583, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,665.94) for the length of stay and the standard reimbursement.","17927.70","17927.70","17927.70","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18833.36","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13480.983","","Fee schedule rate ($18,760.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13480.983","18760.52","18760.52","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18833.36","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","24509.9455","","Fee schedule rate ($18,760.52). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24509.9455","18760.52","18760.52","1 through 10","5858.93","91105.42","case rate",""
"Post-Operative, Post-Traumatic, Other Device Infections,MODERATE","721","DRG","","","","","","","","inpatient","","","18833.36","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7452.80","","Case rate ($8,240.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,670.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8238.32","8238.32","8238.32","1 through 10","5858.93","91105.42","case rate",""
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","49083.56","36812.67","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","18736.33","","Case rate ($18,736.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,158.27, add-ons for qualifying new technology services are included. If operating cost exceeds $62,682.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,850.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $17,107.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,819.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.28. The transfer capital threshold is the transfer adjustment factor * $1,289.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16689.41","16689.41","16689.41","1 through 10","16788.28","18736.33","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections With McC","862","MS-DRG","","","","","","","","inpatient","","","49083.56","36812.67","MEDICARE [2001]","HB BWF MEDICARE","18736.33","","Case rate ($18,736.33). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,158.27, add-ons for qualifying new technology services are included. If operating cost exceeds $62,682.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,850.06, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $17,107.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,819.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,289.28. The transfer capital threshold is the transfer adjustment factor * $1,289.28. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18534.22","18534.22","18534.22","1 through 10","16788.28","18736.33","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","21151.03","15863.27","MEDICARE [2001]","HB BWF MEDICARE","9527.38","","Case rate ($9,527.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,542.35, add-ons for qualifying new technology services are included. If operating cost exceeds $55,066.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,266.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,482.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,203.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.48. The transfer capital threshold is the transfer adjustment factor * $705.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10193.64","10126.59","10193.64","1 through 10","9336.83","9888.0111","other","Inpatient Replacement Plans DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","MS-DRG","","","","","","","","inpatient","","","21151.03","15863.27","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9336.83","","Case rate ($9,527.38). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,542.35, add-ons for qualifying new technology services are included. If operating cost exceeds $55,066.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,266.26, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,482.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,203.11 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $705.48. The transfer capital threshold is the transfer adjustment factor * $705.48. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9137.22","9137.22","9137.22","1 through 10","9336.83","9888.0111","other","Inpatient DRG"
"Postoperative And Post-Traumatic Infections Without McC","863","TRIS-DRG","","","","","","","","inpatient","","","21404.11","","TRICARE [160005]","HB BWF TRICARE","5664.95","","If the length of stay is greater than 1, the reimbursement is as follows: Case rate ($7,825.85). For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $2,898.46, and the first day is paid a rate of $5,796.93. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $2,898.46, and the first day is paid a rate of $5,796.93. The transfer payment is capped at $7,161.94. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $51,647.30 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.70000004768372). Includes reimbursement from new technology add-ons. If the length of stay is less than or equal to 1, the reimbursement is as follows: Per diem ($4,603.44), capped at $7,161.94. For stays with a post-acute discharge disposition of 03, 05, 06, 50, 51, 62, 63, 65, or 82, the transfer payment is a per diem payment of $2,898.46, and the first day is paid a rate of $5,796.93. For stays with a transfer discharge disposition of 02 or 82, the transfer payment is a per diem payment of $2,898.46, and the first day is paid a rate of $5,796.93. The transfer payment is capped at $7,161.94. Billed amount less exclusions adjusted by a cost-to-charge ratio of 0.316 that exceeds an outlier threshold of $51,647.30 is considered a cost outlier and adds an additional payment of 80% of the excess amount. For stays with a post-acute or transfer discharge disposition, the outlier threshold is multiplied by (LOS / 2.70000004768372). Includes reimbursement from new technology add-ons. Final payment is multiplied by 95%.","8164.54","8164.54","8164.54","1 through 10","5664.95","5664.95","other","Inpatient DRGs"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","857","MS-DRG","","","","","","","","inpatient","","","40599.69","30449.77","MEDICARE [2001]","HB BWF MEDICARE","21942.21","","Case rate ($21,942.21). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $20,089.16, add-ons for qualifying new technology services are included. If operating cost exceeds $65,612.89 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,074.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.4. The base transfer operating payment is the transfer adjustment factor * $20,089.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,749.93 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,513.95. The transfer capital threshold is the transfer adjustment factor * $1,513.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12207.51","0.03","21917.00","1 through 10","19655.88","21942.21","other","Inpatient DRG"
"Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC","856","MS-DRG","","","","","","","","inpatient","","","62504.02","46878.01","MEDICARE [2001]","HB BWF MEDICARE","46225.54","","Case rate ($46,225.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $42,289.50, add-ons for qualifying new technology services are included. If operating cost exceeds $87,813.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,776.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 9.1. The base transfer operating payment is the transfer adjustment factor * $42,670.54 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $41,950.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,215.75. The transfer capital threshold is the transfer adjustment factor * $3,215.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","41376.83","46225.54","other","Inpatient DRG"
"Postpartum And Post Abortion Diagnoses Without Procedure,MAJOR","561","DRG","","","","","","","","inpatient","","","28241.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","16311.28","","Standard inlier is a Case rate ($16,311.28). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,224, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,315.32) for the length of stay and the standard reimbursement.","16311.27","16311.27","16311.27","1 through 10","3571.12","25495.33","case rate",""
"Postpartum And Post Abortion Diagnoses Without Procedure,MODERATE","561","DRG","","","","","","","","inpatient","","","15093.46","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8954.83","","Fee schedule rate ($8,954.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8954.83","8954.83","8954.83","1 through 10","3571.12","25495.33","case rate",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","both","","","44.00","33.00","AETNA [1001]","HB CH AETNA HMO / PPO","25.65","58.3","","48.76","24.38","48.76","1 through 10","4.66","32.12","percent of total billed charges",""
"Potassium Serum/ Plasma/ Blood","PX-30000628","CDM","84132","CPT","0301","RC","","","","outpatient","","","44.00","33.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","34.52","78.45","","19.59","19.59","19.59","1 through 10","4.73","34.52","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","69.74","69.74","69.74","1 through 10","14.3","91.98","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","72.08","72.08","72.08","1 through 10","15.04","98.85","percent of total billed charges",""
"Prealbumin","PX-30000630","CDM","84134","CPT","0301","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","94.56","94.56","94.56","1 through 10","15.04","98.85","percent of total billed charges",""
"Precerebral Occlusion Without Infarction With McC","067","MS-DRG","","","","","","","","inpatient","","","74322.66","55741.99","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","15155.15","","Case rate ($15,155.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,884.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,408.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,599.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $13,777.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,545.05 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,038.31. The transfer capital threshold is the transfer adjustment factor * $1,038.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13597.63","13597.63","13597.63","1 through 10","13584.99","15155.15","other","Inpatient DRG"
"Precerebral Occlusion Without Infarction With McC","067","MS-DRG","","","","","","","","inpatient","","","74322.66","55741.99","MEDICARE [2001]","HB BWF MEDICARE","15155.15","","Case rate ($15,155.15). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,884.28, add-ons for qualifying new technology services are included. If operating cost exceeds $59,408.01 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,599.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $13,777.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,545.05 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,038.31. The transfer capital threshold is the transfer adjustment factor * $1,038.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14717.92","14717.92","14717.92","1 through 10","13584.99","15155.15","other","Inpatient DRG"
"Precerebral Occlusion Without Infarction Without McC","068","MS-DRG","","","","","","","","inpatient","","","31346.49","23509.87","MEDICARE [2001]","HB BWF MEDICARE","9059.12","","Case rate ($9,059.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,311.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,834.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,171.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $8,108.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,971.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $611.10. The transfer capital threshold is the transfer adjustment factor * $611.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8957.22","8957.22","9016.34","1 through 10","8132.22","9059.12","other","Inpatient DRG"
"Prep Wound Trk/Arm/Leg 1st 100cm","PX-76000164","CDM","15002","CPT","0761","RC","","","","outpatient","","","1376.00","1032.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","675.20","49.07","","2504.65","2504.65","2504.65","1 through 10","550.4","1079.47","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","AETNA [1001]","HB CH AETNA HMO / PPO","248.36","58.3","","234.74","234.74","234.74","24","60.9","343.29","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","302.22","302.22","302.22","1 through 10","60.9","343.29","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","both","","","426.00","319.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.98","73","","234.74","234.74","234.74","1 through 10","60.9","343.29","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","242.60","727.80","33","176.68","603.55","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.56","242.56","242.56","1 through 10","176.68","603.55","percent of total billed charges",""
"Presumptive Drug Test by Instrument Chemistry Analyzer","PX-30003340","CDM","80307","CPT","0301","RC","","","","outpatient","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","334.20","78.45","","318.28","188.62","318.28","16","176.68","603.55","percent of total billed charges",""
"Primidone","PX-30000032","CDM","80188","CPT","0301","RC","","","","outpatient","","","136.00","102.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","106.69","78.45","","101.48","101.48","101.48","1 through 10","17.12","106.69","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","8840.00","6630.00","AETNA [1001]","HB CH AETNA HMO / PPO","5153.72","58.3","","1830.28","315.58","1830.28","1 through 10","3929.38","8840","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","8840.00","6630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6453.20","73","","4170.85","4170.85","4170.85","1 through 10","3929.38","8840","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","8840.00","6630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3929.38","44.45","","649.55","649.55","649.55","1 through 10","3929.38","8840","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","both","","","8840.00","6630.00","WELLPOINT [1015]","HB CH WELLPOINT","6887.24","77.91","","8998.38","2542.37","8998.38","20","3929.38","8840","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8840.00","6630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5242.12","59.3","","1891.61","1609.14","3664.18","25","4420","6934.98","percent of total billed charges",""
"PROBE RADIOFREQUENCY","SUP-ITM-10319111","CDM","C1889","HCPCS","0272","RC","","","","outpatient","","","8840.00","6630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6934.98","78.45","","1470.68","1310.06","2481.69","19","4420","6934.98","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","both","","","184.00","138.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","134.32","73","","130.67","130.67","130.67","1 through 10","26.68","158.08","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","184.00","138.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.11","59.3","","104.89","104.89","104.89","1 through 10","27.61","168.81","percent of total billed charges",""
"Procalcitonin (Pct)","PX-30000636","CDM","84145","CPT","0301","RC","","","","outpatient","","","184.00","138.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","144.35","78.45","","8.37","8.37","8.37","1 through 10","27.61","168.81","percent of total billed charges",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","58860.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","40106.54","","Standard inlier is a Case rate ($40,106.54). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $52,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,693.28) for the length of stay and the standard reimbursement.","36870.56","36870.56","36870.56","1 through 10","14991.27","73451.83","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MINOR","850","DRG","","","","","","","","inpatient","","","58860.66","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","43082.42","","Standard inlier is a Case rate ($43,082.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $52,793, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,115.37) for the length of stay and the standard reimbursement.","43082.42","43082.42","43082.42","1 through 10","14991.27","73451.83","case rate",""
"Procedure With Diagnosis Of Rehabilitation, Aftercare Or Other Contact With Health Services,MODERATE","850","DRG","","","","","","","","inpatient","","","57607.61","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","58432.51","","Standard inlier is a Case rate ($58,432.51). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $67,451, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($8,294.25) for the length of stay and the standard reimbursement.","58432.51","58432.51","58432.51","1 through 10","14991.27","73451.83","case rate",""
"Procedures For Obesity,MAJOR","403","DRG","","","","","","","","inpatient","","","45103.67","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","24237.9426","","Fee schedule rate ($48,817.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","24237.9426","48817.88","48817.88","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","36076.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","27120.94","","Standard inlier is a Case rate ($27,120.94). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,849.92) for the length of stay and the standard reimbursement.","27120.94","25888.52","30056.24","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","36076.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","29133.30","","Standard inlier is a Case rate ($29,133.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $39,470, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,135.35) for the length of stay and the standard reimbursement.","29133.30","27809.06","29133.30","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","36076.83","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12073.39","","Fee schedule rate ($12,073.39). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11721.82","11721.82","11721.82","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","36076.83","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","25733.85","","Fee schedule rate ($25,733.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","25733.85","25733.85","25733.85","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","36076.83","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","8712.83","","Case rate ($9,633.53). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,063.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9631.16","9631.16","9631.16","19","8712.83","80548.74","case rate",""
"Procedures For Obesity,MINOR","403","DRG","","","","","","","","inpatient","","","36076.83","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8712.83","","Case rate ($9,633.53). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,063.53, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9631.16","9631.16","9631.16","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","46210.22","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","33823.39","","Standard inlier is a Case rate ($33,823.39). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $43,949, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,801.09) for the length of stay and the standard reimbursement.","32285.96","32285.96","32285.96","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","46210.22","","MASSHEALTH [3001]","HB BWF MEDICAID","9539.90","","Case rate ($10,548). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,978, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10545.41","10545.41","10545.41","1 through 10","8712.83","80548.74","case rate",""
"Procedures For Obesity,MODERATE","403","DRG","","","","","","","","inpatient","","","46210.22","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9539.90","","Case rate ($10,548). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,978, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10545.41","10545.41","10545.41","1 through 10","8712.83","80548.74","case rate",""
"Progesterone","PX-30000635","CDM","84144","CPT","0301","RC","","","","outpatient","","","174.00","130.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","103.18","59.3","","99.03","99.03","99.03","1 through 10","21.52","136.5","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","both","","","3744.00","2808.00","WELLPOINT [1015]","HB CH WELLPOINT","2916.95","77.91","","2948.77","2948.77","2948.77","1 through 10","1984.32","3744","percent of total billed charges",""
"PROGRAMMER DEVICE PATIENT SMART INTERSTIM II MODULATION","SUP-ITM-10295477","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3744.00","2808.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2220.19","59.3","","4673.98","4673.98","4673.98","1 through 10","1664.21","2937.17","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","2948.77","2948.77","2948.77","1 through 10","1423.05","2685","percent of total billed charges",""
"PROGRAMMER NEUROSTIMULATOR 2.8X5.6 9.4CM MYSTIM PATIENT HAND HELD","SUP-ITM-10104824","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","4673.98","4673.98","4673.98","1 through 10","1193.48","2106.38","percent of total billed charges",""
"PROGRAMMER PATIENT MYSTIM PC SMART/SMART HANDSET","SUP-ITM-10286922","CDM","C1787","HCPCS","0270","RC","","","","both","","","2685.00","2013.75","WELLPOINT [1015]","HB CH WELLPOINT","2091.88","77.91","","2948.77","2948.77","2948.77","1 through 10","1423.05","2685","percent of total billed charges",""
"PROGRAMMER PATIENT MYSTIM PC SMART/SMART HANDSET","SUP-ITM-10286922","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","2685.00","2013.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1592.21","59.3","","4673.98","4673.98","4673.98","1 through 10","1193.48","2106.38","percent of total billed charges",""
"PROGRAMMER PATIENT PROCLAIM DRG - DISCONTINUED PER SUPPLIER","SUP-ITM-10211137","CDM","C1787","HCPCS","0270","RC","","","","both","","","3800.00","2850.00","WELLPOINT [1015]","HB CH WELLPOINT","2960.58","77.91","","2948.77","2948.77","2948.77","1 through 10","2014","3800","percent of total billed charges",""
"PROGRAMMER PATIENT PROCLAIM DRG - DISCONTINUED PER SUPPLIER","SUP-ITM-10211137","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3800.00","2850.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2253.40","59.3","","4673.98","4673.98","4673.98","1 through 10","1689.1","2981.1","percent of total billed charges",""
"PROGRAMMER PATIENT PRODIGY PULSE IPG - DISCONTINUED PER SUPPLIER","SUP-ITM-10273120","CDM","C1787","HCPCS","0270","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2948.77","2948.77","2948.77","1 through 10","1590","3000","percent of total billed charges",""
"PROGRAMMER PATIENT PRODIGY PULSE IPG - DISCONTINUED PER SUPPLIER","SUP-ITM-10273120","CDM","C1787","HCPCS","0270","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","4673.98","4673.98","4673.98","1 through 10","1333.5","2353.5","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","124.17","124.17","124.17","17","18.99","164.25","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","125.27","125.27","125.27","1 through 10","18.99","164.25","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","128.33","128.33","128.33","1 through 10","19.98","176.51","percent of total billed charges",""
"Prolactin","PX-30000637","CDM","84146","CPT","0301","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","168.37","99.78","168.37","1 through 10","19.98","176.51","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","both","","","293.00","219.75","AETNA [1001]","HB CH AETNA HMO / PPO","170.82","58.3","","161.60","156.23","161.60","1 through 10","40.93","221.8","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","293.00","219.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.75","59.3","","501.03","167.01","501.03","1 through 10","25.74","229.86","percent of total billed charges",""
"Prostaglandin","PX-30000639","CDM","84150","CPT","0301","RC","","","","outpatient","","","293.00","219.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.86","78.45","","219.11","129.85","219.11","1 through 10","25.74","229.86","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","58","18.92","110.96","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","152.00","114.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.96","73","","84.66","83.92","108.04","1 through 10","18.92","110.96","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.56","44.45","","113.78","67.43","113.78","1 through 10","18.92","110.96","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","82","18.96","123.05","percent of total billed charges",""
"Prostate Cancer Screen Psa","PX-30000164","CDM","G0103","HCPCS","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","67.43","113.78","59","18.96","123.05","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","11","18.02","110.96","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","1 through 10","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Free","PX-30000642","CDM","84154","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","67.43","67.43","113.78","1 through 10","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","AETNA [1001]","HB CH AETNA HMO / PPO","88.62","58.3","","83.92","83.92","83.92","40","18.02","110.96","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","both","","","152.00","114.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.56","44.45","","67.43","67.43","67.43","1 through 10","18.02","110.96","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","152.00","114.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.14","59.3","","86.73","86.73","86.73","43","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","152.00","114.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","113.78","113.78","1 through 10","18.96","119.24","percent of total billed charges",""
"Prostatic Specific Antigen Total","PX-30000641","CDM","84153","CPT","0301","RC","","","","outpatient","","","152.00","114.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","119.24","78.45","","113.78","67.43","113.78","38","18.96","119.24","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","AETNA [1001]","HB CH AETNA HMO / PPO","1518.13","58.3","","1634.24","1004.95","1718.99","42","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1900.92","73","","2123.89","1900.92","2123.89","1 through 10","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1518.13","58.3","","3729.00","1254.19","3729.00","1 through 10","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1380.12","53","","939.37","939.37","5593.65","1 through 10","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2213.40","85","","2323.25","1864.50","2882.25","16","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2604.00","100","","2909.44","1772.40","10952.08","45","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2604.00","100","","2323.25","2323.25","2323.25","1 through 10","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2604.00","100","","2882.25","1772.40","10169.17","187","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1900.92","73","","1659.41","1659.41","1659.41","1 through 10","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","both","","","2604.00","1953.00","WELLPOINT [1015]","HB CH WELLPOINT","2028.78","77.91","","2050.91","1468.48","2902.83","52","1157.48","2604","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1544.17","59.3","","1548.60","1092.60","3613.79","82","1302","2042.84","percent of total billed charges",""
"PROSTHESIS JOINT SIZE 5 FINGER SWANSON FLEXSPAN ELASTOMER TITANIUM FLEXIBLE GROMMET CS/1BX/1EA","SUP-ITM-10004999","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2604.00","1953.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2042.84","78.45","","2085.51","998.68","6202.11","56","1302","2042.84","percent of total billed charges",""
"PROTECTOR GRAFT 20X2.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124163","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4078.00","3058.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3199.19","78.45","","555.84","555.84","555.84","1 through 10","2039","3199.19","percent of total billed charges",""
"PROTECTOR GRAFT 40X7.0MM NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124169","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5476.00","4107.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4295.92","78.45","","555.84","555.84","555.84","1 through 10","2738","4295.92","percent of total billed charges",""
"PROTECTOR GRAFT DIA 7.0MM LENGTH 20 NERVE AXOGUARD PORCINE 3D EXTRACELLULAR MATRIX FLEXIBLE WRAP TRANSLUCENT PERIPHERAL","SUP-ITM-10124165","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","4192.00","3144.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3288.62","78.45","","555.84","555.84","555.84","1 through 10","2096","3288.62","percent of total billed charges",""
"PROTECTOR NERVE 40X3.5MM PORCINE MULTI LAMINAR EXTRACELLULAR MATRIX WRAP INJURED PERIPH REINFORCE COAPTATION SITE PREVENT","SUP-ITM-10124167","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","5338.00","4003.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4187.66","78.45","","555.84","555.84","555.84","1 through 10","2669","4187.66","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","554.95","91.85","1421.75","94","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","100.74","73","","2490.03","2490.03","2490.03","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","80.45","58.3","","750.00","750.00","750.00","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","73.14","53","","1192.50","120.84","4149.90","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","117.30","85","","750.00","75.00","750.00","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","138.00","100","","657.00","121.50","1971.00","14","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","138.00","100","","75.00","75.00","75.00","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","138.00","100","","366.00","144.00","1971.00","45","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","100.74","73","","667.50","667.50","667.50","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","61.34","44.45","","123.77","123.77","123.77","1 through 10","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","both","","","138.00","103.50","WELLPOINT [1015]","HB CH WELLPOINT","107.52","77.91","","483.51","229.32","1316.08","96","61.34","138","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","439.50","225.34","1872.27","197","69","108.26","percent of total billed charges",""
"PROTECTOR SURGICAL 0.375XBALL 0.062IN PIN JURGAN FIXATION W SERIES TO BX/6EA","SUP-ITM-10004124","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","385.32","55.36","1815.62","58","69","108.26","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","143.00","107.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.80","59.3","","81.45","81.45","81.45","1 through 10","13.15","112.18","percent of total billed charges",""
"Protein C Activity","PX-30001074","CDM","85303","CPT","0305","RC","","","","outpatient","","","143.00","107.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","112.18","78.45","","106.86","102.37","106.86","1 through 10","13.15","112.18","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","AETNA [1001]","HB CH AETNA HMO / PPO","53.64","58.3","","50.46","50.46","50.46","18","10.53","67.16","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","48.76","53","","47.17","47.17","47.17","1 through 10","10.53","67.16","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","both","","","92.00","69.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","40.89","44.45","","39.96","39.96","39.96","1 through 10","10.53","67.16","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","92.00","69.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","54.56","59.3","","52.15","52.15","156.45","21","11.07","72.17","percent of total billed charges",""
"Protein Electrophoresis","PX-30000650","CDM","84165","CPT","0301","RC","","","","outpatient","","","92.00","69.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.17","78.45","","68.42","40.55","68.42","21","11.07","72.17","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","157.00","117.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.10","59.3","","89.66","89.66","89.66","1 through 10","18.4","123.17","percent of total billed charges",""
"Protein Electrophoretic Other Fluid","PX-30000652","CDM","84166","CPT","0301","RC","","","","outpatient","","","157.00","117.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.17","78.45","","117.63","117.63","117.63","1 through 10","18.4","123.17","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","99.00","74.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","58.71","59.3","","56.26","56.26","56.26","1 through 10","11.97","77.67","percent of total billed charges",""
"Protein S Total","PX-30001075","CDM","85305","CPT","0305","RC","","","","outpatient","","","99.00","74.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.67","78.45","","73.80","73.80","73.80","1 through 10","11.97","77.67","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","both","","","41.00","30.75","AETNA [1001]","HB CH AETNA HMO / PPO","23.90","58.3","","22.68","22.68","22.68","1 through 10","3.92","29.93","percent of total billed charges",""
"Protein Total Other Source","PX-30000646","CDM","84157","CPT","0301","RC","","","","outpatient","","","41.00","30.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.31","59.3","","23.44","23.44","23.44","1 through 10","3.77","32.16","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","both","","","42.00","31.50","AETNA [1001]","HB CH AETNA HMO / PPO","24.49","58.3","","23.25","23.25","23.25","16","3.6","30.66","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","42.00","31.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.91","59.3","","24.03","24.03","72.09","12","3.77","32.95","percent of total billed charges",""
"Protein Total Urine","PX-30000645","CDM","84156","CPT","0301","RC","","","","outpatient","","","42.00","31.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.95","78.45","","31.52","31.52","31.52","1 through 10","3.77","32.95","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","31.00","23.25","AETNA [1001]","HB CH AETNA HMO / PPO","18.07","58.3","","17.01","17.01","17.01","13","3.6","24.05","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","31.00","23.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","16.43","53","","15.90","15.90","15.90","1 through 10","3.6","24.05","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","both","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.78","44.45","","13.47","13.47","13.47","1 through 10","3.6","24.05","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","31.00","23.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","18.38","59.3","","17.58","17.58","52.74","18","3.77","24.32","percent of total billed charges",""
"Protein Total Xcpt Refra Serum Plas","PX-30000643","CDM","84155","CPT","0301","RC","","","","outpatient","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","24.32","78.45","","23.06","13.67","23.06","17","3.77","24.32","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","AETNA [1001]","HB CH AETNA HMO / PPO","20.41","58.3","","19.28","19.28","19.28","48","4.2","25.75","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","25.55","73","","24.82","24.82","24.82","1 through 10","4.2","25.75","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","both","","","35.00","26.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","18.55","53","","18.02","18.02","18.02","1 through 10","4.2","25.75","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","35.00","26.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","20.76","59.3","","19.92","19.92","59.76","56","4.06","27.46","percent of total billed charges",""
"Prothrombin Time (Pt)","PX-30001118","CDM","85610","CPT","0305","RC","","","","outpatient","","","35.00","26.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","27.46","78.45","","26.14","15.49","26.14","46","4.06","27.46","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Prothrombn Frgmnt1and2","PX-30002093","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.14","78.11","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","9.6","83.94","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30000984","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","47.38","47.38","47.38","1 through 10","9.6","83.94","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30001444","CDM","86753","CPT","0302","RC","","","","both","","","107.00","80.25","AETNA [1001]","HB CH AETNA HMO / PPO","62.38","58.3","","58.97","58.97","58.97","1 through 10","12.14","78.11","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30001444","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.45","59.3","","60.94","60.94","60.94","1 through 10","9.6","83.94","percent of total billed charges",""
"Protozoa Antibody Not Specified","PX-30001444","CDM","86753","CPT","0302","RC","","","","outpatient","","","107.00","80.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.94","78.45","","47.38","47.38","47.38","1 through 10","9.6","83.94","percent of total billed charges",""
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8026.84","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","8026.86","8026.86","8026.86","1 through 10","968.31","8026.84","other","OPPS APC"
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","MEDICARE [2001]","HB BWF MEDICARE","7793.05","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","968.31","8026.84","other","OPPS APC"
"Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging","PX-98301709","CDM","64561","CPT","0983","RC","","","","both","","","1827.00","1370.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7637.19","","APC Price ($7,793.05). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7645.47","7645.47","7645.47","1 through 10","968.31","8026.84","other","OPPS APC"
"Prq Impltj Neurostimulator Eltrd Peripheral Nrv","PX-98301708","CDM","64555","CPT","0983","RC","","","","both","","","1782.00","1336.50","MEDICARE [2001]","HB BWF MEDICARE","7793.84","","APC Price ($7,793.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7793.84","7793.84","7793.84","1 through 10","944.46","8027.65","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","AETNA [1001]","HB CH AETNA HMO / PPO","1917.49","58.3","","1813.27","1813.27","1813.27","1 through 10","1147.8","3550.75","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1122.86","1188.88","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1188.88","1188.88","1188.88","12","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1743.17","53","","1694.94","1694.94","1694.94","1 through 10","1147.8","3550.75","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","MEDICARE [2001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1208.21","1208.21","189","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1184.05","1184.05","1184.05","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","MOLINA [1014]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.90","2397.90","2397.90","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","TRICARE [160005]","HB BWF TRICARE","1147.80","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1147.80","1147.80","1147.80","1 through 10","1147.8","3550.75","other","Tricare OPPS"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.45","1118.70","1188.88","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1141.12","1141.12","1141.12","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.05","1122.86","1188.88","59","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","3289.00","2466.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1950.38","59.3","","1874.03","1874.03","1874.03","15","1461.96","3447.02","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","3289.00","2466.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1950.38","59.3","","1829.26","1829.26","1829.26","1 through 10","1461.96","3447.02","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Param Lmtd","PX-74000013","CDM","95810","CPT","0740","RC","","","","outpatient","","","3289.00","2466.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2580.22","78.45","","2458.62","1457.01","2458.62","1 through 10","1461.96","3447.02","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","AETNA [1001]","HB CH AETNA HMO / PPO","1917.49","58.3","","1813.27","1813.27","1813.27","1 through 10","1147.8","3550.75","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1122.86","1188.88","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1188.88","1188.88","1188.88","12","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1743.17","53","","1694.94","1694.94","1694.94","1 through 10","1147.8","3550.75","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","MEDICARE [2001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1208.21","1208.21","189","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1184.05","1184.05","1184.05","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","MOLINA [1014]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.90","2397.90","2397.90","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","TRICARE [160005]","HB BWF TRICARE","1147.80","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1147.80","1147.80","1147.80","1 through 10","1147.8","3550.75","other","Tricare OPPS"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.45","1118.70","1188.88","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1141.12","1141.12","1141.12","1 through 10","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","both","","","3289.00","2466.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.05","1122.86","1188.88","59","1147.8","3550.75","other","OPPS APC"
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","3289.00","2466.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1950.38","59.3","","1874.03","1874.03","1874.03","15","1461.96","3447.02","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","3289.00","2466.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","1950.38","59.3","","1829.26","1829.26","1829.26","1 through 10","1461.96","3447.02","percent of total billed charges",""
"Psg 6 Yrs or Older 4+ Parameters","PX-74000012","CDM","95810","CPT","0740","RC","","","","outpatient","","","3289.00","2466.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2580.22","78.45","","2458.62","1457.01","2458.62","1 through 10","1461.96","3447.02","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1122.86","1188.88","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1188.88","1118.30","1188.88","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","FALLON HEALTH [1008]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1208.21","1208.21","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4887.98","4887.98","4887.98","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","MEDICARE [2001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1141.12","1208.21","109","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1184.05","1184.05","1184.05","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","MOLINA [1014]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.09","2397.09","2397.09","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","TRICARE [160005]","HB BWF TRICARE","1147.80","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1147.80","1147.80","1147.80","1 through 10","1147.8","3910.61","other","Tricare OPPS"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1189.37","1189.37","1189.37","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.55","1119.30","1188.88","20","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","5357.00","4017.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3176.70","59.3","","3052.47","3052.47","3052.47","1 through 10","2145.06","4202.57","percent of total billed charges",""
"Psg 6/> Yrs 4+ Param W/ Cpap Lmtd","PX-74000015","CDM","95811","CPT","0740","RC","","","","outpatient","","","5357.00","4017.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4202.57","78.45","","2254.59","2172.44","2254.59","1 through 10","2145.06","4202.57","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1188.88","1122.86","1188.88","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1188.88","1118.30","1188.88","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","FALLON HEALTH [1008]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1208.21","1208.21","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4887.98","4887.98","4887.98","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","MEDICARE [2001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1208.21","1141.12","1208.21","109","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1184.05","1184.05","1184.05","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","MOLINA [1014]","HB BWF MEDICARE","1208.21","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2397.09","2397.09","2397.09","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","TRICARE [160005]","HB BWF TRICARE","1147.80","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1147.80","1147.80","1147.80","1 through 10","1147.8","3910.61","other","Tricare OPPS"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1189.37","1189.37","1189.37","1 through 10","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","both","","","5357.00","4017.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1184.05","","APC Price ($1,208.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1184.55","1119.30","1188.88","20","1147.8","3910.61","other","OPPS APC"
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","5357.00","4017.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3176.70","59.3","","3052.47","3052.47","3052.47","1 through 10","2145.06","4202.57","percent of total billed charges",""
"Psg 6/> Yrs 4+ Parameters W/ Cpap","PX-74000014","CDM","95811","CPT","0740","RC","","","","outpatient","","","5357.00","4017.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4202.57","78.45","","2254.59","2172.44","2254.59","1 through 10","2145.06","4202.57","percent of total billed charges",""
"Psych Diag Evaluation W/Med Service","PX-90000049","CDM","90792","CPT","0914","RC","","","","both","","","508.00","381.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.42","477.42","477.42","1 through 10","269.24","483.11","other","OPPS APC"
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","27","53.34","157.63","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","53.34","157.63","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","17.49","17.49","17.49","1 through 10","53.34","157.63","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","20.58","16.98","20.58","16","53.34","157.63","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","21.62","20.99","21.62","1 through 10","53.34","157.63","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","22.49","21.83","22.49","50","53.34","157.63","percent of total billed charges",""
"Psych Est/ New Patient (99211) - Low Level (<15 Min)","PX-90000099","CDM","99211","CPT","0914","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","117.00","45.75","117.00","1 through 10","69.24","344","percent of total billed charges",""
"Psych Grp Therapy 15 Min","PX-90000022","CDM","90853","CPT","0915","RC","","","","both","","","133.00","99.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.36","119.36","159.14","80","70.49","222.51","other","OPPS APC"
"Psychiatric Diagnostic Eval W/Medical Services","PX-90000124","CDM","90792","CPT","0914","RC","","","","both","","","508.00","381.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","477.42","477.42","477.42","1 through 10","269.24","483.11","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","480.00","360.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","187.76","1 through 10","213.36","456.48","other","OPPS APC"
"Psychiatric Diagnostic Evaluation","PX-90000048","CDM","90791","CPT","0914","RC","","","","both","","","480.00","360.00","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","453.00","453.00","453.00","1 through 10","213.36","456.48","other","OPPS APC"
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","187.76","187.76","187.76","1 through 10","280.04","598.5","other","OPPS APC"
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","both","","","630.00","472.50","MEDICARE [2001]","HB BWF MEDICARE","","","All partial hospitalization services for a date will be collectively paid at a per diem based on the quantity and type of primary partial hospitalization services performed. Intensive outpatient program: quantity between 1 and 3, Per diem ($319.68), quantity 4 or more, Per diem ($485.18). Intensive outpatient program - community mental health center: quantity between 1 and 3, Per diem ($132.10), quantity 4 or more, Per diem ($199.89). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","453.00","453.00","453.00","1 through 10","280.04","598.5","other","OPPS APC"
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","309.14","49.07","","28.28","28.28","28.28","1 through 10","122.71","494.24","percent of total billed charges",""
"Psychiatric Diagnostic Evaluation - Cans","PX-96100058","CDM","90791","CPT","0961","RC","","","","outpatient","","","630.00","472.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","315.63","50.1","","28.32","28.32","28.32","1 through 10","122.71","494.24","percent of total billed charges",""
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","181.06","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Final payment is multiplied by 105%. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8248.13","8055.91","32337.42","1 through 10","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","9535.94","9535.94","9535.94","1 through 10","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","12815.72","7682.18","24599.83","15","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","11407.39","11407.39","11407.39","1 through 10","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","HUMANA [1012]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","20376.82","20376.82","48183.87","1 through 10","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","MEDICARE [2001]","HB BWF MEDICARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","14172.97","458.94","78289.22","43","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","17796.09","17617.10","210319.00","1 through 10","172.44","14338.15","other","Inpatient Psych"
"Psychoses","885","MS-DRG","","","","","","","","inpatient","","","38223.64","28667.73","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","172.44","","Case rate ($172.44) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","15602.40","14618.59","22341.99","1 through 10","172.44","14338.15","other","Inpatient Psych"
"Pt Contrast Bath 15 Min","PX-42000019","CDM","97034","CPT","0421","RC","","","","both","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14.81","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($15.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($11.24). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","11.24","11.24","11.24","1 through 10","14.81","364.8","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","167.51","95.26","167.78","265","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.86","58.3","","336.00","336.00","336.00","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.69","53","","83.74","83.74","83.74","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","89.90","89.90","285.60","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","27.69","24.19","31.84","945","31.47","364.8","fee schedule",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.59","59.3","","180.75","180.75","180.75","1 through 10","86.5","232","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","168.00","168.00","168.00","1 through 10","86.5","232","percent of total billed charges",""
"Pt Exercise Therapeutic 15 Min","PX-42000023","CDM","97110","CPT","0421","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","129.16","129.16","129.16","1 through 10","86.5","232","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","62.79","62.78","62.79","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","77.38","77.38","154.76","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","129.94","129.94","129.94","1 through 10","31.47","364.8","percent of total billed charges",""
"Pt Gait Training 15 Min","PX-42000026","CDM","97116","CPT","0421","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","31.47","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($32.11). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($23.78). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","23.36","23.31","23.94","14","31.47","364.8","fee schedule",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","AETNA [1001]","HB CH AETNA HMO / PPO","109.02","58.3","","103.19","75.57","178.76","23","35.26","364.8","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","109.02","58.3","","364.00","91.00","364.00","1 through 10","35.26","364.8","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","99.11","53","","96.46","96.46","96.46","1 through 10","35.26","364.8","percent of total billed charges",""
"Pt Home Instruction/Program 15min","PX-42000034","CDM","97535","CPT","0421","RC","","","","both","","","187.00","140.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","35.26","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.98). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($25.72). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.24","25.75","35.27","72","35.26","364.8","fee schedule",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","159.00","119.25","AETNA [1001]","HB CH AETNA HMO / PPO","92.70","58.3","","66.96","66.96","154.85","93","29.66","364.8","percent of total billed charges",""
"Pt Manual Therapy 15 Min","PX-42000029","CDM","97140","CPT","0421","RC","","","","both","","","159.00","119.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","29.66","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($30.27). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($22.53). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","22.25","22.08","22.53","139","29.66","364.8","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","99.79","75.60","99.79","1 through 10","35.02","364.8","percent of total billed charges",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","both","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","35.02","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($35.73). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($26.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","30.66","26.43","35.54","25","35.02","364.8","fee schedule",""
"Pt Neuromuscular Re-ED 15 Min","PX-42000024","CDM","97112","CPT","0421","RC","","","","outpatient","","","181.00","135.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","107.33","59.3","","94.95","94.95","94.95","1 through 10","90.5","240.73","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","100.93","100.93","100.93","1 through 10","38.35","364.8","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","96.99","53","","94.34","89.04","94.34","1 through 10","38.35","364.8","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.59","73","","158.42","158.42","158.42","1 through 10","38.35","364.8","percent of total billed charges",""
"Pt Therapeutic Activity 15 Min","PX-42000031","CDM","97530","CPT","0421","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","38.35","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($39.13). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($27.12). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","38.48","32.77","40.64","84","38.35","364.8","fee schedule",""
"Pt Ultrasound 15 Min","PX-42000020","CDM","97035","CPT","0421","RC","","","","both","","","68.00","51.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","15.19","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($15.50). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($11.43). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","11.43","11.43","11.43","1 through 10","15.19","364.8","fee schedule",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","41.39","41.39","41.39","1 through 10","6.34","54.75","percent of total billed charges",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","38.69","38.69","38.69","1 through 10","6.34","54.75","percent of total billed charges",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","42.78","42.78","213.31","14","6.67","58.84","percent of total billed charges",""
"Ptt Substitution","PX-30001130","CDM","85732","CPT","0305","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","56.12","56.12","56.12","1 through 10","6.67","58.84","percent of total billed charges",""
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","33644.66","25233.49","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11479.86","","Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,732.69, add-ons for qualifying new technology services are included. If operating cost exceeds $57,256.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,434.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,501.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,393.44 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.38. The transfer capital threshold is the transfer adjustment factor * $873.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11282.57","11282.57","11313.70","1 through 10","11479.86","12801.68","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","33644.66","25233.49","HUMANA [1012]","HB BWF MEDICARE","12801.68","","Case rate ($12,801.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,732.69, add-ons for qualifying new technology services are included. If operating cost exceeds $57,256.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,434.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,589.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,393.44 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.38. The transfer capital threshold is the transfer adjustment factor * $873.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11291.18","11291.18","11322.18","1 through 10","11479.86","12801.68","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","33644.66","25233.49","MEDICARE [2001]","HB BWF MEDICARE","12801.68","","Case rate ($12,801.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,732.69, add-ons for qualifying new technology services are included. If operating cost exceeds $57,256.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,434.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $11,589.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,393.44 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.38. The transfer capital threshold is the transfer adjustment factor * $873.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12472.24","0.03","12555.21","34","11479.86","12801.68","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","33644.66","25233.49","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","11479.86","","Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,732.69, add-ons for qualifying new technology services are included. If operating cost exceeds $57,256.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,434.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,501.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,393.44 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.38. The transfer capital threshold is the transfer adjustment factor * $873.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11249.04","11249.04","11249.04","1 through 10","11479.86","12801.68","other","Inpatient DRG"
"Pulmonary Edema And Respiratory Failure","189","MS-DRG","","","","","","","","inpatient","","","33644.66","25233.49","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11479.86","","Case rate ($11,714.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,732.69, add-ons for qualifying new technology services are included. If operating cost exceeds $57,256.42 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,434.15, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $10,501.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $11,393.44 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $873.38. The transfer capital threshold is the transfer adjustment factor * $873.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11256.95","11249.05","11319.69","1 through 10","11479.86","12801.68","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","32594.78","24446.08","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13376.23","","Case rate ($12,986.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,007.23, add-ons for qualifying new technology services are included. If operating cost exceeds $58,530.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,531.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,676.30 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,667.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.08. The transfer capital threshold is the transfer adjustment factor * $971.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","13499.23","13499.23","13499.23","1 through 10","12726.9","14195.83","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","32594.78","24446.08","MEDICARE [2001]","HB BWF MEDICARE","14195.83","","Case rate ($14,195.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,007.23, add-ons for qualifying new technology services are included. If operating cost exceeds $58,530.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,531.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,885.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,667.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.08. The transfer capital threshold is the transfer adjustment factor * $971.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14168.03","11238.52","14262.51","1 through 10","12726.9","14195.83","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","32594.78","24446.08","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12726.90","","Case rate ($12,986.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,007.23, add-ons for qualifying new technology services are included. If operating cost exceeds $58,530.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,531.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,676.30 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,667.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.08. The transfer capital threshold is the transfer adjustment factor * $971.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12803.32","12803.32","12803.32","1 through 10","12726.9","14195.83","other","Inpatient DRG"
"Pulmonary Embolism With McC Or Acute Cor Pulmonale","175","MS-DRG","","","","","","","","inpatient","","","32594.78","24446.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","12726.90","","Case rate ($12,986.63). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,007.23, add-ons for qualifying new technology services are included. If operating cost exceeds $58,530.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,531.87, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $11,676.30 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,667.99 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $971.08. The transfer capital threshold is the transfer adjustment factor * $971.08. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12850.77","12850.77","12850.77","1 through 10","12726.9","14195.83","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","23200.60","17400.45","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7751.25","","Case rate ($7,751.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,763.33, add-ons for qualifying new technology services are included. If operating cost exceeds $53,287.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,129.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,842.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,424.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.10. The transfer capital threshold is the transfer adjustment factor * $569.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7530.68","7530.68","7530.68","1 through 10","7596.23","8054.5905","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","23200.60","17400.45","MEDICARE [2001]","HB BWF MEDICARE","7751.25","","Case rate ($7,751.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,763.33, add-ons for qualifying new technology services are included. If operating cost exceeds $53,287.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,129.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,842.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,424.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.10. The transfer capital threshold is the transfer adjustment factor * $569.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1345.23","0.03","8295.50","1 through 10","7596.23","8054.5905","other","Inpatient Replacement Plans DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","23200.60","17400.45","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7596.23","","Case rate ($7,751.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,763.33, add-ons for qualifying new technology services are included. If operating cost exceeds $53,287.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,129.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,842.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,424.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.10. The transfer capital threshold is the transfer adjustment factor * $569.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","1487.04","1487.04","1487.04","1 through 10","7596.23","8054.5905","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","23200.60","17400.45","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7596.23","","Case rate ($7,751.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,763.33, add-ons for qualifying new technology services are included. If operating cost exceeds $53,287.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,129.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,842.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,424.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.10. The transfer capital threshold is the transfer adjustment factor * $569.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8554.70","8554.70","8554.70","1 through 10","7596.23","8054.5905","other","Inpatient DRG"
"Pulmonary Embolism Without McC","176","MS-DRG","","","","","","","","inpatient","","","23200.60","17400.45","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7596.23","","Case rate ($7,751.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,763.33, add-ons for qualifying new technology services are included. If operating cost exceeds $53,287.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,129.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,842.91 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,424.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.10. The transfer capital threshold is the transfer adjustment factor * $569.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8442.91","8442.91","8442.91","1 through 10","7596.23","8054.5905","other","Inpatient DRG"
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","30960.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25799.59","","Standard inlier is a Case rate ($25,799.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,662.35) for the length of stay and the standard reimbursement.","25799.58","25799.58","25799.58","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","30960.62","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27713.90","","Standard inlier is a Case rate ($27,713.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,933.87) for the length of stay and the standard reimbursement.","26454.17","26454.17","26454.17","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","30960.62","","MASSHEALTH [3001]","HB BWF MEDICAID","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10465.86","10465.86","10465.86","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MAJOR","134","DRG","","","","","","","","inpatient","","","30960.62","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10465.85","10465.85","10465.85","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MINOR","134","DRG","","","","","","","","inpatient","","","14651.19","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","14992.74","","Fee schedule rate ($14,992.74). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19297.88","19297.88","19297.88","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MINOR","134","DRG","","","","","","","","inpatient","","","14651.19","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4207.33","","Case rate ($4,651.93). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,081.93, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4650.79","4650.79","4650.79","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","22602.74","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25799.59","","Standard inlier is a Case rate ($25,799.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,116, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,662.35) for the length of stay and the standard reimbursement.","17883.69","17883.69","17883.69","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","22602.74","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,428.87 and the sum of the standard inlier and any outlier amount.","2085.87","2085.87","2085.87","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","22602.74","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9053.87","","Fee schedule rate ($9,053.87). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9053.87","9053.87","9053.87","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","22602.74","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19297.88","","Fee schedule rate ($19,297.88). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19297.88","19297.88","19297.88","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","22602.74","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,428.87 and the sum of the standard inlier and any outlier amount.","6304.00","6304.00","6304.00","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Embolism,MODERATE","134","DRG","","","","","","","","inpatient","","","22602.74","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9467.93","","Case rate ($10,468.42). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,898.42, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,428.87 and the sum of the standard inlier and any outlier amount.","6781.09","6781.09","6781.09","1 through 10","4207.33","53528.26","case rate",""
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","both","","","189.00","141.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","150.63","150.63","150.63","1 through 10","100.17","414.21","other","OPPS APC"
"Pulmonary Stress Testing","PX-46000084","CDM","94618","CPT","0460","RC","","","","outpatient","","","189.00","141.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","148.27","78.45","","177.92","141.46","177.92","1 through 10","84.01","268.39","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","both","","","521.00","390.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.00","418.00","418.00","1 through 10","176.52","495.47","other","OPPS APC"
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","521.00","390.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","255.65","49.07","","224.50","224.50","224.50","1 through 10","191.73","408.72","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","521.00","390.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","261.02","50.1","","418.00","224.81","418.00","1 through 10","191.73","408.72","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","521.00","390.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","300.62","57.7","","418.00","418.00","418.00","1 through 10","191.73","408.72","percent of total billed charges",""
"Pulmonary Unlstd Proc","PX-46000054","CDM","94799","CPT","0460","RC","","","","outpatient","","","521.00","390.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","315.21","60.5","","418.00","418.00","418.00","1 through 10","191.73","408.72","percent of total billed charges",""
"Pulse Ox Multi Determinations","PX-46000049","CDM","94761","CPT","0460","RC","","","","outpatient","","","90.00","67.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","70.61","78.45","","85.09","85.09","85.09","1 through 10","45","70.61","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","146.00","109.50","AETNA [1001]","HB CH AETNA HMO / PPO","85.12","58.3","","80.51","80.51","80.51","26","77.38","146","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","146.00","109.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","106.58","73","","103.66","100.74","103.66","1 through 10","77.38","146","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","124.10","85","","46.59","46.59","46.59","1 through 10","77.38","146","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","146.00","100","","54.80","54.80","142.00","1 through 10","77.38","146","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","146.00","109.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","146.00","100","","142.00","59.89","142.00","14","77.38","146","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","both","","","146.00","109.50","WELLPOINT [1015]","HB CH WELLPOINT","113.75","77.91","","142.00","111.84","253.84","14","77.38","146","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","outpatient","","","146.00","109.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","86.58","59.3","","83.21","83.21","249.63","15","46.11","114.54","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.90","44.45","","64.70","64.70","64.70","1 through 10","46.11","114.54","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-76002568","CDM","11105","CPT","0761","RC","","","","outpatient","","","146.00","109.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","114.54","78.45","","109.17","64.70","109.17","16","46.11","114.54","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","AETNA [1001]","HB CH AETNA HMO / PPO","64.71","58.3","","80.51","80.51","80.51","26","58.83","111","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","81.03","73","","103.66","100.74","103.66","1 through 10","58.83","111","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","94.35","85","","46.59","46.59","46.59","1 through 10","58.83","111","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","111.00","100","","54.80","54.80","142.00","1 through 10","58.83","111","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","111.00","100","","142.00","59.89","142.00","14","58.83","111","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","both","","","111.00","83.25","WELLPOINT [1015]","HB CH WELLPOINT","86.48","77.91","","142.00","111.84","253.84","14","58.83","111","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","outpatient","","","111.00","83.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.82","59.3","","83.21","83.21","249.63","15","49.34","87.08","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","49.34","44.45","","64.70","64.70","64.70","1 through 10","49.34","87.08","percent of total billed charges",""
"Punch Biopsy Skin Ea Sep/Additional Lesion","PX-98301820","CDM","11105","CPT","0983","RC","","","","outpatient","","","111.00","83.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.08","78.45","","109.17","64.70","109.17","16","49.34","87.08","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","488.70","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.93","488.23","489.13","1 through 10","176.45","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","AETNA [1001]","HB CH AETNA HMO / PPO","213.38","58.3","","201.85","201.85","201.85","26","176.45","558.82","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","474.47","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","69.72","466.88","1 through 10","176.45","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","466.40","466.40","466.40","1 through 10","176.45","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","518.76","518.76","518.76","1 through 10","176.45","558.82","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","457.01","113.66","457.01","1 through 10","176.45","558.82","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","267.18","73","","259.88","252.58","259.88","1 through 10","176.45","558.82","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","MEDICARE [2001]","HB BWF MEDICARE","474.47","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","435.20","474.47","64","176.45","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","TRICARE [160005]","HB BWF TRICARE","450.74","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","450.75","450.75","450.75","1 through 10","176.45","558.82","other","Tricare OPPS"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","464.98","464.98","1 through 10","176.45","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.11","426.50","474.47","1 through 10","176.45","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","both","","","366.00","274.50","WELLPOINT [1015]","HB CH WELLPOINT","285.15","77.91","","356.00","280.39","636.39","14","176.45","558.82","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","291.37","285.32","291.37","55","162.69","567.68","other","ASC "
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","291.77","285.72","291.77","106","162.69","567.68","other","ASC "
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","217.04","59.3","","208.62","208.62","625.86","15","162.69","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","414.66","414.66","829.32","15","162.69","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","435.83","435.83","435.83","1 through 10","162.69","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","435.83","435.83","435.83","1 through 10","162.69","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","162.69","44.45","","162.19","162.19","162.19","1 through 10","162.69","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-76002567","CDM","11104","CPT","0761","RC","","","","outpatient","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","287.13","78.45","","273.69","162.19","273.69","16","162.69","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","488.70","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","488.93","488.23","489.13","1 through 10","108.65","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","AETNA [1001]","HB CH AETNA HMO / PPO","119.52","58.3","","201.85","201.85","201.85","26","108.65","558.82","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","474.47","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","466.88","69.72","466.88","1 through 10","108.65","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","466.40","466.40","466.40","1 through 10","108.65","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","518.76","518.76","518.76","1 through 10","108.65","558.82","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","457.01","113.66","457.01","1 through 10","108.65","558.82","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","149.65","73","","259.88","252.58","259.88","1 through 10","108.65","558.82","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","MEDICARE [2001]","HB BWF MEDICARE","474.47","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","474.47","435.20","474.47","64","108.65","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","TRICARE [160005]","HB BWF TRICARE","450.74","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","450.75","450.75","450.75","1 through 10","108.65","558.82","other","Tricare OPPS"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","464.98","464.98","464.98","1 through 10","108.65","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","464.98","","APC Price ($474.47). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","472.11","426.50","474.47","1 through 10","108.65","558.82","other","OPPS APC"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","both","","","205.00","153.75","WELLPOINT [1015]","HB CH WELLPOINT","159.72","77.91","","356.00","280.39","636.39","14","108.65","558.82","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","121.57","59.3","","208.62","208.62","625.86","15","91.12","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","414.66","414.66","829.32","15","91.12","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","435.83","435.83","435.83","1 through 10","91.12","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","176.45","","Case rate ($176.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","435.83","435.83","435.83","1 through 10","91.12","567.68","other","Multiple Surgery"
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.12","44.45","","162.19","162.19","162.19","1 through 10","91.12","567.68","percent of total billed charges",""
"Punch Biopsy Skin Single Lesion","PX-98301819","CDM","11104","CPT","0983","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.82","78.45","","273.69","162.19","273.69","16","91.12","567.68","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","AETNA [1001]","HB CH AETNA HMO / PPO","2159.26","58.3","","554.95","91.85","1421.75","94","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2703.70","73","","2490.03","2490.03","2490.03","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2159.26","58.3","","750.00","750.00","750.00","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1962.96","53","","1192.50","120.84","4149.90","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3148.15","85","","750.00","75.00","750.00","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3703.70","100","","657.00","121.50","1971.00","14","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3703.70","100","","75.00","75.00","75.00","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3703.70","100","","366.00","144.00","1971.00","45","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2703.70","73","","667.50","667.50","667.50","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1646.29","44.45","","123.77","123.77","123.77","1 through 10","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","both","","","3703.70","2777.77","WELLPOINT [1015]","HB CH WELLPOINT","2885.55","77.91","","483.51","229.32","1316.08","96","1646.29","3703.7","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","2196.29","59.3","","439.50","225.34","1872.27","197","1851.85","2905.55","percent of total billed charges",""
"PUTTY 5CC MAGNETOS EASYPACK","SUP-ITM-10317750","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3703.70","2777.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2905.55","78.45","","385.32","55.36","1815.62","58","1851.85","2905.55","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","AETNA [1001]","HB CH AETNA HMO / PPO","256.89","58.3","","1830.28","315.58","1830.28","1 through 10","195.86","440.64","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","321.67","73","","4170.85","4170.85","4170.85","1 through 10","195.86","440.64","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","195.86","44.45","","649.55","649.55","649.55","1 through 10","195.86","440.64","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","both","","","440.64","330.48","WELLPOINT [1015]","HB CH WELLPOINT","343.30","77.91","","8998.38","2542.37","8998.38","20","195.86","440.64","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","440.64","330.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","261.30","59.3","","1891.61","1609.14","3664.18","25","220.32","345.68","percent of total billed charges",""
"PUTTY BONE 1.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041855","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","440.64","330.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","345.68","78.45","","1470.68","1310.06","2481.69","19","220.32","345.68","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","AETNA [1001]","HB CH AETNA HMO / PPO","1021.42","58.3","","554.95","91.85","1421.75","94","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1278.96","73","","2490.03","2490.03","2490.03","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1021.42","58.3","","750.00","750.00","750.00","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","928.56","53","","1192.50","120.84","4149.90","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1489.20","85","","750.00","75.00","750.00","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1752.00","100","","657.00","121.50","1971.00","14","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1752.00","100","","75.00","75.00","75.00","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1752.00","100","","366.00","144.00","1971.00","45","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1278.96","73","","667.50","667.50","667.50","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","778.76","44.45","","123.77","123.77","123.77","1 through 10","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","both","","","1752.00","1314.00","WELLPOINT [1015]","HB CH WELLPOINT","1364.98","77.91","","483.51","229.32","1316.08","96","778.76","1752","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1752.00","1314.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1038.94","59.3","","439.50","225.34","1872.27","197","876","1374.44","percent of total billed charges",""
"PUTTY BONE 1.5CC MAGNETOS EASYPACK","SUP-ITM-10317749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1752.00","1314.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1374.44","78.45","","385.32","55.36","1815.62","58","876","1374.44","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","AETNA [1001]","HB CH AETNA HMO / PPO","4054.01","58.3","","554.95","91.85","1421.75","94","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5076.20","73","","2490.03","2490.03","2490.03","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4054.01","58.3","","750.00","750.00","750.00","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3685.46","53","","1192.50","120.84","4149.90","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5910.65","85","","750.00","75.00","750.00","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6953.70","100","","657.00","121.50","1971.00","14","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6953.70","100","","75.00","75.00","75.00","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6953.70","100","","366.00","144.00","1971.00","45","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5076.20","73","","667.50","667.50","667.50","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3090.92","44.45","","123.77","123.77","123.77","1 through 10","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","both","","","6953.70","5215.27","WELLPOINT [1015]","HB CH WELLPOINT","5417.63","77.91","","483.51","229.32","1316.08","96","3090.92","6953.7","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","4123.54","59.3","","439.50","225.34","1872.27","197","3476.85","5455.18","percent of total billed charges",""
"PUTTY BONE 10CC MAGNETOS EASYPACK","SUP-ITM-10317751","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6953.70","5215.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5455.18","78.45","","385.32","55.36","1815.62","58","3476.85","5455.18","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","AETNA [1001]","HB CH AETNA HMO / PPO","566.12","58.3","","554.95","91.85","1421.75","94","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","708.86","73","","2490.03","2490.03","2490.03","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","566.12","58.3","","750.00","750.00","750.00","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","514.65","53","","1192.50","120.84","4149.90","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","825.38","85","","750.00","75.00","750.00","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","971.04","100","","657.00","121.50","1971.00","14","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","971.04","100","","75.00","75.00","75.00","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","971.04","100","","366.00","144.00","1971.00","45","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","708.86","73","","667.50","667.50","667.50","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.63","44.45","","123.77","123.77","123.77","1 through 10","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.04","728.28","WELLPOINT [1015]","HB CH WELLPOINT","756.54","77.91","","483.51","229.32","1316.08","96","431.63","971.04","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.04","728.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","575.83","59.3","","439.50","225.34","1872.27","197","485.52","761.78","percent of total billed charges",""
"PUTTY BONE 2.5ML GRAFTON DEMINERALIZED MATRIX OSTEOTECH DBM ASEPTIC JAR","SUP-ITM-10041856","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.04","728.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","761.78","78.45","","385.32","55.36","1815.62","58","485.52","761.78","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","AETNA [1001]","HB CH AETNA HMO / PPO","1028.76","58.3","","1830.28","315.58","1830.28","1 through 10","784.36","1764.6","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1288.16","73","","4170.85","4170.85","4170.85","1 through 10","784.36","1764.6","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","784.36","44.45","","649.55","649.55","649.55","1 through 10","784.36","1764.6","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","both","","","1764.60","1323.45","WELLPOINT [1015]","HB CH WELLPOINT","1374.80","77.91","","8998.38","2542.37","8998.38","20","784.36","1764.6","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1764.60","1323.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","1046.41","59.3","","1891.61","1609.14","3664.18","25","882.3","1384.33","percent of total billed charges",""
"PUTTY BONE 5.0ML GRAFT GRAFTON DEMINERALIZED MATRIX JAR","SUP-ITM-10041857","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1764.60","1323.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1384.33","78.45","","1470.68","1310.06","2481.69","19","882.3","1384.33","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","AETNA [1001]","HB CH AETNA HMO / PPO","2518.56","58.3","","554.95","91.85","1421.75","94","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3153.60","73","","2490.03","2490.03","2490.03","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2518.56","58.3","","750.00","750.00","750.00","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2289.60","53","","1192.50","120.84","4149.90","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3672.00","85","","750.00","75.00","750.00","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4320.00","100","","657.00","121.50","1971.00","14","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4320.00","100","","75.00","75.00","75.00","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4320.00","100","","366.00","144.00","1971.00","45","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3153.60","73","","667.50","667.50","667.50","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1920.24","44.45","","123.77","123.77","123.77","1 through 10","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","both","","","4320.00","3240.00","WELLPOINT [1015]","HB CH WELLPOINT","3365.71","77.91","","483.51","229.32","1316.08","96","1920.24","4320","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2561.76","59.3","","439.50","225.34","1872.27","197","2160","3389.04","percent of total billed charges",""
"PUTTY INJECTABLE 10.0CC BEAST","SUP-ITM-10303278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4320.00","3240.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3389.04","78.45","","385.32","55.36","1815.62","58","2160","3389.04","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","AETNA [1001]","HB CH AETNA HMO / PPO","1023.17","58.3","","554.95","91.85","1421.75","94","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1281.15","73","","2490.03","2490.03","2490.03","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1023.17","58.3","","750.00","750.00","750.00","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","930.15","53","","1192.50","120.84","4149.90","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1491.75","85","","750.00","75.00","750.00","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1755.00","100","","657.00","121.50","1971.00","14","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1755.00","100","","75.00","75.00","75.00","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1755.00","100","","366.00","144.00","1971.00","45","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1281.15","73","","667.50","667.50","667.50","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","780.10","44.45","","123.77","123.77","123.77","1 through 10","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","both","","","1755.00","1316.25","WELLPOINT [1015]","HB CH WELLPOINT","1367.32","77.91","","483.51","229.32","1316.08","96","780.1","1755","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1755.00","1316.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1040.72","59.3","","439.50","225.34","1872.27","197","877.5","1376.8","percent of total billed charges",""
"PUTTY INJECTABLE 2.5CC BEAST","SUP-ITM-10303276","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1755.00","1316.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1376.80","78.45","","385.32","55.36","1815.62","58","877.5","1376.8","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","AETNA [1001]","HB CH AETNA HMO / PPO","1941.39","58.3","","554.95","91.85","1421.75","94","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2430.90","73","","2490.03","2490.03","2490.03","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1941.39","58.3","","750.00","750.00","750.00","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1764.90","53","","1192.50","120.84","4149.90","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2830.50","85","","750.00","75.00","750.00","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3330.00","100","","657.00","121.50","1971.00","14","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3330.00","100","","75.00","75.00","75.00","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3330.00","100","","366.00","144.00","1971.00","45","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2430.90","73","","667.50","667.50","667.50","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1480.19","44.45","","123.77","123.77","123.77","1 through 10","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","both","","","3330.00","2497.50","WELLPOINT [1015]","HB CH WELLPOINT","2594.40","77.91","","483.51","229.32","1316.08","96","1480.19","3330","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3330.00","2497.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1974.69","59.3","","439.50","225.34","1872.27","197","1665","2612.39","percent of total billed charges",""
"PUTTY INJECTABLE 5.0CC BEAST","SUP-ITM-10303277","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3330.00","2497.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2612.39","78.45","","385.32","55.36","1815.62","58","1665","2612.39","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","AETNA [1001]","HB CH AETNA HMO / PPO","1596.07","58.3","","554.95","91.85","1421.75","94","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1998.51","73","","2490.03","2490.03","2490.03","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1596.07","58.3","","750.00","750.00","750.00","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1450.97","53","","1192.50","120.84","4149.90","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2327.03","85","","750.00","75.00","750.00","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2737.68","100","","657.00","121.50","1971.00","14","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2737.68","100","","75.00","75.00","75.00","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2737.68","100","","366.00","144.00","1971.00","45","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1998.51","73","","667.50","667.50","667.50","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1216.90","44.45","","123.77","123.77","123.77","1 through 10","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","both","","","2737.68","2053.26","WELLPOINT [1015]","HB CH WELLPOINT","2132.93","77.91","","483.51","229.32","1316.08","96","1216.9","2737.68","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2737.68","2053.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","1623.44","59.3","","439.50","225.34","1872.27","197","1368.84","2147.71","percent of total billed charges",""
"PUTTY MATRIX 10ML GRAFT BONE ALLOGRAFT GRAFTON DEMINERALIZED JAR","SUP-ITM-10041858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2737.68","2053.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2147.71","78.45","","385.32","55.36","1815.62","58","1368.84","2147.71","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","AETNA [1001]","HB CH AETNA HMO / PPO","12826.00","58.3","","1830.28","315.58","1830.28","1 through 10","9779","22000","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","16060.00","73","","4170.85","4170.85","4170.85","1 through 10","9779","22000","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","9779.00","44.45","","649.55","649.55","649.55","1 through 10","9779","22000","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","both","","","22000.00","16500.00","WELLPOINT [1015]","HB CH WELLPOINT","17140.20","77.91","","8998.38","2542.37","8998.38","20","9779","22000","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","13046.00","59.3","","1891.61","1609.14","3664.18","25","11000","17259","percent of total billed charges",""
"PUTTY OVAL 20X25MM CARTIFORM","SUP-ITM-10165327","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","22000.00","16500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","17259.00","78.45","","1470.68","1310.06","2481.69","19","11000","17259","percent of total billed charges",""
"Pvb Thoracic Single Injection Site W/Img Gid","PX-76002194","CDM","64461","CPT","0761","RC","","","","both","","","442.00","331.50","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","234.26","847.08","other","OPPS APC"
"Pvb Thoracic Single Injection Site W/Img Gid","PX-98301704","CDM","64461","CPT","0983","RC","","","","both","","","420.00","315.00","MEDICARE [2001]","HB BWF MEDICARE","822.41","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","222.6","847.08","other","OPPS APC"
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-76002194","CDM","64461","CPT","0761","RC","","","50","both","","","442.00","331.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","846.24","846.24","846.24","1 through 10","781.29","3494.06","other","OPPS APC"
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-76002194","CDM","64461","CPT","0761","RC","","","50","both","","","442.00","331.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,324). Procedure 2, Per diem ($1,662). Procedures 3 - 9999, Per diem ($831).","7508.00","7508.00","7508.00","1 through 10","781.29","3494.06","per diem",""
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-76002194","CDM","64461","CPT","0761","RC","","","50","both","","","442.00","331.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1114.05","1114.05","1114.05","1 through 10","781.29","3494.06","other","OPPS APC"
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-76002194","CDM","64461","CPT","0761","RC","","","50","outpatient","","","442.00","331.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1027.16","","Case rate ($1,027.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1483.22","1452.40","1483.22","1 through 10","1027.16","3485.45","other","ASC "
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-98301704","CDM","64461","CPT","0983","RC","","","50","both","","","420.00","315.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","846.24","846.24","846.24","1 through 10","781.29","3494.06","other","OPPS APC"
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-98301704","CDM","64461","CPT","0983","RC","","","50","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,324). Procedure 2, Per diem ($1,662). Procedures 3 - 9999, Per diem ($831).","7508.00","7508.00","7508.00","1 through 10","781.29","3494.06","per diem",""
"Pvb Thoracic Single Injection Site W/Img Gid|BILATERAL PROCEDURE","PX-98301704","CDM","64461","CPT","0983","RC","","","50","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","805.96","","APC Price ($822.41). If the procedure is the highest rate for the service date, then the payment is multiplied by 1.5 divided by the quantity. Otherwise the payment is divided by the quantity. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1114.05","1114.05","1114.05","1 through 10","781.29","3494.06","other","OPPS APC"
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","AETNA [1001]","HB CH AETNA HMO / PPO","1007.02","58.3","","554.95","91.85","1421.75","94","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1260.94","73","","2490.03","2490.03","2490.03","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1007.02","58.3","","750.00","750.00","750.00","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","915.47","53","","1192.50","120.84","4149.90","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1468.21","85","","750.00","75.00","750.00","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1727.31","100","","657.00","121.50","1971.00","14","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1727.31","100","","75.00","75.00","75.00","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1727.31","100","","366.00","144.00","1971.00","45","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1260.94","73","","667.50","667.50","667.50","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","767.79","44.45","","123.77","123.77","123.77","1 through 10","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","both","","","1727.31","1295.48","WELLPOINT [1015]","HB CH WELLPOINT","1345.75","77.91","","483.51","229.32","1316.08","96","767.79","1727.31","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.31","1295.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","1024.29","59.3","","439.50","225.34","1872.27","197","863.66","1355.07","percent of total billed charges",""
"RACK SCREW 3.5/4MM CCHS SM CANNULATED","SUP-ITM-10277526","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1727.31","1295.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1355.07","78.45","","385.32","55.36","1815.62","58","863.66","1355.07","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","330.56","330.56","330.56","1 through 10","119.97","438","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","425.59","425.59","425.59","1 through 10","119.97","438","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","16","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","123.76","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","438","other","Tricare OPPS"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.27","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","438","other","OPPS APC"
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw","PX-32000419","CDM","72082","CPT","0320","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","341.64","341.64","341.64","1 through 10","199.42","470.7","percent of total billed charges",""
"Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 4/5 Vw","PX-32000420","CDM","72083","CPT","0320","RC","","","","both","","","650.00","487.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","715.46","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","GENERIC COMMERCIAL [1009]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","96.72","96.72","96.72","1 through 10","99.34","283.24","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","283.24","other","OPPS APC"
"Radex Hip Unilateral With Pelvis 2-3 Views","PX-32000423","CDM","73502","CPT","0320","RC","","","","both","","","388.00","291.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.47","102.97","21","99.34","283.24","other","OPPS APC"
"Radex Hip Unilateral With Pelvis Minimum 4 Views","PX-32000424","CDM","73503","CPT","0320","RC","","","","both","","","482.00","361.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","123.77","124.27","11","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","both","","","366.00","274.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","both","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","outpatient","","","366.00","274.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","217.04","59.3","","208.62","208.62","208.62","1 through 10","162.69","311.62","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 2 Views","PX-32000425","CDM","73521","CPT","0320","RC","","","","outpatient","","","366.00","274.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","287.13","78.45","","162.19","162.19","162.19","1 through 10","162.69","311.62","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis 3-4 Views","PX-32000426","CDM","73522","CPT","0320","RC","","","","both","","","435.00","326.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","17","119.97","423.04","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","AETNA [1001]","HB CH AETNA HMO / PPO","306.66","58.3","","289.74","289.74","289.74","1 through 10","119.97","715.46","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","119.97","715.46","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","715.46","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","61","119.97","715.46","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","124.06","124.06","1 through 10","119.97","715.46","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.36","117.99","124.36","1 through 10","119.97","715.46","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","both","","","526.00","394.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.76","126.15","1 through 10","119.97","715.46","other","OPPS APC"
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","526.00","394.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","311.92","59.3","","299.45","292.29","299.45","1 through 10","199.42","412.65","percent of total billed charges",""
"Radex Hips Bilateral With Pelvis Minimum 5 Views","PX-32000427","CDM","73523","CPT","0320","RC","","","","outpatient","","","526.00","394.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","412.65","78.45","","232.81","232.81","232.81","1 through 10","199.42","412.65","percent of total billed charges",""
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","372.00","279.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.47","1 through 10","99.34","271.56","other","OPPS APC"
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","372.00","279.00","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","271.56","other","OPPS APC"
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","both","","","372.00","279.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","99.18","102.97","1 through 10","99.34","271.56","other","OPPS APC"
"Radex Spine Thoracolumbar Junction Min 2 Views","PX-32000063","CDM","72080","CPT","0320","RC","","","","outpatient","","","372.00","279.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","220.60","59.3","","212.13","212.13","212.13","1 through 10","110.42","291.83","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","AETNA [1001]","HB CH AETNA HMO / PPO","2197.91","58.3","","554.95","91.85","1421.75","94","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2752.10","73","","2490.03","2490.03","2490.03","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2197.91","58.3","","750.00","750.00","750.00","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1998.10","53","","1192.50","120.84","4149.90","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3204.50","85","","750.00","75.00","750.00","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3770.00","100","","657.00","121.50","1971.00","14","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3770.00","100","","75.00","75.00","75.00","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3770.00","100","","366.00","144.00","1971.00","45","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2752.10","73","","667.50","667.50","667.50","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.77","44.45","","123.77","123.77","123.77","1 through 10","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","both","","","3770.00","2827.50","WELLPOINT [1015]","HB CH WELLPOINT","2937.21","77.91","","483.51","229.32","1316.08","96","1675.77","3770","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3770.00","2827.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2235.61","59.3","","439.50","225.34","1872.27","197","1885","2957.57","percent of total billed charges",""
"RADIAL PLATE HEAD RIGHT","SUP-ITM-10170015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3770.00","2827.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2957.57","78.45","","385.32","55.36","1815.62","58","1885","2957.57","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.48","102.48","102.48","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","44","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","102.87","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","both","","","253.00","189.75","WELLPOINT [1015]","HB CH WELLPOINT","197.11","77.91","","193.75","193.75","193.75","1 through 10","99.34","234.25","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","253.00","189.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.03","59.3","","144.16","144.16","144.16","1 through 10","110.42","202.02","percent of total billed charges",""
"Radiologic Exam Abdomen 1 View","PX-32000436","CDM","74018","CPT","0320","RC","","","","outpatient","","","253.00","189.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.48","78.45","","189.12","112.08","189.12","1 through 10","110.42","202.02","percent of total billed charges",""
"Radiologic Exam Abdomen 2 Views","PX-32000437","CDM","74019","CPT","0320","RC","","","","both","","","497.00","372.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","124.07","124.07","1 through 10","119.97","423.04","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","46","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","193.93","193.93","193.93","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","CHAMPVA [160001]","HB BWF TRICARE","99.34","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","381.00","381.00","381.00","1 through 10","99.34","305.41","other","Tricare OPPS"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","99.18","104.56","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","ELDER SERVICES [1037]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","97.20","97.20","97.20","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","286.16","73","","278.13","278.13","278.13","1 through 10","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","HUMANA [1012]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.10","102.47","103.31","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","600","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","97.20","102.77","19","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","MOLINA [1014]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.45","104.56","207.45","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.16","73","","112.38","112.38","112.38","1 through 10","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","52.82","307.41","21","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","102.38","104.56","1 through 10","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.24","44.45","","292.91","173.58","292.91","1 through 10","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.59","102.97","148","99.34","305.41","other","OPPS APC"
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","both","","","392.00","294.00","WELLPOINT [1015]","HB CH WELLPOINT","305.41","77.91","","300.08","300.08","300.08","22","99.34","305.41","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","inpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","219.52","56","","217.93","217.93","217.93","1 through 10","219.52","276.75","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","inpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","276.75","70.6","","292.91","292.91","292.91","1 through 10","219.52","276.75","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","223.27","223.27","223.27","33","110.42","307.52","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","392.00","294.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","110.42","307.52","percent of total billed charges",""
"Radiologic Exam Chest 2 Views","PX-32000440","CDM","71046","CPT","0324","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","173.58","292.91","27","110.42","307.52","percent of total billed charges",""
"Radiologic Exam Chest 4+ Views","PX-32000442","CDM","71048","CPT","0324","RC","","","","both","","","608.00","456.00","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","473.69","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","102.89","102.89","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","13","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","MOLINA [1014]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","196.77","196.77","196.77","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","both","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.77","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Exam Chest Single View","PX-32000439","CDM","71045","CPT","0324","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","215.26","215.26","215.26","1 through 10","110.42","225.94","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","217.75","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","217.74","217.74","217.74","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","AETNA [1001]","HB CH AETNA HMO / PPO","478.64","58.3","","452.47","452.47","452.47","1 through 10","200.84","758.54","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","FALLON HEALTH [1008]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.18","207.18","207.18","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","56","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","207.18","207.18","207.18","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.38","207.38","207.58","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","both","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","207.19","207.49","1 through 10","200.84","758.54","other","OPPS APC"
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","821.00","615.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","486.85","59.3","","467.63","467.63","467.63","1 through 10","309.54","644.07","percent of total billed charges",""
"Radiologic Exam Esophagus Double Contrast Study","PX-32000447","CDM","74221","CPT","0320","RC","","","","outpatient","","","821.00","615.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","644.07","78.45","","613.50","613.50","613.50","1 through 10","309.54","644.07","percent of total billed charges",""
"Radiologic Examination Femur Minimum 2 Views","PX-32000429","CDM","73552","CPT","0320","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.67","102.97","1 through 10","99.34","234.25","other","OPPS APC"
"Radiologic Small Intestine Follow-Through Study","PX-32000448","CDM","74248","CPT","0320","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","468.00","100","","175.94","175.94","175.94","1 through 10","248.04","468","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","AETNA [1001]","HB CH AETNA HMO / PPO","2115.90","58.3","","554.95","91.85","1421.75","94","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2649.41","73","","2490.03","2490.03","2490.03","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2115.90","58.3","","750.00","750.00","750.00","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1923.54","53","","1192.50","120.84","4149.90","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3084.93","85","","750.00","75.00","750.00","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3629.33","100","","657.00","121.50","1971.00","14","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3629.33","100","","75.00","75.00","75.00","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3629.33","100","","366.00","144.00","1971.00","45","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2649.41","73","","667.50","667.50","667.50","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1613.24","44.45","","123.77","123.77","123.77","1 through 10","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","both","","","3629.33","2722.00","WELLPOINT [1015]","HB CH WELLPOINT","2827.61","77.91","","483.51","229.32","1316.08","96","1613.24","3629.33","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3629.33","2722.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2152.19","59.3","","439.50","225.34","1872.27","197","1814.67","2847.21","percent of total billed charges",""
"RADIUS PLATE 2.0X2.3 2.7MM 56 10 HOLE VARIAX TITANIUM LOCKING STANDARD LEFT","SUP-ITM-10086655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3629.33","2722.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2847.21","78.45","","385.32","55.36","1815.62","58","1814.67","2847.21","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","AETNA [1001]","HB CH AETNA HMO / PPO","1214.63","58.3","","554.95","91.85","1421.75","94","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1520.89","73","","2490.03","2490.03","2490.03","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1214.63","58.3","","750.00","750.00","750.00","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1104.21","53","","1192.50","120.84","4149.90","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1770.90","85","","750.00","75.00","750.00","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2083.41","100","","657.00","121.50","1971.00","14","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2083.41","100","","75.00","75.00","75.00","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2083.41","100","","366.00","144.00","1971.00","45","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1520.89","73","","667.50","667.50","667.50","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.08","44.45","","123.77","123.77","123.77","1 through 10","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","both","","","2083.41","1562.56","WELLPOINT [1015]","HB CH WELLPOINT","1623.18","77.91","","483.51","229.32","1316.08","96","926.08","2083.41","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.41","1562.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1235.46","59.3","","439.50","225.34","1872.27","197","1041.71","1634.44","percent of total billed charges",""
"RADIUS PLATE 2.4X45MM LCP STAINLESS STEEL 6X2 HOLE 2 COLUMN VARIABLE ANGLE DISTAL VOLAR RIGHT","SUP-ITM-10056609","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2083.41","1562.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1634.44","78.45","","385.32","55.36","1815.62","58","1041.71","1634.44","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","AETNA [1001]","HB CH AETNA HMO / PPO","1037.09","58.3","","554.95","91.85","1421.75","94","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1298.58","73","","2490.03","2490.03","2490.03","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1037.09","58.3","","750.00","750.00","750.00","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","942.81","53","","1192.50","120.84","4149.90","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1512.05","85","","750.00","75.00","750.00","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1778.88","100","","657.00","121.50","1971.00","14","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1778.88","100","","75.00","75.00","75.00","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1778.88","100","","366.00","144.00","1971.00","45","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1298.58","73","","667.50","667.50","667.50","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","790.71","44.45","","123.77","123.77","123.77","1 through 10","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","both","","","1778.88","1334.16","WELLPOINT [1015]","HB CH WELLPOINT","1385.93","77.91","","483.51","229.32","1316.08","96","790.71","1778.88","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1778.88","1334.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","1054.88","59.3","","439.50","225.34","1872.27","197","889.44","1395.53","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE HEAD 3 SHAFT VA LCP SS COMPRESSION EXTRA ARTICULAR VOLAR DISTAL RIGHT","SUP-ITM-10023225","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1778.88","1334.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1395.53","78.45","","385.32","55.36","1815.62","58","889.44","1395.53","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","AETNA [1001]","HB CH AETNA HMO / PPO","938.58","58.3","","554.95","91.85","1421.75","94","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1175.24","73","","2490.03","2490.03","2490.03","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","938.58","58.3","","750.00","750.00","750.00","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","853.26","53","","1192.50","120.84","4149.90","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1368.43","85","","750.00","75.00","750.00","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1609.92","100","","657.00","121.50","1971.00","14","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1609.92","100","","75.00","75.00","75.00","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1609.92","100","","366.00","144.00","1971.00","45","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1175.24","73","","667.50","667.50","667.50","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","715.61","44.45","","123.77","123.77","123.77","1 through 10","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","both","","","1609.92","1207.44","WELLPOINT [1015]","HB CH WELLPOINT","1254.29","77.91","","483.51","229.32","1316.08","96","715.61","1609.92","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1609.92","1207.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","954.68","59.3","","439.50","225.34","1872.27","197","804.96","1262.98","percent of total billed charges",""
"RADIUS PLATE 2.4X48MM 5 HOLE SHORT LCP SS STRAIGHT DISTAL","SUP-ITM-10016910","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1609.92","1207.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1262.98","78.45","","385.32","55.36","1815.62","58","804.96","1262.98","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","AETNA [1001]","HB CH AETNA HMO / PPO","922.81","58.3","","554.95","91.85","1421.75","94","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1155.49","73","","2490.03","2490.03","2490.03","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","922.81","58.3","","750.00","750.00","750.00","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","838.92","53","","1192.50","120.84","4149.90","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1345.43","85","","750.00","75.00","750.00","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1582.86","100","","657.00","121.50","1971.00","14","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1582.86","100","","75.00","75.00","75.00","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1582.86","100","","366.00","144.00","1971.00","45","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1155.49","73","","667.50","667.50","667.50","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","703.58","44.45","","123.77","123.77","123.77","1 through 10","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","both","","","1582.86","1187.14","WELLPOINT [1015]","HB CH WELLPOINT","1233.21","77.91","","483.51","229.32","1316.08","96","703.58","1582.86","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1582.86","1187.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","938.64","59.3","","439.50","225.34","1872.27","197","791.43","1241.75","percent of total billed charges",""
"RADIUS PLATE 2.4X50MM 4 HOLE LCP SS RADIAL HEAD RIM","SUP-ITM-10018684","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1582.86","1187.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1241.75","78.45","","385.32","55.36","1815.62","58","791.43","1241.75","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","AETNA [1001]","HB CH AETNA HMO / PPO","1262.80","58.3","","554.95","91.85","1421.75","94","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1581.20","73","","2490.03","2490.03","2490.03","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1262.80","58.3","","750.00","750.00","750.00","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1148.00","53","","1192.50","120.84","4149.90","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1841.13","85","","750.00","75.00","750.00","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2166.03","100","","657.00","121.50","1971.00","14","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2166.03","100","","75.00","75.00","75.00","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2166.03","100","","366.00","144.00","1971.00","45","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1581.20","73","","667.50","667.50","667.50","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","962.80","44.45","","123.77","123.77","123.77","1 through 10","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","both","","","2166.03","1624.52","WELLPOINT [1015]","HB CH WELLPOINT","1687.55","77.91","","483.51","229.32","1316.08","96","962.8","2166.03","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2166.03","1624.52","CIGNA [1006]","HB CH CIGNA HMO / PPO","1284.46","59.3","","439.50","225.34","1872.27","197","1083.02","1699.25","percent of total billed charges",""
"RADIUS PLATE 2.4X54MM 6X3 HOLE LCP SS 2 COLUMN VARIABLE ANGLE LEFT","SUP-ITM-10056536","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2166.03","1624.52","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1699.25","78.45","","385.32","55.36","1815.62","58","1083.02","1699.25","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","AETNA [1001]","HB CH AETNA HMO / PPO","922.16","58.3","","554.95","91.85","1421.75","94","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1154.68","73","","2490.03","2490.03","2490.03","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","922.16","58.3","","750.00","750.00","750.00","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","838.33","53","","1192.50","120.84","4149.90","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1344.49","85","","750.00","75.00","750.00","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1581.75","100","","657.00","121.50","1971.00","14","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1581.75","100","","75.00","75.00","75.00","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1581.75","100","","366.00","144.00","1971.00","45","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1154.68","73","","667.50","667.50","667.50","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","703.09","44.45","","123.77","123.77","123.77","1 through 10","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","both","","","1581.75","1186.31","WELLPOINT [1015]","HB CH WELLPOINT","1232.34","77.91","","483.51","229.32","1316.08","96","703.09","1581.75","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.75","1186.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","937.98","59.3","","439.50","225.34","1872.27","197","790.88","1240.88","percent of total billed charges",""
"RADIUS PLATE 2.4X56MM 4 HOLE RADIAL HEAD RIM SS LEFT LCP","SUP-ITM-10019760","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1581.75","1186.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1240.88","78.45","","385.32","55.36","1815.62","58","790.88","1240.88","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","AETNA [1001]","HB CH AETNA HMO / PPO","990.48","58.3","","554.95","91.85","1421.75","94","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1240.22","73","","2490.03","2490.03","2490.03","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","990.48","58.3","","750.00","750.00","750.00","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","900.43","53","","1192.50","120.84","4149.90","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1444.09","85","","750.00","75.00","750.00","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1698.93","100","","657.00","121.50","1971.00","14","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1698.93","100","","75.00","75.00","75.00","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1698.93","100","","366.00","144.00","1971.00","45","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1240.22","73","","667.50","667.50","667.50","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","755.17","44.45","","123.77","123.77","123.77","1 through 10","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","both","","","1698.93","1274.20","WELLPOINT [1015]","HB CH WELLPOINT","1323.64","77.91","","483.51","229.32","1316.08","96","755.17","1698.93","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1698.93","1274.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1007.47","59.3","","439.50","225.34","1872.27","197","849.47","1332.81","percent of total billed charges",""
"RADIUS PLATE 2.4X57MM 6 HOLE LONG LCP STRAIGHT","SUP-ITM-10016911","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1698.93","1274.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1332.81","78.45","","385.32","55.36","1815.62","58","849.47","1332.81","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","AETNA [1001]","HB CH AETNA HMO / PPO","1072.91","58.3","","554.95","91.85","1421.75","94","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1343.43","73","","2490.03","2490.03","2490.03","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1072.91","58.3","","750.00","750.00","750.00","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","975.37","53","","1192.50","120.84","4149.90","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1564.27","85","","750.00","75.00","750.00","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1840.32","100","","657.00","121.50","1971.00","14","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1840.32","100","","75.00","75.00","75.00","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1840.32","100","","366.00","144.00","1971.00","45","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1343.43","73","","667.50","667.50","667.50","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","818.02","44.45","","123.77","123.77","123.77","1 through 10","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","both","","","1840.32","1380.24","WELLPOINT [1015]","HB CH WELLPOINT","1433.79","77.91","","483.51","229.32","1316.08","96","818.02","1840.32","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.32","1380.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","1091.31","59.3","","439.50","225.34","1872.27","197","920.16","1443.73","percent of total billed charges",""
"RADIUS PLATE 2.4X5MM 7 HOLE HEAD 3 SHAFT VA LCP SS 2 COLUMN DISTAL VOLAR LEFT","SUP-ITM-10096848","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1840.32","1380.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1443.73","78.45","","385.32","55.36","1815.62","58","920.16","1443.73","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","AETNA [1001]","HB CH AETNA HMO / PPO","1053.88","58.3","","554.95","91.85","1421.75","94","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1319.61","73","","2490.03","2490.03","2490.03","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1053.88","58.3","","750.00","750.00","750.00","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","958.07","53","","1192.50","120.84","4149.90","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1536.53","85","","750.00","75.00","750.00","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1807.68","100","","657.00","121.50","1971.00","14","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1807.68","100","","75.00","75.00","75.00","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1807.68","100","","366.00","144.00","1971.00","45","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1319.61","73","","667.50","667.50","667.50","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.51","44.45","","123.77","123.77","123.77","1 through 10","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","both","","","1807.68","1355.76","WELLPOINT [1015]","HB CH WELLPOINT","1408.36","77.91","","483.51","229.32","1316.08","96","803.51","1807.68","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.68","1355.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","1071.95","59.3","","439.50","225.34","1872.27","197","903.84","1418.12","percent of total billed charges",""
"RADIUS PLATE 2.4X75MM LCP STAINLESS STEEL 2 COLUMN VARIABLE ANGLE 6X5 HOLE VOLAR DISTAL RADIAL LEFT","SUP-ITM-10080029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1807.68","1355.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.12","78.45","","385.32","55.36","1815.62","58","903.84","1418.12","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","AETNA [1001]","HB CH AETNA HMO / PPO","1054.44","58.3","","554.95","91.85","1421.75","94","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1320.31","73","","2490.03","2490.03","2490.03","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1054.44","58.3","","750.00","750.00","750.00","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","958.58","53","","1192.50","120.84","4149.90","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1537.34","85","","750.00","75.00","750.00","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1808.64","100","","657.00","121.50","1971.00","14","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1808.64","100","","75.00","75.00","75.00","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1808.64","100","","366.00","144.00","1971.00","45","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1320.31","73","","667.50","667.50","667.50","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.94","44.45","","123.77","123.77","123.77","1 through 10","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.64","1356.48","WELLPOINT [1015]","HB CH WELLPOINT","1409.11","77.91","","483.51","229.32","1316.08","96","803.94","1808.64","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.64","1356.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","1072.52","59.3","","439.50","225.34","1872.27","197","904.32","1418.88","percent of total billed charges",""
"RADIUS PLATE 2.4X77MM 7 HOLE HEAD LCP SS 2 COLUMN 5 SHAFT DISTAL VOLAR RIGHT","SUP-ITM-10080032","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.64","1356.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.88","78.45","","385.32","55.36","1815.62","58","904.32","1418.88","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","AETNA [1001]","HB CH AETNA HMO / PPO","1721.02","58.3","","554.95","91.85","1421.75","94","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2154.96","73","","2490.03","2490.03","2490.03","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1721.02","58.3","","750.00","750.00","750.00","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1564.56","53","","1192.50","120.84","4149.90","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2509.20","85","","750.00","75.00","750.00","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2952.00","100","","657.00","121.50","1971.00","14","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2952.00","100","","75.00","75.00","75.00","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2952.00","100","","366.00","144.00","1971.00","45","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2154.96","73","","667.50","667.50","667.50","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1312.16","44.45","","123.77","123.77","123.77","1 through 10","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","both","","","2952.00","2214.00","WELLPOINT [1015]","HB CH WELLPOINT","2299.90","77.91","","483.51","229.32","1316.08","96","1312.16","2952","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.00","2214.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1750.54","59.3","","439.50","225.34","1872.27","197","1476","2315.84","percent of total billed charges",""
"RADIUS PLATE 4 HOLE BONE DISTAL VOLAR RADIAL GEMINUS TITANIUM RT NARROW","SUP-ITM-10130523","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2952.00","2214.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2315.84","78.45","","385.32","55.36","1815.62","58","1476","2315.84","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","AETNA [1001]","HB CH AETNA HMO / PPO","2025.93","58.3","","554.95","91.85","1421.75","94","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2536.75","73","","2490.03","2490.03","2490.03","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2025.93","58.3","","750.00","750.00","750.00","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1841.75","53","","1192.50","120.84","4149.90","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2953.75","85","","750.00","75.00","750.00","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3475.00","100","","657.00","121.50","1971.00","14","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3475.00","100","","75.00","75.00","75.00","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3475.00","100","","366.00","144.00","1971.00","45","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2536.75","73","","667.50","667.50","667.50","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1544.64","44.45","","123.77","123.77","123.77","1 through 10","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","both","","","3475.00","2606.25","WELLPOINT [1015]","HB CH WELLPOINT","2707.37","77.91","","483.51","229.32","1316.08","96","1544.64","3475","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.00","2606.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2060.68","59.3","","439.50","225.34","1872.27","197","1737.5","2726.14","percent of total billed charges",""
"RADIUS PLATE 49MM BONE ARM VOLAR ACU LOC 2 VDR TITANIUM DISTAL PROXIMALIMAL STANDARD RIGHT","SUP-ITM-10116073","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3475.00","2606.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2726.14","78.45","","385.32","55.36","1815.62","58","1737.5","2726.14","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","AETNA [1001]","HB CH AETNA HMO / PPO","1891.21","58.3","","554.95","91.85","1421.75","94","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2368.07","73","","2490.03","2490.03","2490.03","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1891.21","58.3","","750.00","750.00","750.00","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1719.28","53","","1192.50","120.84","4149.90","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2757.34","85","","750.00","75.00","750.00","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3243.93","100","","657.00","121.50","1971.00","14","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3243.93","100","","75.00","75.00","75.00","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3243.93","100","","366.00","144.00","1971.00","45","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2368.07","73","","667.50","667.50","667.50","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1441.93","44.45","","123.77","123.77","123.77","1 through 10","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","both","","","3243.93","2432.95","WELLPOINT [1015]","HB CH WELLPOINT","2527.35","77.91","","483.51","229.32","1316.08","96","1441.93","3243.93","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3243.93","2432.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","1923.65","59.3","","439.50","225.34","1872.27","197","1621.97","2544.86","percent of total billed charges",""
"RADIUS PLATE 57MM SMARTLOCK LONG","SUP-ITM-10143635","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3243.93","2432.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2544.86","78.45","","385.32","55.36","1815.62","58","1621.97","2544.86","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","AETNA [1001]","HB CH AETNA HMO / PPO","1825.96","58.3","","554.95","91.85","1421.75","94","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2286.36","73","","2490.03","2490.03","2490.03","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1825.96","58.3","","750.00","750.00","750.00","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1659.96","53","","1192.50","120.84","4149.90","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2662.20","85","","750.00","75.00","750.00","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3132.00","100","","657.00","121.50","1971.00","14","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3132.00","100","","75.00","75.00","75.00","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3132.00","100","","366.00","144.00","1971.00","45","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2286.36","73","","667.50","667.50","667.50","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1392.17","44.45","","123.77","123.77","123.77","1 through 10","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","both","","","3132.00","2349.00","WELLPOINT [1015]","HB CH WELLPOINT","2440.14","77.91","","483.51","229.32","1316.08","96","1392.17","3132","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.00","2349.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1857.28","59.3","","439.50","225.34","1872.27","197","1566","2457.05","percent of total billed charges",""
"RADIUS PLATE BONE RADIAL STYLOID DIVERGENT DISTAL FIXATION SYSTEM ACU LOC 2","SUP-ITM-10082333","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3132.00","2349.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2457.05","78.45","","385.32","55.36","1815.62","58","1566","2457.05","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","AETNA [1001]","HB CH AETNA HMO / PPO","1214.19","58.3","","554.95","91.85","1421.75","94","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1520.34","73","","2490.03","2490.03","2490.03","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1214.19","58.3","","750.00","750.00","750.00","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1103.81","53","","1192.50","120.84","4149.90","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1770.26","85","","750.00","75.00","750.00","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2082.66","100","","657.00","121.50","1971.00","14","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2082.66","100","","75.00","75.00","75.00","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2082.66","100","","366.00","144.00","1971.00","45","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1520.34","73","","667.50","667.50","667.50","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","925.74","44.45","","123.77","123.77","123.77","1 through 10","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","both","","","2082.66","1561.99","WELLPOINT [1015]","HB CH WELLPOINT","1622.60","77.91","","483.51","229.32","1316.08","96","925.74","2082.66","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.66","1561.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","1235.02","59.3","","439.50","225.34","1872.27","197","1041.33","1633.85","percent of total billed charges",""
"RADIUS PLATE SM 2.5MM PROXIMALIMAL A.L.P.S.","SUP-ITM-10071497","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2082.66","1561.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1633.85","78.45","","385.32","55.36","1815.62","58","1041.33","1633.85","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","AETNA [1001]","HB CH AETNA HMO / PPO","2075.29","58.3","","554.95","91.85","1421.75","94","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2598.57","73","","2490.03","2490.03","2490.03","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2075.29","58.3","","750.00","750.00","750.00","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1886.63","53","","1192.50","120.84","4149.90","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3025.73","85","","750.00","75.00","750.00","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3559.68","100","","657.00","121.50","1971.00","14","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3559.68","100","","75.00","75.00","75.00","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3559.68","100","","366.00","144.00","1971.00","45","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2598.57","73","","667.50","667.50","667.50","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1582.28","44.45","","123.77","123.77","123.77","1 through 10","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","both","","","3559.68","2669.76","WELLPOINT [1015]","HB CH WELLPOINT","2773.35","77.91","","483.51","229.32","1316.08","96","1582.28","3559.68","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.68","2669.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","2110.89","59.3","","439.50","225.34","1872.27","197","1779.84","2792.57","percent of total billed charges",""
"RADIUS PLATE VOLAR 175.3X24.4MM BONE HAND DISTAL ANATOMIC EXTRA EXTENDED LEFT","SUP-ITM-10041413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3559.68","2669.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2792.57","78.45","","385.32","55.36","1815.62","58","1779.84","2792.57","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","AETNA [1001]","HB CH AETNA HMO / PPO","1224.37","58.3","","554.95","91.85","1421.75","94","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1533.09","73","","2490.03","2490.03","2490.03","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1224.37","58.3","","750.00","750.00","750.00","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1113.06","53","","1192.50","120.84","4149.90","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1785.10","85","","750.00","75.00","750.00","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2100.12","100","","657.00","121.50","1971.00","14","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2100.12","100","","75.00","75.00","75.00","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2100.12","100","","366.00","144.00","1971.00","45","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.09","73","","667.50","667.50","667.50","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.50","44.45","","123.77","123.77","123.77","1 through 10","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","both","","","2100.12","1575.09","WELLPOINT [1015]","HB CH WELLPOINT","1636.20","77.91","","483.51","229.32","1316.08","96","933.5","2100.12","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.12","1575.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.37","59.3","","439.50","225.34","1872.27","197","1050.06","1647.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 2.4X47MM 4 3 HOLE BONE DISTAL LCP EXTRA ARTICULAR LEFT","SUP-ITM-10017460","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2100.12","1575.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.54","78.45","","385.32","55.36","1815.62","58","1050.06","1647.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","AETNA [1001]","HB CH AETNA HMO / PPO","1284.08","58.3","","554.95","91.85","1421.75","94","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1607.85","73","","2490.03","2490.03","2490.03","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1284.08","58.3","","750.00","750.00","750.00","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1167.35","53","","1192.50","120.84","4149.90","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1872.16","85","","750.00","75.00","750.00","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2202.54","100","","657.00","121.50","1971.00","14","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2202.54","100","","75.00","75.00","75.00","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2202.54","100","","366.00","144.00","1971.00","45","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1607.85","73","","667.50","667.50","667.50","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","979.03","44.45","","123.77","123.77","123.77","1 through 10","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","both","","","2202.54","1651.90","WELLPOINT [1015]","HB CH WELLPOINT","1716.00","77.91","","483.51","229.32","1316.08","96","979.03","2202.54","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2202.54","1651.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","1306.11","59.3","","439.50","225.34","1872.27","197","1101.27","1727.89","percent of total billed charges",""
"RADIUS PLATE VOLAR 89.5X24.4MM BONE HAND DISTAL DOUBLE TIERED EXTENDED NARROW RIGHT","SUP-ITM-10016566","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2202.54","1651.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1727.89","78.45","","385.32","55.36","1815.62","58","1101.27","1727.89","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","AETNA [1001]","HB CH AETNA HMO / PPO","36.15","58.3","","34.02","34.02","34.02","118","5.12","45.26","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.86","53","","31.80","31.80","127.20","1 through 10","5.12","45.26","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","both","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.56","44.45","","46.13","46.13","46.13","17","5.12","45.26","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.77","59.3","","35.16","35.16","35.16","90","5.39","48.64","percent of total billed charges",""
"Rast Allergen Ige Qn Sq Ea","PX-30000775","CDM","86003","CPT","0302","RC","","","","outpatient","","","62.00","46.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.64","78.45","","46.13","19.60","46.13","246","5.39","48.64","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","AETNA [1001]","HB CH AETNA HMO / PPO","696.10","58.3","","1634.24","1004.95","1718.99","42","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","871.62","73","","2123.89","1900.92","2123.89","1 through 10","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","696.10","58.3","","3729.00","1254.19","3729.00","1 through 10","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","632.82","53","","939.37","939.37","5593.65","1 through 10","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1014.90","85","","2323.25","1864.50","2882.25","16","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1194.00","100","","2909.44","1772.40","10952.08","45","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1194.00","100","","2323.25","2323.25","2323.25","1 through 10","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1194.00","100","","2882.25","1772.40","10169.17","187","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","871.62","73","","1659.41","1659.41","1659.41","1 through 10","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","both","","","1194.00","895.50","WELLPOINT [1015]","HB CH WELLPOINT","930.25","77.91","","2050.91","1468.48","2902.83","52","530.73","1194","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1194.00","895.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","708.04","59.3","","1548.60","1092.60","3613.79","82","597","936.69","percent of total billed charges",""
"RAT CD45RC BV711 OX-22 50UG","SUP-ITM-10220993","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1194.00","895.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","936.69","78.45","","2085.51","998.68","6202.11","56","597","936.69","percent of total billed charges",""
"RBC Antibody Elution","PX-30000068","CDM","86860","CPT","0302","RC","","","","outpatient","","","277.00","207.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","164.26","59.3","","157.87","157.87","157.87","1 through 10","132.74","489.19","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","127.01","127.01","127.01","1 through 10","102.24","1456.11","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","HUMANA [1012]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.99","419.99","419.99","1 through 10","102.24","1456.11","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","121.90","53","","118.72","118.72","118.72","1 through 10","102.24","1456.11","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","427.19","427.19","1 through 10","102.24","1456.11","other","OPPS APC"
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","both","","","230.00","172.50","WELLPOINT [1015]","HB CH WELLPOINT","179.19","77.91","","176.42","176.42","176.42","1 through 10","102.24","1456.11","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","230.00","172.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","136.39","59.3","","124.12","124.12","124.12","1 through 10","115","926.86","percent of total billed charges",""
"RBC Antibody Identification Panel","PX-30000069","CDM","86870","CPT","0302","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","172.21","172.21","172.21","1 through 10","115","926.86","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.22","82.22","82.22","55","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","63.45","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","145.00","145.00","145.00","1 through 10","60.28","270.7","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","108.77","73","","105.85","103.66","105.85","1 through 10","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.21","72.50","82.21","1 through 10","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","78.97","53","","76.85","75.26","76.85","12","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","TRICARE [160005]","HB BWF TRICARE","60.28","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","145.43","145.43","145.43","1 through 10","60.28","270.7","other","Tricare OPPS"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","62.18","","APC Price ($63.45). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","17.24","17.24","17.24","1 through 10","60.28","270.7","other","OPPS APC"
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.23","44.45","","66.06","66.06","66.06","1 through 10","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","both","","","149.00","111.75","WELLPOINT [1015]","HB CH WELLPOINT","116.09","77.91","","114.20","114.20","259.20","25","60.28","270.7","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","149.00","111.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.36","59.3","","84.97","84.97","254.91","84","74.5","172.31","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","149.00","111.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","111.48","111.48","111.48","1 through 10","74.5","172.31","percent of total billed charges",""
"RBC Antibody Screen","PX-30000067","CDM","86850","CPT","0302","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","111.48","66.06","111.48","57","74.5","172.31","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1152.00","864.00","AETNA [1001]","HB CH AETNA HMO / PPO","671.62","58.3","","1830.28","315.58","1830.28","1 through 10","512.06","1152","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1152.00","864.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","840.96","73","","4170.85","4170.85","4170.85","1 through 10","512.06","1152","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1152.00","864.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","512.06","44.45","","649.55","649.55","649.55","1 through 10","512.06","1152","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","both","","","1152.00","864.00","WELLPOINT [1015]","HB CH WELLPOINT","897.52","77.91","","8998.38","2542.37","8998.38","20","512.06","1152","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1152.00","864.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","683.14","59.3","","1891.61","1609.14","3664.18","25","576","903.74","percent of total billed charges",""
"REAMER SPINAL 4.75MM POLARIS PROBE STRAIGHT RATCHET HANDLE","SUP-ITM-10088448","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1152.00","864.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","903.74","78.45","","1470.68","1310.06","2481.69","19","576","903.74","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING LARGE","SUP-ITM-10340248","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"REAMER VIP MGS AUGMENTED LOCKING SMALL","SUP-ITM-10340251","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","40425.27","30318.95","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13667.35","","Case rate ($13,269.27). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,290.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,814.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,553.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $11,937.26 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,951.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.78. The transfer capital threshold is the transfer adjustment factor * $992.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","13480.70","13480.70","13480.70","1 through 10","13003.88","14505.49","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","40425.27","30318.95","FALLON HEALTH [1008]","HB BWF MEDICARE","14505.49","","Case rate ($14,505.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,290.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,814.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,553.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,173.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,951.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.78. The transfer capital threshold is the transfer adjustment factor * $992.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12795.24","12795.24","12795.24","1 through 10","13003.88","14505.49","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","40425.27","30318.95","HUMANA [1012]","HB BWF MEDICARE","14505.49","","Case rate ($14,505.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,290.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,814.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,553.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,173.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,951.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.78. The transfer capital threshold is the transfer adjustment factor * $992.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9216.67","9216.67","9216.67","1 through 10","13003.88","14505.49","other","Inpatient DRG"
"Red Blood Cell Disorders With McC","811","MS-DRG","","","","","","","","inpatient","","","40425.27","30318.95","MEDICARE [2001]","HB BWF MEDICARE","14505.49","","Case rate ($14,505.49). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,290.35, add-ons for qualifying new technology services are included. If operating cost exceeds $58,814.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,553.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $13,173.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,951.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $992.78. The transfer capital threshold is the transfer adjustment factor * $992.78. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14146.29","0.03","14240.63","20","13003.88","14505.49","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","24952.11","18714.08","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","9601.84","","Case rate ($9,601.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,807.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,331.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,209.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $8,613.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,468.08 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.13. The transfer capital threshold is the transfer adjustment factor * $649.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9277.15","9277.15","9277.15","1 through 10","8617.67","9601.84","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","24952.11","18714.08","HUMANA [1012]","HB BWF MEDICARE","9601.84","","Case rate ($9,601.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,807.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,331.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,209.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $8,613.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,468.08 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.13. The transfer capital threshold is the transfer adjustment factor * $649.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8511.96","8511.96","8511.96","1 through 10","8617.67","9601.84","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","24952.11","18714.08","MEDICARE [2001]","HB BWF MEDICARE","9601.84","","Case rate ($9,601.84). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,807.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,331.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,209.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $8,613.47 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,468.08 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.13. The transfer capital threshold is the transfer adjustment factor * $649.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9366.12","9366.12","9428.00","1 through 10","8617.67","9601.84","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","24952.11","18714.08","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8617.67","","Case rate ($8,793.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,807.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,331.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,209.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,805.17 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,468.08 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.13. The transfer capital threshold is the transfer adjustment factor * $649.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8509.28","8509.28","8509.28","1 through 10","8617.67","9601.84","other","Inpatient DRG"
"Red Blood Cell Disorders Without McC","812","MS-DRG","","","","","","","","inpatient","","","24952.11","18714.08","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8617.67","","Case rate ($8,793.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,807.32, add-ons for qualifying new technology services are included. If operating cost exceeds $54,331.05 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,209.91, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,805.17 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,468.08 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $649.13. The transfer capital threshold is the transfer adjustment factor * $649.13. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8475.76","8475.76","8475.76","1 through 10","8617.67","9601.84","other","Inpatient DRG"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","1323.00","992.25","MEDICARE [2001]","HB BWF MEDICARE","255.80","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","255.80","255.80","255.80","1 through 10","243.01","1258.17","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","both","","","1323.00","992.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","250.68","","APC Price ($255.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","247.43","247.43","247.43","1 through 10","243.01","1258.17","other","OPPS APC"
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","1323.00","992.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","784.54","59.3","","1286.00","1286.00","1286.00","1 through 10","453.02","1037.89","percent of total billed charges",""
"Red Cells L/R Irr Ea","PX-39000020","CDM","P9040","HCPCS","0390","RC","","","","outpatient","","","1323.00","992.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","763.37","57.7","","255.58","255.58","255.58","1 through 10","453.02","1037.89","percent of total billed charges",""
"Rem FB Muscle/Tendon Cplx","PX-76000284","CDM","20525","CPT","0761","RC","","","","both","","","5840.00","4380.00","AETNA [1001]","HB CH AETNA HMO / PPO","3404.72","58.3","","3384.99","3384.99","3384.99","1 through 10","263.22","4549.94","percent of total billed charges",""
"Rem FB Muscle/Tendon Cplx","PX-76000284","CDM","20525","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","3851.11","3851.11","1 through 10","2140.46","7178","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","3749.00","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","3197.90","3197.90","3197.90","1 through 10","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","AETNA [1001]","HB CH AETNA HMO / PPO","3404.72","58.3","","4949.91","3173.63","7293.89","1 through 10","2378.29","4549.94","percent of total billed charges",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3344.48","3344.48","3344.48","1 through 10","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","12319.54","12319.54","12319.54","1 through 10","2378.29","4549.94","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MEDICARE [2001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3398.86","3398.86","3398.86","12","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","3639.81","","APC Price ($3,639.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3336.88","3336.88","3336.88","1 through 10","2378.29","4549.94","other","OPPS APC"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","2378.29","4549.94","per diem",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,310). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","2130.00","2130.00","2130.00","1 through 10","2378.29","4549.94","per diem",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","both","","","5840.00","4380.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","2378.29","4549.94","per diem",""
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3927.26","3845.67","3927.26","1 through 10","2378.29","4581.48","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2719.71","","Case rate ($2,719.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3851.11","1966.35","3932.70","1 through 10","2378.29","4581.48","other","ASC "
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","5588.98","5588.98","5588.98","1 through 10","2378.29","4581.48","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2378.29","","Case rate ($2,378.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","11320.66","11320.66","11320.66","1 through 10","2378.29","4581.48","other","Multiple Surgery"
"Rem Impl Wire Deep","PX-76000304","CDM","20680","CPT","0761","RC","","","","outpatient","","","5840.00","4380.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4581.48","78.45","","6356.44","6356.44","6356.44","1 through 10","2378.29","4581.48","percent of total billed charges",""
"Rem Pericatheter Mat Cv Device","PX-76001111","CDM","36595","CPT","0761","RC","","","","both","","","6468.00","4851.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","3663.09","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1831.56","1831.56","1831.56","1 through 10","2377.37","5039.22","other","OPPS APC"
"Rem Prosthetic Matrl/Mesh Abd Wall","PX-76000018","CDM","11008","CPT","0761","RC","","","","outpatient","","","1208.00","906.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","947.68","78.45","","4061.57","4061.57","4061.57","1 through 10","463.96","1873.9","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.28","1815.28","1815.28","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","MEDICARE [2001]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","1844.80","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2087.36","2087.36","2087.36","1 through 10","620.01","2115.26","other","OPPS APC"
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","both","","","2715.00","2036.25","WELLPOINT [1015]","HB CH WELLPOINT","2115.26","77.91","","6775.90","6775.90","6775.90","1 through 10","620.01","2115.26","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","501.28","501.28","501.28","1 through 10","620.01","2129.92","other","ASC "
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","501.99","501.98","501.99","1 through 10","620.01","2129.92","other","ASC "
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1610.00","59.3","","5728.88","5728.88","5728.88","1 through 10","620.01","2129.92","percent of total billed charges",""
"Rem Tnld Cv Access W/Port/Pump","PX-76001105","CDM","36590","CPT","0361","RC","","","","outpatient","","","2715.00","2036.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","765.71","765.71","765.71","1 through 10","620.01","2129.92","other","Multiple Surgery"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","AETNA [1001]","HB CH AETNA HMO / PPO","911.81","58.3","","862.41","862.41","862.41","1 through 10","620.01","1218.51","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","734.22","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","722.47","674.67","722.47","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","719.54","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","722.47","719.54","722.47","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","MEDICARE [2001]","HB BWF MEDICARE","734.22","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","685.64","734.22","44","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1648.00","1648.00","1648.00","1 through 10","620.01","1218.51","per diem",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","MOLINA [1014]","HB BWF MEDICARE","734.22","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1453.76","1453.76","1453.76","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","719.54","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","100.66","724.94","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","719.54","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","671.93","722.47","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","both","","","1564.00","1173.00","WELLSENSE [1003]","HB BWF MEDICARE","734.22","","APC Price ($734.22). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","719.54","719.54","719.54","1 through 10","620.01","1218.51","other","OPPS APC"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1564.00","1173.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1002.55","1002.55","1023.82","1 through 10","620.01","1226.96","other","ASC "
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1564.00","1173.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","709.02","","Case rate ($709.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1003.97","501.99","1025.24","1 through 10","620.01","1226.96","other","ASC "
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1564.00","1173.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","927.45","59.3","","891.31","870.01","891.31","1 through 10","620.01","1226.96","percent of total billed charges",""
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1564.00","1173.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1429.82","28.60","1457.02","1 through 10","620.01","1226.96","other","Multiple Surgery"
"Rem Tnld Cv Cath W/O Port/Pump","PX-76001104","CDM","36589","CPT","0361","RC","","","","outpatient","","","1564.00","1173.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","620.01","","Case rate ($620.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1482.08","1482.08","1482.08","1 through 10","620.01","1226.96","other","Multiple Surgery"
"Removal Anal Seton Other Marker","PX-75000210","CDM","46030","CPT","0750","RC","","","","outpatient","","","1592.00","1194.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","797.59","50.1","","810.09","810.09","810.09","1 through 10","636.8","1248.92","percent of total billed charges",""
"Removal Non-Biodegradable Drug Delivery Implant","PX-76001576","CDM","11982","CPT","0761","RC","","","","outpatient","","","463.00","347.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","398.14","","Case rate ($398.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","281.49","281.49","281.49","1 through 10","205.8","859.96","other","ASC "
"Removal Subcutaneous Cardiac Rhythm Monitor","PX-36000446","CDM","33286","CPT","0361","RC","","","","outpatient","","","2193.00","1644.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","662.51","","Case rate ($662.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","479.00","479.00","479.00","1 through 10","579.34","1873.9","other","ASC "
"Remove Contraceptive Capsule","PX-76000102","CDM","11976","CPT","0761","RC","","","","both","","","1072.00","804.00","MEDICARE [2001]","HB BWF MEDICARE","735.08","","APC Price ($735.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","835.56","835.56","835.56","1 through 10","459.89","1707.36","other","OPPS APC"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","AETNA [1001]","HB CH AETNA HMO / PPO","371.95","58.3","","6252.88","2343.98","6252.88","1 through 10","165.93","873.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 294%, 147 procedures at 0%.","487.83","243.92","487.83","1 through 10","165.93","873.33","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","both","","","638.00","478.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","338.14","53","","7671.75","7671.75","7671.75","1 through 10","165.93","873.33","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","137.00","134.16","137.00","1 through 10","165.93","567.68","other","ASC "
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","189.75","","Case rate ($189.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","137.19","134.35","274.38","1 through 10","165.93","567.68","other","ASC "
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","378.33","59.3","","13619.85","1547.92","13619.85","1 through 10","165.93","567.68","percent of total billed charges",""
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","389.94","187.50","584.91","1 through 10","165.93","567.68","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","165.93","","Case rate ($165.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","614.79","614.79","614.79","1 through 10","165.93","567.68","other","Multiple Surgery"
"Remove Device Intrauterine Iud","PX-76001383","CDM","58301","CPT","0761","RC","","","","outpatient","","","638.00","478.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","500.51","78.45","","4944.92","4944.92","4944.92","1 through 10","165.93","567.68","percent of total billed charges",""
"Remove Impaction Fecal/FB W/Anes","PX-75000208","CDM","45915","CPT","0750","RC","","","","both","","","4775.00","3581.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1374.73","1374.73","1374.73","1 through 10","979.79","3720.2","other","OPPS APC"
"Remove Spine Eltrd Perq Aray","PX-76001491","CDM","63661","CPT","0761","RC","","","","outpatient","","","5753.00","4314.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2823.00","49.07","","1347.03","1319.05","1347.03","1 through 10","2301.2","4513.23","percent of total billed charges",""
"Remove Spine Eltrd Perq Aray","PX-76001491","CDM","63661","CPT","0761","RC","","","","outpatient","","","5753.00","4314.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2882.25","50.1","","1348.90","1348.90","1348.90","1 through 10","2301.2","4513.23","percent of total billed charges",""
"Remove Spine Eltrd Perq Aray","PX-76001491","CDM","63661","CPT","0761","RC","","","","outpatient","","","5753.00","4314.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","3411.53","59.3","","6191.68","6191.68","6191.68","1 through 10","2301.2","4513.23","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","both","","","340.00","255.00","AETNA [1001]","HB CH AETNA HMO / PPO","198.22","58.3","","3646.94","3646.94","3646.94","1 through 10","145.86","484.93","percent of total billed charges",""
"Remove Tag Skin <15","PX-76000033","CDM","11200","CPT","0761","RC","","","","outpatient","","","340.00","255.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","201.78","","Case rate ($201.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","4870.80","4870.80","4870.80","1 through 10","170","567.68","other","ASC "
"Renal Dialysis Access Procedures,MAJOR","444","DRG","","","","","","","","inpatient","","","67845.44","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","23860.60","","Case rate ($26,381.99). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $68,811.99, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","2758.27","2758.27","2758.27","1 through 10","23860.6","86575.14","case rate",""
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8655.23","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7567.48","7567.48","7567.48","1 through 10","8235.08","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","8403.14","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8195.99","8195.99","8218.42","1 through 10","8235.08","8990.09","other","Inpatient Replacement Plans DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8235.08","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8183.73","8183.73","8206.09","1 through 10","8235.08","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","HUMANA [1012]","HB BWF MEDICARE","8403.14","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18447.02","18447.02","18447.02","1 through 10","8235.08","8990.09","other","Inpatient Replacement Plans DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","MEDICARE [2001]","HB BWF MEDICARE","8403.14","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9030.31","0.03","9089.92","42","8235.08","8990.09","other","Inpatient Replacement Plans DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","8403.14","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8185.21","8185.21","8185.21","1 through 10","8235.08","8990.09","other","Inpatient Replacement Plans DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8235.08","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8150.20","8150.20","8150.20","1 through 10","8235.08","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8235.08","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9646.60","9646.60","9646.60","1 through 10","8235.08","8990.09","other","Inpatient DRG"
"Renal Failure With Cc","683","MS-DRG","","","","","","","","inpatient","","","24064.33","18048.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8235.08","","Case rate ($8,403.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,416.29, add-ons for qualifying new technology services are included. If operating cost exceeds $53,940.02 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,179.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3. The base transfer operating payment is the transfer adjustment factor * $7,444.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,077.04 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $619.16. The transfer capital threshold is the transfer adjustment factor * $619.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","42051.95","42051.95","42051.95","1 through 10","8235.08","8990.09","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13696.00","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13738.45","12482.32","83475.10","1 through 10","13696","14852.2891","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","HUMANA [1012]","HB BWF MEDICARE","13975.51","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13613.83","13613.83","13613.83","1 through 10","13696","14852.2891","other","Inpatient Replacement Plans DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","MEDICARE [2001]","HB BWF MEDICARE","13975.51","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15084.56","0.03","15185.27","48","13696","14852.2891","other","Inpatient Replacement Plans DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","13975.51","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13638.74","13638.74","13638.74","1 through 10","13696","14852.2891","other","Inpatient Replacement Plans DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13696.00","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13634.51","13616.99","13638.77","1 through 10","13696","14852.2891","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13696.00","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13600.99","12430.62","13917.11","1 through 10","13696","14852.2891","other","Inpatient DRG"
"Renal Failure With McC","682","MS-DRG","","","","","","","","inpatient","","","33855.79","25391.84","WELLSENSE [1003]","HB BWF MEDICARE","13975.51","","Case rate ($13,975.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,997.72, add-ons for qualifying new technology services are included. If operating cost exceeds $59,521.45 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,607.79, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $12,589.25 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,658.48 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,047.01. The transfer capital threshold is the transfer adjustment factor * $1,047.01. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13672.29","13672.29","13672.29","1 through 10","13696","14852.2891","other","Inpatient Replacement Plans DRG"
"Renal Failure Without Cc/McC","684","MS-DRG","","","","","","","","inpatient","","","19702.93","14777.20","MEDICARE [2001]","HB BWF MEDICARE","5866.48","","Case rate ($5,866.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $5,875.49, add-ons for qualifying new technology services are included. If operating cost exceeds $51,399.22 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $2,985.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,102.85 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,536.25 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $424.39. The transfer capital threshold is the transfer adjustment factor * $424.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","5741.82","5741.82","5741.82","1 through 10","5749.15","6042.47","other","Inpatient Replacement Plans DRG"
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","29815.98","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12432.6204","","Fee schedule rate ($21,535.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12432.6204","21535.28","21535.28","1 through 10","12432.6204","35532.89","case rate",""
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","29815.98","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13054.1878","","Fee schedule rate ($22,611.94). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13054.1878","23688.59","23688.59","1 through 10","12432.6204","35532.89","case rate",""
"Renal Failure,MAJOR","460","DRG","","","","","","","","inpatient","","","29815.98","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","23688.59","","Fee schedule rate ($23,688.59). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","22775.04","22775.04","22775.04","1 through 10","12432.6204","35532.89","case rate",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","109.00","81.75","AETNA [1001]","HB CH AETNA HMO / PPO","63.55","58.3","","60.10","60.10","60.10","1 through 10","8.51","79.57","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","both","","","109.00","81.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.77","53","","56.18","56.18","56.18","1 through 10","8.51","79.57","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","109.00","81.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.64","59.3","","62.12","62.12","62.12","1 through 10","8.96","85.51","percent of total billed charges",""
"Renal Function Panel","PX-30000175","CDM","80069","CPT","0301","RC","","","","outpatient","","","109.00","81.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.51","78.45","","48.29","48.29","48.29","1 through 10","8.96","85.51","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","100.93","100.93","100.93","1 through 10","21.55","133.59","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.34","44.45","","136.85","136.85","136.85","1 through 10","21.55","133.59","percent of total billed charges",""
"Renin","PX-30000667","CDM","84244","CPT","0301","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.56","78.45","","136.85","136.85","136.85","1 through 10","22.69","143.56","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","554.95","91.85","1421.75","94","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","2490.03","2490.03","2490.03","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1486.65","58.3","","750.00","750.00","750.00","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1351.50","53","","1192.50","120.84","4149.90","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2167.50","85","","750.00","75.00","750.00","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2550.00","100","","657.00","121.50","1971.00","14","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2550.00","100","","75.00","75.00","75.00","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2550.00","100","","366.00","144.00","1971.00","45","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","667.50","667.50","667.50","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","123.77","123.77","123.77","1 through 10","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","483.51","229.32","1316.08","96","1133.48","2550","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","439.50","225.34","1872.27","197","1275","2000.48","percent of total billed charges",""
"REPAIR BICEP NUMBER 2 SYSTEM DELIVERY IMPLANT DISTAL STRAIGHT NEEDLE","SUP-ITM-10036458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","385.32","55.36","1815.62","58","1275","2000.48","percent of total billed charges",""
"Repl Cath Cv Non-Tnl W/O Port","PX-76001098","CDM","36580","CPT","0361","RC","","","","outpatient","","","2763.00","2072.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1384.26","50.1","","1808.41","1808.41","1808.41","1 through 10","1105.2","2167.57","percent of total billed charges",""
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","AETNA [1001]","HB CH AETNA HMO / PPO","2765.17","58.3","","2615.00","2615.00","2615.00","1 through 10","2108.26","3849.98","percent of total billed charges",""
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","3663.09","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","2412.24","2412.24","2412.24","1 through 10","2108.26","3849.98","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2765.17","58.3","","2615.00","2615.00","2615.00","1 through 10","2108.26","3849.98","percent of total billed charges",""
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","MEDICARE [2001]","HB BWF MEDICARE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","11213.55","3737.85","11213.55","18","2108.26","3849.98","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","both","","","4743.00","3557.25","MOLINA [1014]","HB BWF MEDICARE","3737.85","","APC Price ($3,737.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7415.89","7415.89","7415.89","1 through 10","2108.26","3849.98","other","OPPS APC"
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","outpatient","","","4743.00","3557.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3020.73","","Case rate ($3,020.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4361.93","4271.31","4361.93","1 through 10","2371.5","4472.66","other","ASC "
"Repl Cath Cv Tnl W/O Port","PX-76001099","CDM","36581","CPT","0361","RC","","","","outpatient","","","4743.00","3557.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2377.37","","Case rate ($2,377.37). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","11211.53","37.89","11211.53","1 through 10","2371.5","4472.66","other","Multiple Surgery"
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","AETNA [1001]","HB CH AETNA HMO / PPO","5142.06","58.3","","1634.24","1004.95","1718.99","42","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6438.60","73","","2123.89","1900.92","2123.89","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5142.06","58.3","","3729.00","1254.19","3729.00","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4674.60","53","","939.37","939.37","5593.65","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7497.00","85","","2323.25","1864.50","2882.25","16","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8820.00","100","","2909.44","1772.40","10952.08","45","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8820.00","100","","2323.25","2323.25","2323.25","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8820.00","100","","2882.25","1772.40","10169.17","187","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6438.60","73","","1659.41","1659.41","1659.41","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","WELLPOINT [1015]","HB CH WELLPOINT","6871.66","77.91","","2050.91","1468.48","2902.83","52","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5230.26","59.3","","1548.60","1092.60","3613.79","82","4410","6919.29","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL RT STANDARD CS/1BX/1EA","SUP-ITM-10013862","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6919.29","78.45","","2085.51","998.68","6202.11","56","4410","6919.29","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","AETNA [1001]","HB CH AETNA HMO / PPO","5142.06","58.3","","1634.24","1004.95","1718.99","42","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6438.60","73","","2123.89","1900.92","2123.89","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5142.06","58.3","","3729.00","1254.19","3729.00","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4674.60","53","","939.37","939.37","5593.65","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7497.00","85","","2323.25","1864.50","2882.25","16","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8820.00","100","","2909.44","1772.40","10952.08","45","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8820.00","100","","2323.25","2323.25","2323.25","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8820.00","100","","2882.25","1772.40","10169.17","187","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6438.60","73","","1659.41","1659.41","1659.41","1 through 10","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","both","","","8820.00","6615.00","WELLPOINT [1015]","HB CH WELLPOINT","6871.66","77.91","","2050.91","1468.48","2902.83","52","3920.49","8820","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5230.26","59.3","","1548.60","1092.60","3613.79","82","4410","6919.29","percent of total billed charges",""
"REPLACEMENT MODULAR 65MM SMALL COMPONENT FEMORAL KNEE GLOBAL TITANIUM DISTAL LT CS/1BX/1EA","SUP-ITM-10013860","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8820.00","6615.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6919.29","78.45","","2085.51","998.68","6202.11","56","4410","6919.29","percent of total billed charges",""
"Reposition Cv Cath W/Fluoro","PX-76001113","CDM","36597","CPT","0361","RC","","","","outpatient","","","2856.00","2142.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1093.63","","Case rate ($1,093.63). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","12.27","12.27","12.27","1 through 10","1093.63","4472.66","other","Multiple Surgery"
"Reposition of Peritoneal Dialysis Catheter","PX-76002871","CDM","49999","CPT","0761","RC","","","","both","","","2941.00","2205.75","WELLPOINT [1015]","HB CH WELLPOINT","2291.33","77.91","","3449.15","3449.15","3449.15","1 through 10","1057.74","2796.89","percent of total billed charges",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","78023.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","46403.14","","Standard inlier is a Case rate ($46,403.14). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $55,963, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,586.73) for the length of stay and the standard reimbursement.","44293.90","44293.90","44293.90","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,EXTREME","133","DRG","","","","","","","","inpatient","","","78023.42","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","18564.59","","Case rate ($20,526.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,956.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","20521.31","20521.31","20521.31","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17378.68","","Standard inlier is a Case rate ($17,378.68). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $22,446, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,466.97) for the length of stay and the standard reimbursement.","26172.21","26172.21","26172.21","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18668.17","","Standard inlier is a Case rate ($18,668.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,649.87) for the length of stay and the standard reimbursement.","28114.17","28114.17","28114.17","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","FALLON HEALTH [1008]","HB BWF MEDICAID","6533.19","","Case rate ($7,223.57). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12539.33","12539.33","12539.33","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11926.4826","","Fee schedule rate ($28,767.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11926.4826","28767.78","28767.78","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12522.7457","","Fee schedule rate ($30,206.02). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12522.7457","20138.36","20138.36","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","MASSHEALTH [3001]","HB BWF MEDICAID","6533.19","","Case rate ($7,223.57). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12539.32","12539.32","12539.32","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MAJOR","133","DRG","","","","","","","","inpatient","","","54925.56","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6533.19","","Case rate ($7,223.57). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9739.28","9739.28","9739.28","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","19484.96","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18668.17","","Standard inlier is a Case rate ($18,668.17). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,476, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,649.87) for the length of stay and the standard reimbursement.","17819.61","17819.61","17819.61","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","19484.96","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11926.4826","","Fee schedule rate ($28,767.78). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11926.4826","18936.20","18936.20","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","19484.96","","MASSHEALTH [3001]","HB BWF MEDICAID","6533.19","","Case rate ($7,223.57). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7221.80","7221.80","7221.80","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Failure,MODERATE","133","DRG","","","","","","","","inpatient","","","19484.96","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6533.19","","Case rate ($7,223.57). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,653.57, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7221.79","7221.79","7221.79","1 through 10","6533.19","66616.1","case rate",""
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","9605.49","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","9577.17","9577.17","9577.17","1 through 10","9139.21","10018.64","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9139.21","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9101.39","9101.39","9125.47","1 through 10","9139.21","10018.64","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","MEDICARE [2001]","HB BWF MEDICARE","9325.72","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10049.57","0.03","10116.09","31","9139.21","10018.64","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9139.21","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10305.45","10305.45","10305.45","1 through 10","9139.21","10018.64","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9139.21","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13781.97","13781.97","13781.97","1 through 10","9139.21","10018.64","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9139.21","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9092.83","9092.83","9092.83","1 through 10","9139.21","10018.64","other","Inpatient DRG"
"Respiratory Infections And Inflammations With Cc","178","MS-DRG","","","","","","","","inpatient","","","30231.91","22673.93","WELLSENSE [1003]","HB BWF MEDICARE","9325.72","","Case rate ($9,325.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,340.38, add-ons for qualifying new technology services are included. If operating cost exceeds $54,864.11 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,250.77, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $8,296.49 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,001.13 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $689.99. The transfer capital threshold is the transfer adjustment factor * $689.99. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9092.83","9092.83","9092.83","1 through 10","9139.21","10018.64","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","15169.58","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","15409.46","15409.46","15409.46","1 through 10","14433.2","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","14727.75","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12817.46","12817.46","14743.22","1 through 10","14433.2","16041.12","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14433.20","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14685.80","9620.78","21320.31","1 through 10","14433.2","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","HUMANA [1012]","HB BWF MEDICARE","14727.75","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14620.00","14620.00","14620.00","1 through 10","14433.2","16041.12","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","INTERNATIONAL COMMERCIAL [140001]","HB CH GMMI INTERNATIONAL","","53","","28403.43","28403.43","28403.43","1 through 10","14433.2","16041.12","percent of total billed charges",""
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","MEDICARE [2001]","HB BWF MEDICARE","14727.75","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16216.39","0.03","16324.78","94","14433.2","16041.12","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","MOLINA [1014]","HB BWF MEDICARE","14727.75","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14693.30","14693.30","14693.30","1 through 10","14433.2","16041.12","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","14433.20","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14666.66","14666.66","14680.67","1 through 10","14433.2","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14433.20","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14660.66","14620.00","14698.16","1 through 10","14433.2","16041.12","other","Inpatient DRG"
"Respiratory Infections And Inflammations With McC","177","MS-DRG","","","","","","","","inpatient","","","44001.21","33000.91","WELLSENSE [1003]","HB BWF MEDICARE","14727.75","","Case rate ($14,727.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,751.20, add-ons for qualifying new technology services are included. If operating cost exceeds $60,274.93 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,665.55, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.4. The base transfer operating payment is the transfer adjustment factor * $13,283.74 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,411.96 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,104.77. The transfer capital threshold is the transfer adjustment factor * $1,104.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14620.00","14620.00","14620.00","1 through 10","14433.2","16041.12","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations Without Cc/McC","179","MS-DRG","","","","","","","","inpatient","","","28728.69","21546.52","MEDICARE [2001]","HB BWF MEDICARE","7290.87","","Case rate ($7,290.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,302.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,825.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,417.88 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,962.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.75. The transfer capital threshold is the transfer adjustment factor * $533.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7904.65","7904.65","7904.65","1 through 10","7145.05","7611.5633","other","Inpatient Replacement Plans DRG"
"Respiratory Infections And Inflammations Without Cc/McC","179","MS-DRG","","","","","","","","inpatient","","","28728.69","21546.52","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7145.05","","Case rate ($7,290.87). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,302.21, add-ons for qualifying new technology services are included. If operating cost exceeds $52,825.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,094.53, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $6,417.88 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $6,962.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $533.75. The transfer capital threshold is the transfer adjustment factor * $533.75. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8371.44","8371.44","8371.44","1 through 10","7145.05","7611.5633","other","Inpatient DRG"
"Respiratory Malignancy,MAJOR","136","DRG","","","","","","","","inpatient","","","103581.26","","MASSHEALTH [3001]","HB BWF MEDICAID","11865.76","","Case rate ($13,119.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $55,549.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13116.41","13116.41","13116.41","1 through 10","5757.52","53905.52","case rate",""
"Respiratory Malignancy,MINOR","136","DRG","","","","","","","","inpatient","","","32194.12","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","14519.706","","Fee schedule rate ($14,519.71). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","14519.706","14519.70","14519.70","1 through 10","5757.52","53905.52","case rate",""
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","54275.40","40706.55","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9996.42","","Case rate ($10,200.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,216.51, add-ons for qualifying new technology services are included. If operating cost exceeds $55,740.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,317.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,104.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,877.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.15. The transfer capital threshold is the transfer adjustment factor * $757.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10158.88","10158.88","10158.88","1 through 10","9996.42","10993.82","other","Inpatient DRG"
"Respiratory Neoplasms With Cc","181","MS-DRG","","","","","","","","inpatient","","","54275.40","40706.55","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9996.42","","Case rate ($10,200.43). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,216.51, add-ons for qualifying new technology services are included. If operating cost exceeds $55,740.24 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,317.93, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $9,104.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,877.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $757.15. The transfer capital threshold is the transfer adjustment factor * $757.15. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10183.82","10183.82","10183.82","1 through 10","9996.42","10993.82","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","54257.62","40693.21","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","18154.26","","Case rate ($18,154.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,626.12, add-ons for qualifying new technology services are included. If operating cost exceeds $62,149.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,809.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,566.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,286.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.49. The transfer capital threshold is the transfer adjustment factor * $1,248.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15876.54","15876.54","15876.54","1 through 10","16267.64","18154.26","other","Inpatient DRG"
"Respiratory Neoplasms With McC","180","MS-DRG","","","","","","","","inpatient","","","54257.62","40693.21","MEDICARE [2001]","HB BWF MEDICARE","18154.26","","Case rate ($18,154.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,626.12, add-ons for qualifying new technology services are included. If operating cost exceeds $62,149.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,809.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,566.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,286.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,248.49. The transfer capital threshold is the transfer adjustment factor * $1,248.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17513.18","17513.18","17513.18","1 through 10","16267.64","18154.26","other","Inpatient DRG"
"Respiratory Signs And Symptoms","204","MS-DRG","","","","","","","","inpatient","","","21779.96","16334.97","MEDICARE [2001]","HB BWF MEDICARE","8484.11","","Case rate ($8,484.11). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,785.47, add-ons for qualifying new technology services are included. If operating cost exceeds $53,309.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,131.57, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,574.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,446.23 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $570.80. The transfer capital threshold is the transfer adjustment factor * $570.80. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1219.42","728.09","8315.33","1 through 10","7617.87","8484.11","other","Inpatient DRG"
"Respiratory Signs, Symptoms And Miscellaneous Diagnoses,MAJOR","144","DRG","","","","","","","","inpatient","","","24963.40","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","9573.03","","Case rate ($10,584.63). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,014.63, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10582.03","10582.03","10582.03","1 through 10","3904.61","27284.87","case rate",""
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","69393.96","52045.47","MEDICARE [2001]","HB BWF MEDICARE","25647.80","","Case rate ($25,647.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,689.05, add-ons for qualifying new technology services are included. If operating cost exceeds $71,212.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,504.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $23,365.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,349.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,943.22. The transfer capital threshold is the transfer adjustment factor * $1,943.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","26937.45","26757.48","26937.45","1 through 10","25134.84","26737.8782","other","Inpatient Replacement Plans DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","69393.96","52045.47","MOLINA [1014]","HB BWF MEDICARE","25647.80","","Case rate ($25,647.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,689.05, add-ons for qualifying new technology services are included. If operating cost exceeds $71,212.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,504.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $23,365.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,349.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,943.22. The transfer capital threshold is the transfer adjustment factor * $1,943.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","55726.83","55726.83","55726.83","1 through 10","25134.84","26737.8782","other","Inpatient Replacement Plans DRG"
"Respiratory System Diagnosis With Ventilator Support <=96 Hours","208","MS-DRG","","","","","","","","inpatient","","","69393.96","52045.47","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","25134.84","","Case rate ($25,647.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,689.05, add-ons for qualifying new technology services are included. If operating cost exceeds $71,212.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,504.00, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.9. The base transfer operating payment is the transfer adjustment factor * $23,365.34 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,349.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,943.22. The transfer capital threshold is the transfer adjustment factor * $1,943.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","26843.88","26843.88","26843.88","1 through 10","25134.84","26737.8782","other","Inpatient DRG"
"Respiratory System Diagnosis With Ventilator Support > 96 Hours,EXTREME","130","DRG","","","","","","","","inpatient","","","186704.87","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","130471.80","","Standard inlier is a Case rate ($130,471.80). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $136,251, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($18,519.92) for the length of stay and the standard reimbursement.","124541.26","124541.26","124541.26","1 through 10","56888.43","202150.53","case rate",""
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","137050.45","102787.84","MEDICARE [2001]","HB BWF MEDICARE","59586.53","","Case rate ($59,586.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $59,683.10, add-ons for qualifying new technology services are included. If operating cost exceeds $105,206.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $7,109.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $54,698.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $59,343.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,549.07. The transfer capital threshold is the transfer adjustment factor * $4,549.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","64557.53","64557.53","64557.53","1 through 10","58394.8","63954.1408","other","Inpatient Replacement Plans DRG"
"Respiratory System Diagnosis With Ventilator Support >96 Hours","207","MS-DRG","","","","","","","","inpatient","","","137050.45","102787.84","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","58394.80","","Case rate ($59,586.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $59,683.10, add-ons for qualifying new technology services are included. If operating cost exceeds $105,206.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $7,109.85, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.5. The base transfer operating payment is the transfer adjustment factor * $54,698.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $59,343.85 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,549.07. The transfer capital threshold is the transfer adjustment factor * $4,549.07. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","57752.21","57752.21","57752.21","1 through 10","58394.8","63954.1408","other","Inpatient DRG"
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","both","","","430.00","322.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.00","418.00","418.00","1 through 10","176.52","408.93","other","OPPS APC"
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","430.00","322.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","211.00","49.07","","224.50","224.50","224.50","1 through 10","191.14","337.34","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","430.00","322.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","215.43","50.1","","418.00","224.81","418.00","1 through 10","191.14","337.34","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","430.00","322.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","248.11","57.7","","418.00","418.00","418.00","1 through 10","191.14","337.34","percent of total billed charges",""
"Resporatory Muscle Force","PX-46000058","CDM","94799","CPT","0460","RC","","","","outpatient","","","430.00","322.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","260.15","60.5","","418.00","418.00","418.00","1 through 10","191.14","337.34","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","1634.24","1004.95","1718.99","42","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","2123.89","1900.92","2123.89","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","3729.00","1254.19","3729.00","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","939.37","939.37","5593.65","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.50","85","","2323.25","1864.50","2882.25","16","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.00","100","","2909.44","1772.40","10952.08","45","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.00","100","","2323.25","2323.25","2323.25","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","2882.25","1772.40","10169.17","187","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","1659.41","1659.41","1659.41","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","2050.91","1468.48","2902.83","52","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","1548.60","1092.60","3613.79","82","75","117.68","percent of total billed charges",""
"RESTRICTOR CEMENT 12MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10020549","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","2085.51","998.68","6202.11","56","75","117.68","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","1634.24","1004.95","1718.99","42","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","2123.89","1900.92","2123.89","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","3729.00","1254.19","3729.00","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","939.37","939.37","5593.65","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.50","85","","2323.25","1864.50","2882.25","16","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.00","100","","2909.44","1772.40","10952.08","45","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.00","100","","2323.25","2323.25","2323.25","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","2882.25","1772.40","10169.17","187","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","1659.41","1659.41","1659.41","1 through 10","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","2050.91","1468.48","2902.83","52","66.68","150","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","1548.60","1092.60","3613.79","82","75","117.68","percent of total billed charges",""
"RESTRICTOR CEMENT 8MM BIOSTOP G GLYCEROL GELATIN BIOABSORBABLE FEMORAL","SUP-ITM-10019277","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","2085.51","998.68","6202.11","56","75","117.68","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1634.24","1004.95","1718.99","42","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2123.89","1900.92","2123.89","1 through 10","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","3729.00","1254.19","3729.00","1 through 10","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","939.37","939.37","5593.65","1 through 10","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","2323.25","1864.50","2882.25","16","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","2909.44","1772.40","10952.08","45","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","2323.25","2323.25","2323.25","1 through 10","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","2882.25","1772.40","10169.17","187","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","1659.41","1659.41","1659.41","1 through 10","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","2050.91","1468.48","2902.83","52","33.34","75","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1548.60","1092.60","3613.79","82","37.5","58.84","percent of total billed charges",""
"RESTRICTOR HIP 30MM UNIVERSAL LG REVISION CEMENT UNIV 16B B000-1300","SUP-ITM-10015663","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","2085.51","998.68","6202.11","56","37.5","58.84","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","1634.24","1004.95","1718.99","42","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","2123.89","1900.92","2123.89","1 through 10","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.67","58.3","","3729.00","1254.19","3729.00","1 through 10","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","939.37","939.37","5593.65","1 through 10","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","216.75","85","","2323.25","1864.50","2882.25","16","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","255.00","100","","2909.44","1772.40","10952.08","45","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","255.00","100","","2323.25","2323.25","2323.25","1 through 10","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","255.00","100","","2882.25","1772.40","10169.17","187","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","1659.41","1659.41","1659.41","1 through 10","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","2050.91","1468.48","2902.83","52","113.35","255","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","1548.60","1092.60","3613.79","82","127.5","200.05","percent of total billed charges",""
"RESTRICTOR SHOULDER 8 15MM BONE CEMENT 09","SUP-ITM-10005350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","2085.51","998.68","6202.11","56","127.5","200.05","percent of total billed charges",""
"Reticuloendothelial And Immunity Disorders With Cc","815","MS-DRG","","","","","","","","inpatient","","","15585.10","11688.82","MEDICARE [2001]","HB BWF MEDICARE","10568.26","","Case rate ($10,568.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,690.83, add-ons for qualifying new technology services are included. If operating cost exceeds $55,214.56 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,277.65, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $9,512.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,351.59 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $716.86. The transfer capital threshold is the transfer adjustment factor * $716.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10354.71","10354.71","10354.71","1 through 10","9482.11","10568.26","other","Inpatient DRG"
"Reticuloendothelial And Immunity Disorders With McC","814","MS-DRG","","","","","","","","inpatient","","","16648.00","12486.00","MEDICARE [2001]","HB BWF MEDICARE","19920.76","","Case rate ($19,920.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,952.67, add-ons for qualifying new technology services are included. If operating cost exceeds $65,476.40 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,064.27, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $18,078.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,613.43 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,503.49. The transfer capital threshold is the transfer adjustment factor * $1,503.49. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","20897.81","20897.81","20897.81","1 through 10","19522.34","20672.9545","other","Inpatient Replacement Plans DRG"
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","136.74","53","","69.13","15.86","85.00","1 through 10","114.68","258","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","219.30","85","","29.94","29.94","29.94","1 through 10","114.68","258","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","258.00","100","","60.23","29.94","60.23","12","114.68","258","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","258.00","100","","65.22","29.94","360.69","1 through 10","114.68","258","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB CH WELLPOINT","201.01","77.91","","51.37","51.37","284.08","1 through 10","114.68","258","percent of total billed charges",""
"RETRACTOR ENDOSCOPIC PERCUTANEOUS TLIF LAPAROSCOPY BX/25EA","SUP-ITM-10132520","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","123.30","23.02","333.57","1 through 10","129","202.4","percent of total billed charges",""
"Retrieval Device Fractured Med Device T1","PX-27000092","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","1239.79","929.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","972.62","78.45","","119.66","119.66","119.66","1 through 10","619.9","972.62","percent of total billed charges",""
"Retrieval Device Fractured Med Device T2","PX-27000093","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","3593.75","2695.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2819.30","78.45","","119.66","119.66","119.66","1 through 10","1796.88","2819.3","percent of total billed charges",""
"Retrieval Device Fractured Med Device T3","PX-27000094","CDM","C1773","HCPCS","0272","RC","","","","outpatient","","","6203.64","4652.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4866.76","78.45","","119.66","119.66","119.66","1 through 10","3101.82","4866.76","percent of total billed charges",""
"Retrograde Egd Diagnostic via G-Tube","PX-75000477","CDM","43999","CPT","0750","RC","","","","both","","","1780.00","1335.00","WELLPOINT [1015]","HB CH WELLPOINT","1386.80","77.91","","2383.28","2383.28","2383.28","1 through 10","763.62","1692.78","percent of total billed charges",""
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","both","","","5753.00","4314.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","4083.62","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4018.69","4018.69","4018.69","1 through 10","2468.04","4482.16","other","OPPS APC"
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","both","","","5753.00","4314.75","MEDICARE [2001]","HB BWF MEDICARE","4083.62","","APC Price ($4,083.62). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4084.03","4084.03","4084.03","1 through 10","2468.04","4482.16","other","OPPS APC"
"Rev/Rem Elect Neurostim Peripherial","PX-76001564","CDM","64585","CPT","0761","RC","","","","outpatient","","","5753.00","4314.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3293.22","","Case rate ($3,293.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","4755.41","4755.41","4755.41","1 through 10","1873.9","4513.23","other","ASC "
"Revise Spine Eltrd Perq Aray","PX-76001493","CDM","63663","CPT","0761","RC","","","","both","","","16397.00","12297.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","1722.95","1722.95","1722.95","1 through 10","7034.31","12774.9","per diem",""
"Revise Spine Eltrd Perq Aray","PX-76001493","CDM","63663","CPT","0761","RC","","","","outpatient","","","16397.00","12297.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8214.90","50.1","","9682.51","9682.51","9682.51","1 through 10","6558.8","12863.45","percent of total billed charges",""
"Revise Spine Eltrd Perq Aray","PX-76001493","CDM","63663","CPT","0761","RC","","","","outpatient","","","16397.00","12297.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","9723.42","59.3","","25197.71","25197.71","25197.71","1 through 10","6558.8","12863.45","percent of total billed charges",""
"Revise/Rem Generator/Receiver Neuro","PX-76001496","CDM","63688","CPT","0761","RC","","","","outpatient","","","7470.00","5602.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3665.53","49.07","","4755.41","4656.61","4755.41","1 through 10","2988","5860.22","percent of total billed charges",""
"Revise/Rem Generator/Receiver Neuro","PX-76001496","CDM","63688","CPT","0761","RC","","","","outpatient","","","7470.00","5602.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3742.47","50.1","","4762.00","2331.60","4762.00","1 through 10","2988","5860.22","percent of total billed charges",""
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","53738.74","40304.05","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","35914.79","","Case rate ($35,914.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,863.21, add-ons for qualifying new technology services are included. If operating cost exceeds $78,386.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,053.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $33,082.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,523.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,493.16. The transfer capital threshold is the transfer adjustment factor * $2,493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","20667.66","20667.66","20667.66","1 through 10","32154.07","35914.79","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement With Cc","467","MS-DRG","","","","","","","","inpatient","","","53738.74","40304.05","MEDICARE [2001]","HB BWF MEDICARE","35914.79","","Case rate ($35,914.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $32,863.21, add-ons for qualifying new technology services are included. If operating cost exceeds $78,386.94 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,053.94, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $33,082.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $32,523.97 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,493.16. The transfer capital threshold is the transfer adjustment factor * $2,493.16. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","34079.84","22957.86","34309.52","1 through 10","32154.07","35914.79","other","Inpatient DRG"
"Revision Of Hip Or Knee Replacement Without Cc/McC","468","MS-DRG","","","","","","","","inpatient","","","43510.03","32632.52","MEDICARE [2001]","HB BWF MEDICARE","25641.36","","Case rate ($25,641.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $25,682.60, add-ons for qualifying new technology services are included. If operating cost exceeds $71,206.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,503.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.5. The base transfer operating payment is the transfer adjustment factor * $23,359.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $25,343.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,942.73. The transfer capital threshold is the transfer adjustment factor * $1,942.73. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. For stays with condition code 49 or 50, reimbursement is reduced by any reported device reduction amounts.","26159.95","0.03","26335.85","1 through 10","25128.53","28208.22","other","Inpatient Replacement Plans DRG"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","both","","","1184.00","888.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1125.98","other","OPPS APC"
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1184.00","888.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","580.99","49.07","","2115.00","2115.00","2115.00","1 through 10","526.29","928.85","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1184.00","888.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","593.18","50.1","","331.25","331.25","331.25","1 through 10","526.29","928.85","percent of total billed charges",""
"Revision or Removal Pulse Gen/Elect","PX-76001746","CDM","64999","CPT","0761","RC","","","","outpatient","","","1184.00","888.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","928.85","78.45","","282.15","282.15","282.15","1 through 10","526.29","928.85","percent of total billed charges",""
"Revj Incl Rplcmt Nstim Eltrd Plt/Pdle Incl Fluor","PX-76001494","CDM","63664","CPT","0761","RC","","","","outpatient","","","16397.00","12297.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8214.90","50.1","","30292.08","30292.08","30292.08","1 through 10","6558.8","12863.45","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","66.00","49.50","AETNA [1001]","HB CH AETNA HMO / PPO","38.48","58.3","","36.29","36.29","36.29","15","5.56","48.18","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","both","","","66.00","49.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.98","53","","33.92","33.92","33.92","1 through 10","5.56","48.18","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","66.00","49.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","39.14","59.3","","37.50","37.50","37.50","13","5.85","51.78","percent of total billed charges",""
"Rheumatoid Factor Qn","PX-30000867","CDM","86431","CPT","0302","RC","","","","outpatient","","","66.00","49.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.78","78.45","","49.20","29.16","49.20","18","5.85","51.78","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","AETNA [1001]","HB CH AETNA HMO / PPO","1175.84","58.3","","554.95","91.85","1421.75","94","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1472.32","73","","2490.03","2490.03","2490.03","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1175.84","58.3","","750.00","750.00","750.00","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1068.94","53","","1192.50","120.84","4149.90","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1714.34","85","","750.00","75.00","750.00","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2016.87","100","","657.00","121.50","1971.00","14","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2016.87","100","","75.00","75.00","75.00","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2016.87","100","","366.00","144.00","1971.00","45","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1472.32","73","","667.50","667.50","667.50","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","896.50","44.45","","123.77","123.77","123.77","1 through 10","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","both","","","2016.87","1512.65","WELLPOINT [1015]","HB CH WELLPOINT","1571.34","77.91","","483.51","229.32","1316.08","96","896.5","2016.87","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.87","1512.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","1196.00","59.3","","439.50","225.34","1872.27","197","1008.44","1582.23","percent of total billed charges",""
"RIM VOLAR 2.4X57MM 6 HOLE HEAD 5 SHAFT PLATE BONE VA LCP SS DISTAL RADIUS LEFT","SUP-ITM-10091785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2016.87","1512.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1582.23","78.45","","385.32","55.36","1815.62","58","1008.44","1582.23","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","AETNA [1001]","HB CH AETNA HMO / PPO","1697.70","58.3","","554.95","91.85","1421.75","94","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2125.77","73","","2490.03","2490.03","2490.03","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1697.70","58.3","","750.00","750.00","750.00","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1543.37","53","","1192.50","120.84","4149.90","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2475.21","85","","750.00","75.00","750.00","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2912.01","100","","657.00","121.50","1971.00","14","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2912.01","100","","75.00","75.00","75.00","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2912.01","100","","366.00","144.00","1971.00","45","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2125.77","73","","667.50","667.50","667.50","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.39","44.45","","123.77","123.77","123.77","1 through 10","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","both","","","2912.01","2184.01","WELLPOINT [1015]","HB CH WELLPOINT","2268.75","77.91","","483.51","229.32","1316.08","96","1294.39","2912.01","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2912.01","2184.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","1726.82","59.3","","439.50","225.34","1872.27","197","1456.01","2284.47","percent of total billed charges",""
"RIM VOLAR PLATE BONE DVR RADIUS STANDARD RIGHT","SUP-ITM-10188739","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2912.01","2184.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2284.47","78.45","","385.32","55.36","1815.62","58","1456.01","2284.47","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","1634.24","1004.95","1718.99","42","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2123.89","1900.92","2123.89","1 through 10","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","3729.00","1254.19","3729.00","1 through 10","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","939.37","939.37","5593.65","1 through 10","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","2323.25","1864.50","2882.25","16","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","2909.44","1772.40","10952.08","45","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","2323.25","2323.25","2323.25","1 through 10","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","2882.25","1772.40","10169.17","187","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","1659.41","1659.41","1659.41","1 through 10","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","2050.91","1468.48","2902.83","52","72.01","162","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","1548.60","1092.60","3613.79","82","81","127.09","percent of total billed charges",""
"RING ACETABULAR 56MM HIP LOCKING DYNAMIC DURALOC","SUP-ITM-10003914","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","2085.51","998.68","6202.11","56","81","127.09","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","554.95","91.85","1421.75","94","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","2490.03","2490.03","2490.03","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","750.00","750.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","1192.50","120.84","4149.90","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","382.50","85","","750.00","75.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.00","100","","657.00","121.50","1971.00","14","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","450.00","100","","75.00","75.00","75.00","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","366.00","144.00","1971.00","45","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","667.50","667.50","667.50","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","123.77","123.77","123.77","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","483.51","229.32","1316.08","96","200.03","450","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","439.50","225.34","1872.27","197","225","353.03","percent of total billed charges",""
"ROD 5.5MM CURVED TITANIUM ALLOY 35MM LENGTH","SUP-ITM-10140423","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","385.32","55.36","1815.62","58","225","353.03","percent of total billed charges",""
"ROD 5.5X50MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111303","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","1830.28","315.58","1830.28","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5X50MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111303","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","4170.85","4170.85","4170.85","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5X50MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111303","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","649.55","649.55","649.55","1 through 10","200.03","450","percent of total billed charges",""
"ROD 5.5X50MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111303","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","8998.38","2542.37","8998.38","20","200.03","450","percent of total billed charges",""
"ROD 5.5X50MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111303","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","1891.61","1609.14","3664.18","25","225","353.03","percent of total billed charges",""
"ROD 5.5X50MM SPINAL CD HORIZON SOLERA TITANIUM CURVE","SUP-ITM-10111303","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1470.68","1310.06","2481.69","19","225","353.03","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","AETNA [1001]","HB CH AETNA HMO / PPO","283.76","58.3","","1830.28","315.58","1830.28","1 through 10","216.35","486.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.31","73","","4170.85","4170.85","4170.85","1 through 10","216.35","486.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.35","44.45","","649.55","649.55","649.55","1 through 10","216.35","486.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","both","","","486.72","365.04","WELLPOINT [1015]","HB CH WELLPOINT","379.20","77.91","","8998.38","2542.37","8998.38","20","216.35","486.72","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.62","59.3","","1891.61","1609.14","3664.18","25","243.36","381.83","percent of total billed charges",""
"ROD BONE 11X250MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004238","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","381.83","78.45","","1470.68","1310.06","2481.69","19","243.36","381.83","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","AETNA [1001]","HB CH AETNA HMO / PPO","311.18","58.3","","1830.28","315.58","1830.28","1 through 10","237.26","533.76","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","389.64","73","","4170.85","4170.85","4170.85","1 through 10","237.26","533.76","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.26","44.45","","649.55","649.55","649.55","1 through 10","237.26","533.76","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","both","","","533.76","400.32","WELLPOINT [1015]","HB CH WELLPOINT","415.85","77.91","","8998.38","2542.37","8998.38","20","237.26","533.76","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","533.76","400.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.52","59.3","","1891.61","1609.14","3664.18","25","266.88","418.73","percent of total billed charges",""
"ROD BONE 11X400MM EXTERNAL FIXATION CARBON FIBER STRAIGHT HYBRID","SUP-ITM-10004241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","533.76","400.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.73","78.45","","1470.68","1310.06","2481.69","19","266.88","418.73","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","554.95","91.85","1421.75","94","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","2490.03","2490.03","2490.03","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","750.00","750.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","1192.50","120.84","4149.90","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.25","85","","750.00","75.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.00","100","","657.00","121.50","1971.00","14","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.00","100","","75.00","75.00","75.00","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.00","100","","366.00","144.00","1971.00","45","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","667.50","667.50","667.50","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","123.77","123.77","123.77","1 through 10","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","483.51","229.32","1316.08","96","633.41","1425","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","439.50","225.34","1872.27","197","712.5","1117.91","percent of total billed charges",""
"ROD PRE-CONTOURED 5.5MM L COCR","SUP-ITM-10331601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","385.32","55.36","1815.62","58","712.5","1117.91","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","554.95","91.85","1421.75","94","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","2490.03","2490.03","2490.03","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","750.00","750.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","1192.50","120.84","4149.90","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","382.50","85","","750.00","75.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.00","100","","657.00","121.50","1971.00","14","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","450.00","100","","75.00","75.00","75.00","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","366.00","144.00","1971.00","45","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","667.50","667.50","667.50","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","123.77","123.77","123.77","1 through 10","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","483.51","229.32","1316.08","96","200.03","450","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","439.50","225.34","1872.27","197","225","353.03","percent of total billed charges",""
"ROD SPINE 5.4X60MM ROMEO 2 PREBENT PK/2EA","SUP-ITM-10114450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","385.32","55.36","1815.62","58","225","353.03","percent of total billed charges",""
"ROD TITANIUM 5.5X35MM LORDOSED TRIALTIS","SUP-ITM-10330768","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","1830.28","315.58","1830.28","1 through 10","200.03","450","percent of total billed charges",""
"ROD TITANIUM 5.5X35MM LORDOSED TRIALTIS","SUP-ITM-10330768","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","4170.85","4170.85","4170.85","1 through 10","200.03","450","percent of total billed charges",""
"ROD TITANIUM 5.5X35MM LORDOSED TRIALTIS","SUP-ITM-10330768","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","649.55","649.55","649.55","1 through 10","200.03","450","percent of total billed charges",""
"ROD TITANIUM 5.5X35MM LORDOSED TRIALTIS","SUP-ITM-10330768","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","8998.38","2542.37","8998.38","20","200.03","450","percent of total billed charges",""
"ROD TITANIUM 5.5X35MM LORDOSED TRIALTIS","SUP-ITM-10330768","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","1891.61","1609.14","3664.18","25","225","353.03","percent of total billed charges",""
"ROD TITANIUM 5.5X35MM LORDOSED TRIALTIS","SUP-ITM-10330768","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1470.68","1310.06","2481.69","19","225","353.03","percent of total billed charges",""
"Rp Loclzj Tum Spect 2 Area/Sep Acquisj Img","PX-34000187","CDM","78831","CPT","0341","RC","","","","both","","","5287.00","3965.25","MEDICARE [2001]","HB BWF MEDICARE","1550.18","","APC Price ($1,550.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1550.34","1550.34","1550.34","1 through 10","1472.82","4622.47","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","AETNA [1001]","HB CH AETNA HMO / PPO","1308.84","58.3","","7293.89","7293.89","7293.89","1 through 10","963.11","16506.88","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6817.79","6817.79","6817.79","1 through 10","963.11","16506.88","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","both","","","2245.00","1683.75","MEDICARE [2001]","HB BWF MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","963.11","16506.88","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","8361.31","8187.60","8361.31","1 through 10","1122.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Ncrc8/Strangulated","PX-98302390","CDM","49592","CPT","0983","RC","","","","outpatient","","","2245.00","1683.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","8372.89","8199.18","8372.89","1 through 10","1122.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","AETNA [1001]","HB CH AETNA HMO / PPO","943.29","58.3","","9510.29","8268.00","9510.29","1 through 10","694.12","11217.29","percent of total billed charges",""
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","MEDICARE [2001]","HB BWF MEDICARE","4488.08","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4190.97","4190.97","7069.32","12","694.12","11217.29","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","both","","","1618.00","1213.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","4398.31","","APC Price ($4,488.08). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4115.06","4107.15","6927.93","1 through 10","694.12","11217.29","other","OPPS APC"
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","5563.91","5563.91","5563.91","1 through 10","809","7939.38","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","5571.78","2844.91","5689.82","15","809","7939.38","other","ASC "
"Rpr Aa Hernia 1st < 3 Cm Reducible","PX-98302389","CDM","49591","CPT","0983","RC","","","","outpatient","","","1618.00","1213.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1269.32","78.45","","8328.41","4813.87","8328.41","1 through 10","809","7939.38","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated","PX-98302394","CDM","49596","CPT","0983","RC","","","","outpatient","","","4411.00","3308.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2164.48","49.07","","8397.50","8397.50","8397.50","1 through 10","1764.4","3460.43","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Ncrc8/Strangulated","PX-98302394","CDM","49596","CPT","0983","RC","","","","outpatient","","","4411.00","3308.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2209.91","50.1","","8409.13","8409.13","8409.13","1 through 10","1764.4","3460.43","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Reducible","PX-98302393","CDM","49595","CPT","0983","RC","","","","both","","","3769.00","2826.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3769.00","100","","3797.00","3797.00","3797.00","1 through 10","1616.9","3769","percent of total billed charges",""
"Rpr Aa Hernia 1st > 10 Cm Reducible","PX-98302393","CDM","49595","CPT","0983","RC","","","","outpatient","","","3769.00","2826.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1888.27","50.1","","5689.82","5689.82","5689.82","1 through 10","1507.6","2956.78","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7642.43","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","7138.48","7136.58","7138.48","1 through 10","1507.94","16506.88","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","AETNA [1001]","HB CH AETNA HMO / PPO","2049.25","58.3","","48965.62","48965.62","48965.62","1 through 10","1507.94","16506.88","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6817.79","6817.79","6817.79","1 through 10","1507.94","16506.88","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","MEDICARE [2001]","HB BWF MEDICARE","7419.84","","APC Price ($7,419.84). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6928.65","6928.65","6928.65","1 through 10","1507.94","16506.88","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","both","","","3515.00","2636.25","WELLPOINT [1015]","HB CH WELLPOINT","2738.54","77.91","","13751.50","13751.50","13751.50","1 through 10","1507.94","16506.88","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","8361.31","8361.31","8361.31","1 through 10","1757.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Ncrc8/Strangulated","PX-98302392","CDM","49594","CPT","0983","RC","","","","outpatient","","","3515.00","2636.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","5790.38","","Case rate ($5,790.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","8372.89","8199.18","8372.89","1 through 10","1757.5","12722.53","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","MEDICARE [2001]","HB BWF MEDICARE","7935.39","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","7410.08","7410.08","7410.08","1 through 10","1160.02","11217.29","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7776.68","","APC Price ($7,935.39). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","7263.38","7263.38","7263.38","1 through 10","1160.02","11217.29","other","OPPS APC"
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","both","","","2704.00","2028.00","WELLPOINT [1015]","HB CH WELLPOINT","2106.69","77.91","","10495.56","10495.56","10495.56","1 through 10","1160.02","11217.29","percent of total billed charges",""
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","5681.95","5563.91","5681.95","1 through 10","1352","7939.38","other","ASC "
"Rpr Aa Hernia 1st 3-10 Cm Reducible","PX-98302391","CDM","49593","CPT","0983","RC","","","","outpatient","","","2704.00","2028.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3934.87","","Case rate ($3,934.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","5689.82","5571.78","5689.82","1 through 10","1352","7939.38","other","ASC "
"Rpr Aa Hernia Recr > 10 Cm Ncrc8/Strangulated","PX-98302400","CDM","49618","CPT","0983","RC","","","","both","","","5345.00","4008.75","AETNA [1001]","HB CH AETNA HMO / PPO","3116.14","58.3","","8207.33","8207.33","8207.33","1 through 10","2293.01","5345","percent of total billed charges",""
"Rpr Aa Hernia Recr > 10 Cm Reducible","PX-98302399","CDM","49617","CPT","0983","RC","","","","outpatient","","","3823.00","2867.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1915.32","50.1","","8409.13","8409.13","8409.13","1 through 10","1529.2","2999.14","percent of total billed charges",""
"Rpr Aa Hernia Recr > 10 Cm Reducible","PX-98302399","CDM","49617","CPT","0983","RC","","","","outpatient","","","3823.00","2867.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2267.04","59.3","","14542.18","14542.18","14542.18","1 through 10","1529.2","2999.14","percent of total billed charges",""
"Rpr Cath Cv W/O Port/Pump","PX-76001095","CDM","36575","CPT","0361","RC","","","","both","","","1566.00","1174.50","MEDICARE [2001]","HB BWF MEDICARE","734.22","","APC Price ($734.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","734.22","734.22","734.22","1 through 10","620.01","1220.07","other","OPPS APC"
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","outpatient","","","1376.00","1032.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","552.21","","Case rate ($552.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","781.93","781.93","781.93","1 through 10","482.89","1079.47","other","ASC "
"Rpr Lac Cplx Trunk 2.6-7.5cm","PX-76000141","CDM","13101","CPT","0761","RC","","","","outpatient","","","1376.00","1032.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1079.47","78.45","","3383.44","3383.44","3383.44","1 through 10","482.89","1079.47","percent of total billed charges",""
"Rpr Lac Cplx Trunk Ea Add 5cm","PX-76000142","CDM","13102","CPT","0761","RC","","","","outpatient","","","368.00","276.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","288.70","78.45","","3383.44","3383.44","3383.44","1 through 10","126.18","288.7","percent of total billed charges",""
"Rpr Lac Intermd Hnd/Ft/Gen <2.5cm","PX-76000127","CDM","12041","CPT","0761","RC","","","","outpatient","","","847.00","635.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","518.64","518.64","518.64","1 through 10","314.08","664.47","other","ASC "
"Rpr Lac Intermd Hnd/Ft/Gen 2.6-7.5","PX-76000128","CDM","12042","CPT","0761","RC","","","","both","","","972.00","729.00","WELLPOINT [1015]","HB CH WELLPOINT","757.29","77.91","","9682.54","9682.54","9682.54","1 through 10","314.08","926.73","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil <2.5cm","PX-76000121","CDM","12031","CPT","0761","RC","","","","both","","","800.00","600.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","464.93","","APC Price ($474.42). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","237.24","233.44","237.24","1 through 10","314.08","926.73","other","OPPS APC"
"Rpr Lac Intermd Scalp/Axil >30.0cm","PX-76000126","CDM","12037","CPT","0761","RC","","","","outpatient","","","1480.00","1110.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","877.64","59.3","","5115.78","5115.78","5115.78","1 through 10","592","1161.06","percent of total billed charges",""
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","978.00","733.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","519.36","259.68","519.36","1 through 10","314.08","970.06","other","ASC "
"Rpr Lac Intermd Scalp/Axil 2.6-7.5","PX-76000122","CDM","12032","CPT","0761","RC","","","","outpatient","","","978.00","733.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","314.08","","Case rate ($314.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1107.15","1107.15","1107.15","1 through 10","314.08","970.06","other","Multiple Surgery"
"Rpr Lac Intermd Scalp/Axil 7.6-12.5","PX-76000123","CDM","12034","CPT","0761","RC","","","","outpatient","","","983.00","737.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","359.17","","Case rate ($359.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","518.64","518.64","518.64","1 through 10","314.08","970.06","other","ASC "
"Rpr Lac Smp Face/Ear/Lip 2.6-5.0cm","PX-76000113","CDM","12013","CPT","0761","RC","","","","outpatient","","","568.00","426.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","336.82","59.3","","552.00","552.00","552.00","1 through 10","176.45","1873.9","percent of total billed charges",""
"Rpr Tendon Finger Extensor W/O","PX-76000491","CDM","26418","CPT","0761","RC","","","","both","","","2942.00","2206.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1994.61","","APC Price ($2,035.32). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1862.57","1862.57","1862.57","1 through 10","1182.01","2292.11","other","OPPS APC"
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","130.42","18","14.1","86.14","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","both","","","118.00","88.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","86.14","73","","97.75","97.75","97.75","1 through 10","14.1","86.14","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","67.39","202.17","24","14.84","92.57","percent of total billed charges",""
"Rubella Antibody","PX-30000991","CDM","86762","CPT","0302","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.39","183.15","18","14.84","92.57","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","1 through 10","12.62","110.23","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","both","","","151.00","113.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.23","73","","124.95","124.95","124.95","1 through 10","12.62","110.23","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","172.28","1 through 10","13.29","118.46","percent of total billed charges",""
"Rubeola Antibody","PX-30000993","CDM","86765","CPT","0302","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","60.92","113.01","1 through 10","13.29","118.46","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","71.00","53.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.10","59.3","","40.43","40.43","176.96","1 through 10","6.19","55.7","percent of total billed charges",""
"Russell Viper Venom Diluted","PX-30001121","CDM","85613","CPT","0305","RC","","","","outpatient","","","71.00","53.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.70","78.45","","53.05","50.81","53.05","1 through 10","6.19","55.7","percent of total billed charges",""
"Saturation Sampling Imaging Guidanc","PX-76001324","CDM","55706","CPT","0761","RC","","","","both","","","2220.00","1665.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","952.38","1620.6","per diem",""
"Sc Infus Thpy/Proph/Dx Intl Up to 1","PX-26000007","CDM","96369","CPT","0260","RC","","","","both","","","2054.00","1540.50","MEDICARE [2001]","HB BWF MEDICARE","250.18","","APC Price ($250.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.21","250.21","250.21","1 through 10","237.7","1611.36","other","OPPS APC"
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","AETNA [1001]","HB CH AETNA HMO / PPO","1983.37","58.3","","554.95","91.85","1421.75","94","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2483.46","73","","2490.03","2490.03","2490.03","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1983.37","58.3","","750.00","750.00","750.00","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1803.06","53","","1192.50","120.84","4149.90","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2891.70","85","","750.00","75.00","750.00","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3402.00","100","","657.00","121.50","1971.00","14","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3402.00","100","","75.00","75.00","75.00","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3402.00","100","","366.00","144.00","1971.00","45","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2483.46","73","","667.50","667.50","667.50","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1512.19","44.45","","123.77","123.77","123.77","1 through 10","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","both","","","3402.00","2551.50","WELLPOINT [1015]","HB CH WELLPOINT","2650.50","77.91","","483.51","229.32","1316.08","96","1512.19","3402","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3402.00","2551.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2017.39","59.3","","439.50","225.34","1872.27","197","1701","2668.87","percent of total billed charges",""
"SCAPULA PLATE 4 HOLE BONE GLENOID LOCKING LEFT","SUP-ITM-10045071","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3402.00","2551.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2668.87","78.45","","385.32","55.36","1815.62","58","1701","2668.87","percent of total billed charges",""
"Schizophrenia And Other Severe Psychotic Disorders,EXTREME","750","DRG","","","","","","","","inpatient","","","295481.74","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","62048.75","","Case rate ($68,605.56). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $111,035.56, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6187.16","6187.16","6187.16","1 through 10","954.59","139412.2","case rate",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","AETNA [1001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","16","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","135.78","73","","132.13","132.13","132.13","1 through 10","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.44","58.3","","102.63","102.63","102.63","1 through 10","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.78","73","","80.48","74.21","181.00","1 through 10","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","TRICARE [160005]","HB BWF TRICARE","176.70","95","","27.26","26.49","27.88","1 through 10","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","TUFTS HEALTH PLAN [170001]","HB BWF TRICARE","176.70","95","","27.88","27.88","27.88","1 through 10","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.68","44.45","","139.15","82.46","139.15","16","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","both","","","186.00","139.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.68","44.45","","82.46","82.46","82.46","1 through 10","27.32","197.87","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","69.66","","Case rate ($69.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","34.83","34.83","34.83","1212","69.66","145.92","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS INDEMNITY","69.66","","Case rate ($69.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","34.83","34.83","34.83","1 through 10","69.66","145.92","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","69.66","","Case rate ($69.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","34.83","34.83","34.83","1824","69.66","145.92","other","Multiple Imaging"
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","110.30","59.3","","106.07","106.07","106.07","268","69.66","145.92","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","139.15","139.15","1 through 10","69.66","145.92","percent of total billed charges",""
"Screening Digital Breast Tomosynthesis Bi","PX-32000401","CDM","77063","CPT","0403","RC","","","","outpatient","","","186.00","139.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.92","78.45","","139.15","82.46","139.15","233","69.66","145.92","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","AETNA [1001]","HB CH AETNA HMO / PPO","260.25","58.3","","554.95","91.85","1421.75","94","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","325.87","73","","2490.03","2490.03","2490.03","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","260.25","58.3","","750.00","750.00","750.00","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","236.59","53","","1192.50","120.84","4149.90","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","379.44","85","","750.00","75.00","750.00","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","446.40","100","","657.00","121.50","1971.00","14","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","446.40","100","","75.00","75.00","75.00","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","446.40","100","","366.00","144.00","1971.00","45","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","325.87","73","","667.50","667.50","667.50","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.42","44.45","","123.77","123.77","123.77","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","WELLPOINT [1015]","HB CH WELLPOINT","347.79","77.91","","483.51","229.32","1316.08","96","198.42","446.4","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","264.72","59.3","","439.50","225.34","1872.27","197","223.2","350.2","percent of total billed charges",""
"SCREW 3.5X10MM SMALL R3CON NON LOCKING PLATE PERI OP ORTHO JOINTS","SUP-ITM-10194749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","350.20","78.45","","385.32","55.36","1815.62","58","223.2","350.2","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","AETNA [1001]","HB CH AETNA HMO / PPO","138.49","58.3","","554.95","91.85","1421.75","94","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.40","73","","2490.03","2490.03","2490.03","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.49","58.3","","750.00","750.00","750.00","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.90","53","","1192.50","120.84","4149.90","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.91","85","","750.00","75.00","750.00","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.54","100","","657.00","121.50","1971.00","14","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.54","100","","75.00","75.00","75.00","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.54","100","","366.00","144.00","1971.00","45","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.40","73","","667.50","667.50","667.50","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.59","44.45","","123.77","123.77","123.77","1 through 10","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.54","178.15","WELLPOINT [1015]","HB CH WELLPOINT","185.07","77.91","","483.51","229.32","1316.08","96","105.59","237.54","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.54","178.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.86","59.3","","439.50","225.34","1872.27","197","118.77","186.35","percent of total billed charges",""
"SCREW BONE 1.3X18MM LOCKING CORTEX SELF TAP T4 STARDRIVE RECESS","SUP-ITM-10164655","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.54","178.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.35","78.45","","385.32","55.36","1815.62","58","118.77","186.35","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","AETNA [1001]","HB CH AETNA HMO / PPO","90.00","58.3","","554.95","91.85","1421.75","94","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","112.69","73","","2490.03","2490.03","2490.03","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","90.00","58.3","","750.00","750.00","750.00","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.82","53","","1192.50","120.84","4149.90","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","131.21","85","","750.00","75.00","750.00","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","154.37","100","","657.00","121.50","1971.00","14","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","154.37","100","","75.00","75.00","75.00","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","154.37","100","","366.00","144.00","1971.00","45","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","112.69","73","","667.50","667.50","667.50","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.62","44.45","","123.77","123.77","123.77","1 through 10","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","both","","","154.37","115.78","WELLPOINT [1015]","HB CH WELLPOINT","120.27","77.91","","483.51","229.32","1316.08","96","68.62","154.37","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.37","115.78","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.54","59.3","","439.50","225.34","1872.27","197","77.19","121.1","percent of total billed charges",""
"SCREW BONE 1.3X4MM CORTEX TITANIUM PLUSDRIVE RECESS SELF TAPPING PK/5EA","SUP-ITM-10075753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","154.37","115.78","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.10","78.45","","385.32","55.36","1815.62","58","77.19","121.1","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","AETNA [1001]","HB CH AETNA HMO / PPO","117.13","58.3","","554.95","91.85","1421.75","94","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","146.66","73","","2490.03","2490.03","2490.03","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.13","58.3","","750.00","750.00","750.00","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","106.48","53","","1192.50","120.84","4149.90","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","170.77","85","","750.00","75.00","750.00","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","200.91","100","","657.00","121.50","1971.00","14","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","200.91","100","","75.00","75.00","75.00","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","200.91","100","","366.00","144.00","1971.00","45","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","146.66","73","","667.50","667.50","667.50","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.30","44.45","","123.77","123.77","123.77","1 through 10","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","both","","","200.91","150.68","WELLPOINT [1015]","HB CH WELLPOINT","156.53","77.91","","483.51","229.32","1316.08","96","89.3","200.91","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.91","150.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.14","59.3","","439.50","225.34","1872.27","197","100.46","157.61","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037061","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","200.91","150.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","157.61","78.45","","385.32","55.36","1815.62","58","100.46","157.61","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","AETNA [1001]","HB CH AETNA HMO / PPO","128.78","58.3","","554.95","91.85","1421.75","94","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","161.25","73","","2490.03","2490.03","2490.03","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","128.78","58.3","","750.00","750.00","750.00","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","117.07","53","","1192.50","120.84","4149.90","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","187.76","85","","750.00","75.00","750.00","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","220.89","100","","657.00","121.50","1971.00","14","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","220.89","100","","75.00","75.00","75.00","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","220.89","100","","366.00","144.00","1971.00","45","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","161.25","73","","667.50","667.50","667.50","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","98.19","44.45","","123.77","123.77","123.77","1 through 10","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","both","","","220.89","165.67","WELLPOINT [1015]","HB CH WELLPOINT","172.10","77.91","","483.51","229.32","1316.08","96","98.19","220.89","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.89","165.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","130.99","59.3","","439.50","225.34","1872.27","197","110.45","173.29","percent of total billed charges",""
"SCREW BONE 1.3X6MM CORTICAL SELF TAPPING TI","SUP-ITM-10002187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","220.89","165.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.29","78.45","","385.32","55.36","1815.62","58","110.45","173.29","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","554.95","91.85","1421.75","94","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2490.03","2490.03","2490.03","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","750.00","750.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","1192.50","120.84","4149.90","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","750.00","75.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","657.00","121.50","1971.00","14","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","75.00","75.00","75.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","366.00","144.00","1971.00","45","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","667.50","667.50","667.50","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","123.77","123.77","123.77","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","483.51","229.32","1316.08","96","133.35","300","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","439.50","225.34","1872.27","197","150","235.35","percent of total billed charges",""
"SCREW BONE 1.5MM 7X20 FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD TRAC CANNULA ROUND HEAD","SUP-ITM-10049357","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","385.32","55.36","1815.62","58","150","235.35","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","AETNA [1001]","HB CH AETNA HMO / PPO","77.01","58.3","","554.95","91.85","1421.75","94","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","96.43","73","","2490.03","2490.03","2490.03","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","77.01","58.3","","750.00","750.00","750.00","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","70.01","53","","1192.50","120.84","4149.90","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","112.28","85","","750.00","75.00","750.00","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","132.09","100","","657.00","121.50","1971.00","14","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","132.09","100","","75.00","75.00","75.00","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","132.09","100","","366.00","144.00","1971.00","45","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","96.43","73","","667.50","667.50","667.50","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","58.71","44.45","","123.77","123.77","123.77","1 through 10","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","both","","","132.09","99.07","WELLPOINT [1015]","HB CH WELLPOINT","102.91","77.91","","483.51","229.32","1316.08","96","58.71","132.09","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.33","59.3","","439.50","225.34","1872.27","197","66.05","103.62","percent of total billed charges",""
"SCREW BONE 1.5X13MM CORTEX SS SELF TAPPING FULL THREAD STARDRIVE RECESS","SUP-ITM-10077551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","132.09","99.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","103.62","78.45","","385.32","55.36","1815.62","58","66.05","103.62","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","AETNA [1001]","HB CH AETNA HMO / PPO","67.30","58.3","","554.95","91.85","1421.75","94","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","84.27","73","","2490.03","2490.03","2490.03","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","67.30","58.3","","750.00","750.00","750.00","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","61.18","53","","1192.50","120.84","4149.90","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","98.12","85","","750.00","75.00","750.00","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","115.44","100","","657.00","121.50","1971.00","14","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","115.44","100","","75.00","75.00","75.00","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","115.44","100","","366.00","144.00","1971.00","45","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","84.27","73","","667.50","667.50","667.50","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","51.31","44.45","","123.77","123.77","123.77","1 through 10","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","both","","","115.44","86.58","WELLPOINT [1015]","HB CH WELLPOINT","89.94","77.91","","483.51","229.32","1316.08","96","51.31","115.44","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.44","86.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","68.46","59.3","","439.50","225.34","1872.27","197","57.72","90.56","percent of total billed charges",""
"SCREW BONE 1.5X14MM CORTEX SS NONLOCKING SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019114","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","115.44","86.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","90.56","78.45","","385.32","55.36","1815.62","58","57.72","90.56","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","AETNA [1001]","HB CH AETNA HMO / PPO","165.67","58.3","","554.95","91.85","1421.75","94","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","207.44","73","","2490.03","2490.03","2490.03","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","165.67","58.3","","750.00","750.00","750.00","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","150.60","53","","1192.50","120.84","4149.90","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","241.54","85","","750.00","75.00","750.00","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","284.16","100","","657.00","121.50","1971.00","14","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","284.16","100","","75.00","75.00","75.00","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","284.16","100","","366.00","144.00","1971.00","45","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","207.44","73","","667.50","667.50","667.50","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.31","44.45","","123.77","123.77","123.77","1 through 10","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","both","","","284.16","213.12","WELLPOINT [1015]","HB CH WELLPOINT","221.39","77.91","","483.51","229.32","1316.08","96","126.31","284.16","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","284.16","213.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","168.51","59.3","","439.50","225.34","1872.27","197","142.08","222.92","percent of total billed charges",""
"SCREW BONE 1.5X24MM SS LOCKING VARIABLE ANGLE SELF TAPPING","SUP-ITM-10164628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","284.16","213.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","222.92","78.45","","385.32","55.36","1815.62","58","142.08","222.92","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","AETNA [1001]","HB CH AETNA HMO / PPO","63.87","58.3","","554.95","91.85","1421.75","94","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","79.98","73","","2490.03","2490.03","2490.03","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","63.87","58.3","","750.00","750.00","750.00","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","58.07","53","","1192.50","120.84","4149.90","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","93.13","85","","750.00","75.00","750.00","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","109.56","100","","657.00","121.50","1971.00","14","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","109.56","100","","75.00","75.00","75.00","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","109.56","100","","366.00","144.00","1971.00","45","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","79.98","73","","667.50","667.50","667.50","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.70","44.45","","123.77","123.77","123.77","1 through 10","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","both","","","109.56","82.17","WELLPOINT [1015]","HB CH WELLPOINT","85.36","77.91","","483.51","229.32","1316.08","96","48.7","109.56","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","109.56","82.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.97","59.3","","439.50","225.34","1872.27","197","54.78","85.95","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","109.56","82.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.95","78.45","","385.32","55.36","1815.62","58","54.78","85.95","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","AETNA [1001]","HB CH AETNA HMO / PPO","75.14","58.3","","554.95","91.85","1421.75","94","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","94.09","73","","2490.03","2490.03","2490.03","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.14","58.3","","750.00","750.00","750.00","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.31","53","","1192.50","120.84","4149.90","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","109.56","85","","750.00","75.00","750.00","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","128.89","100","","657.00","121.50","1971.00","14","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","128.89","100","","75.00","75.00","75.00","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","128.89","100","","366.00","144.00","1971.00","45","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.09","73","","667.50","667.50","667.50","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.29","44.45","","123.77","123.77","123.77","1 through 10","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","both","","","128.89","96.67","WELLPOINT [1015]","HB CH WELLPOINT","100.42","77.91","","483.51","229.32","1316.08","96","57.29","128.89","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.89","96.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.43","59.3","","439.50","225.34","1872.27","197","64.45","101.11","percent of total billed charges",""
"SCREW BONE 1.5X4MM CORTICAL SELF DRILLING WITH PLUSDRIVE RECESS TI PK/5EA","SUP-ITM-10015479","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","128.89","96.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.11","78.45","","385.32","55.36","1815.62","58","64.45","101.11","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","AETNA [1001]","HB CH AETNA HMO / PPO","100.17","58.3","","554.95","91.85","1421.75","94","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","125.42","73","","2490.03","2490.03","2490.03","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","100.17","58.3","","750.00","750.00","750.00","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.06","53","","1192.50","120.84","4149.90","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","146.04","85","","750.00","75.00","750.00","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","171.81","100","","657.00","121.50","1971.00","14","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","171.81","100","","75.00","75.00","75.00","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","171.81","100","","366.00","144.00","1971.00","45","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","125.42","73","","667.50","667.50","667.50","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.37","44.45","","123.77","123.77","123.77","1 through 10","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","both","","","171.81","128.86","WELLPOINT [1015]","HB CH WELLPOINT","133.86","77.91","","483.51","229.32","1316.08","96","76.37","171.81","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.81","128.86","CIGNA [1006]","HB CH CIGNA HMO / PPO","101.88","59.3","","439.50","225.34","1872.27","197","85.91","134.78","percent of total billed charges",""
"SCREW BONE 1.5X5MM TI MATRIX MIDFACE SELF DRILL SILVER","SUP-ITM-10131093","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","171.81","128.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","134.78","78.45","","385.32","55.36","1815.62","58","85.91","134.78","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","AETNA [1001]","HB CH AETNA HMO / PPO","73.46","58.3","","554.95","91.85","1421.75","94","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","2490.03","2490.03","2490.03","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","73.46","58.3","","750.00","750.00","750.00","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","66.78","53","","1192.50","120.84","4149.90","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","107.10","85","","750.00","75.00","750.00","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","126.00","100","","657.00","121.50","1971.00","14","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","126.00","100","","75.00","75.00","75.00","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","126.00","100","","366.00","144.00","1971.00","45","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.98","73","","667.50","667.50","667.50","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","56.01","44.45","","123.77","123.77","123.77","1 through 10","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","both","","","126.00","94.50","WELLPOINT [1015]","HB CH WELLPOINT","98.17","77.91","","483.51","229.32","1316.08","96","56.01","126","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.00","94.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.72","59.3","","439.50","225.34","1872.27","197","63","98.85","percent of total billed charges",""
"SCREW BONE 1.5X6MM TIMAX TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","126.00","94.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.85","78.45","","385.32","55.36","1815.62","58","63","98.85","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","AETNA [1001]","HB CH AETNA HMO / PPO","59.54","58.3","","554.95","91.85","1421.75","94","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","74.55","73","","2490.03","2490.03","2490.03","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","59.54","58.3","","750.00","750.00","750.00","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","54.12","53","","1192.50","120.84","4149.90","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","86.80","85","","750.00","75.00","750.00","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","102.12","100","","657.00","121.50","1971.00","14","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","102.12","100","","75.00","75.00","75.00","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","102.12","100","","366.00","144.00","1971.00","45","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","74.55","73","","667.50","667.50","667.50","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.39","44.45","","123.77","123.77","123.77","1 through 10","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","both","","","102.12","76.59","WELLPOINT [1015]","HB CH WELLPOINT","79.56","77.91","","483.51","229.32","1316.08","96","45.39","102.12","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","102.12","76.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","60.56","59.3","","439.50","225.34","1872.27","197","51.06","80.11","percent of total billed charges",""
"SCREW BONE 1.5X9MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","102.12","76.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.11","78.45","","385.32","55.36","1815.62","58","51.06","80.11","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","AETNA [1001]","HB CH AETNA HMO / PPO","365.54","58.3","","554.95","91.85","1421.75","94","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","457.71","73","","2490.03","2490.03","2490.03","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","365.54","58.3","","750.00","750.00","750.00","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","332.31","53","","1192.50","120.84","4149.90","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","532.95","85","","750.00","75.00","750.00","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","627.00","100","","657.00","121.50","1971.00","14","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","627.00","100","","75.00","75.00","75.00","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","627.00","100","","366.00","144.00","1971.00","45","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","457.71","73","","667.50","667.50","667.50","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.70","44.45","","123.77","123.77","123.77","1 through 10","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.00","470.25","WELLPOINT [1015]","HB CH WELLPOINT","488.50","77.91","","483.51","229.32","1316.08","96","278.7","627","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.00","470.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.81","59.3","","439.50","225.34","1872.27","197","313.5","491.88","percent of total billed charges",""
"SCREW BONE 1.7X10MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075776","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.00","470.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.88","78.45","","385.32","55.36","1815.62","58","313.5","491.88","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","AETNA [1001]","HB CH AETNA HMO / PPO","314.58","58.3","","554.95","91.85","1421.75","94","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","393.89","73","","2490.03","2490.03","2490.03","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","314.58","58.3","","750.00","750.00","750.00","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","285.98","53","","1192.50","120.84","4149.90","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","458.64","85","","750.00","75.00","750.00","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","539.58","100","","657.00","121.50","1971.00","14","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","539.58","100","","75.00","75.00","75.00","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","539.58","100","","366.00","144.00","1971.00","45","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","393.89","73","","667.50","667.50","667.50","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.84","44.45","","123.77","123.77","123.77","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","WELLPOINT [1015]","HB CH WELLPOINT","420.39","77.91","","483.51","229.32","1316.08","96","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.58","404.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","319.97","59.3","","439.50","225.34","1872.27","197","269.79","423.3","percent of total billed charges",""
"SCREW BONE 1.7X10MM VARIAX SS LOCKING","SUP-ITM-10143466","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.58","404.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","423.30","78.45","","385.32","55.36","1815.62","58","269.79","423.3","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","AETNA [1001]","HB CH AETNA HMO / PPO","314.58","58.3","","554.95","91.85","1421.75","94","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","393.89","73","","2490.03","2490.03","2490.03","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","314.58","58.3","","750.00","750.00","750.00","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","285.98","53","","1192.50","120.84","4149.90","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","458.64","85","","750.00","75.00","750.00","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","539.58","100","","657.00","121.50","1971.00","14","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","539.58","100","","75.00","75.00","75.00","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","539.58","100","","366.00","144.00","1971.00","45","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","393.89","73","","667.50","667.50","667.50","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","239.84","44.45","","123.77","123.77","123.77","1 through 10","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","both","","","539.58","404.68","WELLPOINT [1015]","HB CH WELLPOINT","420.39","77.91","","483.51","229.32","1316.08","96","239.84","539.58","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.58","404.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","319.97","59.3","","439.50","225.34","1872.27","197","269.79","423.3","percent of total billed charges",""
"SCREW BONE 1.7X11MM LOCKING SELF TAPPING","SUP-ITM-10143467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","539.58","404.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","423.30","78.45","","385.32","55.36","1815.62","58","269.79","423.3","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","AETNA [1001]","HB CH AETNA HMO / PPO","94.36","58.3","","554.95","91.85","1421.75","94","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.15","73","","2490.03","2490.03","2490.03","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.36","58.3","","750.00","750.00","750.00","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.78","53","","1192.50","120.84","4149.90","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.57","85","","750.00","75.00","750.00","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","161.85","100","","657.00","121.50","1971.00","14","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","161.85","100","","75.00","75.00","75.00","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","161.85","100","","366.00","144.00","1971.00","45","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.15","73","","667.50","667.50","667.50","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.94","44.45","","123.77","123.77","123.77","1 through 10","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","both","","","161.85","121.39","WELLPOINT [1015]","HB CH WELLPOINT","126.10","77.91","","483.51","229.32","1316.08","96","71.94","161.85","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.85","121.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","95.98","59.3","","439.50","225.34","1872.27","197","80.93","126.97","percent of total billed charges",""
"SCREW BONE 1.7X4MM CORTEX PLUSDRIVE RECESS TITANIUM SELF TAPPING PK/5EA","SUP-ITM-10075772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","161.85","121.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","126.97","78.45","","385.32","55.36","1815.62","58","80.93","126.97","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","AETNA [1001]","HB CH AETNA HMO / PPO","260.27","58.3","","554.95","91.85","1421.75","94","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","325.89","73","","2490.03","2490.03","2490.03","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","260.27","58.3","","750.00","750.00","750.00","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","236.61","53","","1192.50","120.84","4149.90","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","379.47","85","","750.00","75.00","750.00","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","446.43","100","","657.00","121.50","1971.00","14","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","446.43","100","","75.00","75.00","75.00","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","446.43","100","","366.00","144.00","1971.00","45","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","325.89","73","","667.50","667.50","667.50","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.44","44.45","","123.77","123.77","123.77","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","WELLPOINT [1015]","HB CH WELLPOINT","347.81","77.91","","483.51","229.32","1316.08","96","198.44","446.43","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.43","334.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","264.73","59.3","","439.50","225.34","1872.27","197","223.22","350.22","percent of total billed charges",""
"SCREW BONE 1.7X8MM PROFYLE TI CROSS PIN SELF TAPPING","SUP-ITM-10143878","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.43","334.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","350.22","78.45","","385.32","55.36","1815.62","58","223.22","350.22","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","AETNA [1001]","HB CH AETNA HMO / PPO","556.18","58.3","","554.95","91.85","1421.75","94","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","696.42","73","","2490.03","2490.03","2490.03","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","556.18","58.3","","750.00","750.00","750.00","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","505.62","53","","1192.50","120.84","4149.90","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","810.90","85","","750.00","75.00","750.00","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","954.00","100","","657.00","121.50","1971.00","14","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","954.00","100","","75.00","75.00","75.00","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","954.00","100","","366.00","144.00","1971.00","45","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","696.42","73","","667.50","667.50","667.50","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","424.05","44.45","","123.77","123.77","123.77","1 through 10","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","both","","","954.00","715.50","WELLPOINT [1015]","HB CH WELLPOINT","743.26","77.91","","483.51","229.32","1316.08","96","424.05","954","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","565.72","59.3","","439.50","225.34","1872.27","197","477","748.41","percent of total billed charges",""
"SCREW BONE 1.9MMX2.5MMX24MM INTERPHALANGEAL FUSION ACUTRAK - DISCONTINUED PER SUPPLIER/CONTRACTS","SUP-ITM-10021700","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","954.00","715.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","748.41","78.45","","385.32","55.36","1815.62","58","477","748.41","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","AETNA [1001]","HB CH AETNA HMO / PPO","1496.11","58.3","","554.95","91.85","1421.75","94","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1873.35","73","","2490.03","2490.03","2490.03","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1496.11","58.3","","750.00","750.00","750.00","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1360.10","53","","1192.50","120.84","4149.90","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2181.30","85","","750.00","75.00","750.00","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2566.23","100","","657.00","121.50","1971.00","14","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2566.23","100","","75.00","75.00","75.00","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2566.23","100","","366.00","144.00","1971.00","45","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1873.35","73","","667.50","667.50","667.50","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.69","44.45","","123.77","123.77","123.77","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","WELLPOINT [1015]","HB CH WELLPOINT","1999.35","77.91","","483.51","229.32","1316.08","96","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1521.77","59.3","","439.50","225.34","1872.27","197","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10.5X90MM LAG GAMMA 3 TI SELF TAPPING PARTIAL THREAD","SUP-ITM-10021382","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2013.21","78.45","","385.32","55.36","1815.62","58","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","AETNA [1001]","HB CH AETNA HMO / PPO","844.50","58.3","","554.95","91.85","1421.75","94","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","2490.03","2490.03","2490.03","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.50","58.3","","750.00","750.00","750.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.73","53","","1192.50","120.84","4149.90","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1231.27","85","","750.00","75.00","750.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1448.55","100","","657.00","121.50","1971.00","14","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1448.55","100","","75.00","75.00","75.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1448.55","100","","366.00","144.00","1971.00","45","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","667.50","667.50","667.50","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","123.77","123.77","123.77","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","WELLPOINT [1015]","HB CH WELLPOINT","1128.57","77.91","","483.51","229.32","1316.08","96","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.99","59.3","","439.50","225.34","1872.27","197","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 10.5X90MM TI GOLD PERFORATED TFN-ADVANCED NAIL FEMORAL PROXIMAL","SUP-ITM-10233827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","385.32","55.36","1815.62","58","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","AETNA [1001]","HB CH AETNA HMO / PPO","844.50","58.3","","554.95","91.85","1421.75","94","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","2490.03","2490.03","2490.03","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.50","58.3","","750.00","750.00","750.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.73","53","","1192.50","120.84","4149.90","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1231.27","85","","750.00","75.00","750.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1448.55","100","","657.00","121.50","1971.00","14","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1448.55","100","","75.00","75.00","75.00","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1448.55","100","","366.00","144.00","1971.00","45","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1057.44","73","","667.50","667.50","667.50","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.88","44.45","","123.77","123.77","123.77","1 through 10","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1448.55","1086.41","WELLPOINT [1015]","HB CH WELLPOINT","1128.57","77.91","","483.51","229.32","1316.08","96","643.88","1448.55","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.99","59.3","","439.50","225.34","1872.27","197","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 105MM PROXIMAL FEM TFN ADVANCED","SUP-ITM-10163884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1448.55","1086.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1136.39","78.45","","385.32","55.36","1815.62","58","724.28","1136.39","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","AETNA [1001]","HB CH AETNA HMO / PPO","1496.11","58.3","","554.95","91.85","1421.75","94","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1873.35","73","","2490.03","2490.03","2490.03","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1496.11","58.3","","750.00","750.00","750.00","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1360.10","53","","1192.50","120.84","4149.90","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2181.30","85","","750.00","75.00","750.00","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2566.23","100","","657.00","121.50","1971.00","14","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2566.23","100","","75.00","75.00","75.00","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2566.23","100","","366.00","144.00","1971.00","45","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1873.35","73","","667.50","667.50","667.50","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1140.69","44.45","","123.77","123.77","123.77","1 through 10","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","both","","","2566.23","1924.67","WELLPOINT [1015]","HB CH WELLPOINT","1999.35","77.91","","483.51","229.32","1316.08","96","1140.69","2566.23","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","1521.77","59.3","","439.50","225.34","1872.27","197","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 105X10.5MM LAG GAMMA 3 TITANIUM SELF TAPPING PARTIAL THREAD","SUP-ITM-10021613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2566.23","1924.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2013.21","78.45","","385.32","55.36","1815.62","58","1283.12","2013.21","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","AETNA [1001]","HB CH AETNA HMO / PPO","411.02","58.3","","554.95","91.85","1421.75","94","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","2490.03","2490.03","2490.03","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","411.02","58.3","","750.00","750.00","750.00","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.65","53","","1192.50","120.84","4149.90","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","599.25","85","","750.00","75.00","750.00","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","705.00","100","","657.00","121.50","1971.00","14","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","705.00","100","","75.00","75.00","75.00","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","705.00","100","","366.00","144.00","1971.00","45","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","514.65","73","","667.50","667.50","667.50","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","313.37","44.45","","123.77","123.77","123.77","1 through 10","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","both","","","705.00","528.75","WELLPOINT [1015]","HB CH WELLPOINT","549.27","77.91","","483.51","229.32","1316.08","96","313.37","705","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","418.07","59.3","","439.50","225.34","1872.27","197","352.5","553.07","percent of total billed charges",""
"SCREW BONE 10MM BIOCOMPOSITE","SUP-ITM-10073311","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","705.00","528.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","553.07","78.45","","385.32","55.36","1815.62","58","352.5","553.07","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","AETNA [1001]","HB CH AETNA HMO / PPO","304.33","58.3","","554.95","91.85","1421.75","94","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","381.06","73","","2490.03","2490.03","2490.03","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","304.33","58.3","","750.00","750.00","750.00","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.66","53","","1192.50","120.84","4149.90","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","443.70","85","","750.00","75.00","750.00","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","522.00","100","","657.00","121.50","1971.00","14","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","522.00","100","","75.00","75.00","75.00","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","522.00","100","","366.00","144.00","1971.00","45","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","381.06","73","","667.50","667.50","667.50","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","123.77","123.77","123.77","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","WELLPOINT [1015]","HB CH WELLPOINT","406.69","77.91","","483.51","229.32","1316.08","96","232.03","522","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","309.55","59.3","","439.50","225.34","1872.27","197","261","409.51","percent of total billed charges",""
"SCREW BONE 10X1.5MM HAND HEXAGONAL DRIVE 4 TRILOCK APTUS TI GREEN","SUP-ITM-10116072","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","385.32","55.36","1815.62","58","261","409.51","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","554.95","91.85","1421.75","94","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","2490.03","2490.03","2490.03","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.39","58.3","","750.00","750.00","750.00","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.54","53","","1192.50","120.84","4149.90","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","270.30","85","","750.00","75.00","750.00","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","318.00","100","","657.00","121.50","1971.00","14","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","318.00","100","","75.00","75.00","75.00","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","318.00","100","","366.00","144.00","1971.00","45","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","667.50","667.50","667.50","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","123.77","123.77","123.77","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","483.51","229.32","1316.08","96","141.35","318","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","439.50","225.34","1872.27","197","159","249.47","percent of total billed charges",""
"SCREW BONE 10X2.0MM CORTICAL APTUS TITANIUM HEXADRIVE 6 A-5400.10/1","SUP-ITM-10028193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","385.32","55.36","1815.62","58","159","249.47","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","AETNA [1001]","HB CH AETNA HMO / PPO","201.14","58.3","","554.95","91.85","1421.75","94","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","2490.03","2490.03","2490.03","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.14","58.3","","750.00","750.00","750.00","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","182.85","53","","1192.50","120.84","4149.90","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","293.25","85","","750.00","75.00","750.00","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","345.00","100","","657.00","121.50","1971.00","14","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","345.00","100","","75.00","75.00","75.00","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","345.00","100","","366.00","144.00","1971.00","45","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","251.85","73","","667.50","667.50","667.50","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.35","44.45","","123.77","123.77","123.77","1 through 10","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","both","","","345.00","258.75","WELLPOINT [1015]","HB CH WELLPOINT","268.79","77.91","","483.51","229.32","1316.08","96","153.35","345","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","204.59","59.3","","439.50","225.34","1872.27","197","172.5","270.65","percent of total billed charges",""
"SCREW BONE 10X2.7MM CANCELLOUS LOCKING SS LOW PROFILE","SUP-ITM-10076907","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","345.00","258.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","270.65","78.45","","385.32","55.36","1815.62","58","172.5","270.65","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","554.95","91.85","1421.75","94","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","2490.03","2490.03","2490.03","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","750.00","750.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","1192.50","120.84","4149.90","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","510.00","85","","750.00","75.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","600.00","100","","657.00","121.50","1971.00","14","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","600.00","100","","75.00","75.00","75.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","600.00","100","","366.00","144.00","1971.00","45","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","667.50","667.50","667.50","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","123.77","123.77","123.77","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","483.51","229.32","1316.08","96","266.7","600","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","439.50","225.34","1872.27","197","300","470.7","percent of total billed charges",""
"SCREW BONE 10X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","385.32","55.36","1815.62","58","300","470.7","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","554.95","91.85","1421.75","94","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","2490.03","2490.03","2490.03","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","750.00","750.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","1192.50","120.84","4149.90","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.71","85","","750.00","75.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.30","100","","657.00","121.50","1971.00","14","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.30","100","","75.00","75.00","75.00","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.30","100","","366.00","144.00","1971.00","45","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","667.50","667.50","667.50","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","123.77","123.77","123.77","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","483.51","229.32","1316.08","96","105.48","237.3","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","439.50","225.34","1872.27","197","118.65","186.16","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL DVR TI ANATOMIC","SUP-ITM-10043040","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","385.32","55.36","1815.62","58","118.65","186.16","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","554.95","91.85","1421.75","94","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","2490.03","2490.03","2490.03","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","750.00","750.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","1192.50","120.84","4149.90","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.20","85","","750.00","75.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","312.00","100","","657.00","121.50","1971.00","14","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","312.00","100","","75.00","75.00","75.00","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","312.00","100","","366.00","144.00","1971.00","45","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","667.50","667.50","667.50","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","123.77","123.77","123.77","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","483.51","229.32","1316.08","96","138.68","312","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","439.50","225.34","1872.27","197","156","244.76","percent of total billed charges",""
"SCREW BONE 10X3.5MM CORTICAL GEMINUS NONLOCKING","SUP-ITM-10126425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","385.32","55.36","1815.62","58","156","244.76","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","AETNA [1001]","HB CH AETNA HMO / PPO","187.14","58.3","","554.95","91.85","1421.75","94","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","234.33","73","","2490.03","2490.03","2490.03","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","187.14","58.3","","750.00","750.00","750.00","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","170.13","53","","1192.50","120.84","4149.90","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","272.85","85","","750.00","75.00","750.00","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","321.00","100","","657.00","121.50","1971.00","14","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","321.00","100","","75.00","75.00","75.00","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","321.00","100","","366.00","144.00","1971.00","45","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","234.33","73","","667.50","667.50","667.50","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","142.68","44.45","","123.77","123.77","123.77","1 through 10","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","both","","","321.00","240.75","WELLPOINT [1015]","HB CH WELLPOINT","250.09","77.91","","483.51","229.32","1316.08","96","142.68","321","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","321.00","240.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","190.35","59.3","","439.50","225.34","1872.27","197","160.5","251.82","percent of total billed charges",""
"SCREW BONE 10X3.5MM L LOCKING CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING SYSTEM","SUP-ITM-10130597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","321.00","240.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","251.82","78.45","","385.32","55.36","1815.62","58","160.5","251.82","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","AETNA [1001]","HB CH AETNA HMO / PPO","388.28","58.3","","554.95","91.85","1421.75","94","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","486.18","73","","2490.03","2490.03","2490.03","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","388.28","58.3","","750.00","750.00","750.00","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","352.98","53","","1192.50","120.84","4149.90","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","566.10","85","","750.00","75.00","750.00","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","666.00","100","","657.00","121.50","1971.00","14","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","666.00","100","","75.00","75.00","75.00","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","666.00","100","","366.00","144.00","1971.00","45","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","486.18","73","","667.50","667.50","667.50","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.04","44.45","","123.77","123.77","123.77","1 through 10","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","both","","","666.00","499.50","WELLPOINT [1015]","HB CH WELLPOINT","518.88","77.91","","483.51","229.32","1316.08","96","296.04","666","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","394.94","59.3","","439.50","225.34","1872.27","197","333","522.48","percent of total billed charges",""
"SCREW BONE 10X35MM BIORCI CANNULATED INTERFERENCE BIOABSORBABLE","SUP-ITM-10049507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","666.00","499.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","522.48","78.45","","385.32","55.36","1815.62","58","333","522.48","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","554.95","91.85","1421.75","94","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","2490.03","2490.03","2490.03","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","750.00","750.00","750.00","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","1192.50","120.84","4149.90","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","803.25","85","","750.00","75.00","750.00","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","945.00","100","","657.00","121.50","1971.00","14","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","945.00","100","","75.00","75.00","75.00","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","945.00","100","","366.00","144.00","1971.00","45","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","667.50","667.50","667.50","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","420.05","44.45","","123.77","123.77","123.77","1 through 10","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","483.51","229.32","1316.08","96","420.05","945","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","439.50","225.34","1872.27","197","472.5","741.35","percent of total billed charges",""
"SCREW BONE 10X4MM INTERFERENCE VENTED BIO TENODESIS PEEK","SUP-ITM-10115575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","385.32","55.36","1815.62","58","472.5","741.35","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","554.95","91.85","1421.75","94","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2490.03","2490.03","2490.03","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","750.00","750.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","1192.50","120.84","4149.90","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","750.00","75.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","657.00","121.50","1971.00","14","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","75.00","75.00","75.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","366.00","144.00","1971.00","45","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","667.50","667.50","667.50","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","123.77","123.77","123.77","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","483.51","229.32","1316.08","96","533.4","1200","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","439.50","225.34","1872.27","197","600","941.4","percent of total billed charges",""
"SCREW BONE 10X80MM SPINE PEDICLE EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10111618","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","385.32","55.36","1815.62","58","600","941.4","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","AETNA [1001]","HB CH AETNA HMO / PPO","185.39","58.3","","554.95","91.85","1421.75","94","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","2490.03","2490.03","2490.03","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","185.39","58.3","","750.00","750.00","750.00","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","168.54","53","","1192.50","120.84","4149.90","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","270.30","85","","750.00","75.00","750.00","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","318.00","100","","657.00","121.50","1971.00","14","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","318.00","100","","75.00","75.00","75.00","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","318.00","100","","366.00","144.00","1971.00","45","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","232.14","73","","667.50","667.50","667.50","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","141.35","44.45","","123.77","123.77","123.77","1 through 10","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","both","","","318.00","238.50","WELLPOINT [1015]","HB CH WELLPOINT","247.75","77.91","","483.51","229.32","1316.08","96","141.35","318","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","188.57","59.3","","439.50","225.34","1872.27","197","159","249.47","percent of total billed charges",""
"SCREW BONE 11X1.5MM CORTICAL APTUS TITANIUM HEXADRIVE 4 A-5200.11/1","SUP-ITM-10028178","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","249.47","78.45","","385.32","55.36","1815.62","58","159","249.47","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","AETNA [1001]","HB CH AETNA HMO / PPO","981.45","58.3","","554.95","91.85","1421.75","94","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1228.92","73","","2490.03","2490.03","2490.03","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","981.45","58.3","","750.00","750.00","750.00","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","892.23","53","","1192.50","120.84","4149.90","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1430.93","85","","750.00","75.00","750.00","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1683.45","100","","657.00","121.50","1971.00","14","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1683.45","100","","75.00","75.00","75.00","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1683.45","100","","366.00","144.00","1971.00","45","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1228.92","73","","667.50","667.50","667.50","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","748.29","44.45","","123.77","123.77","123.77","1 through 10","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","both","","","1683.45","1262.59","WELLPOINT [1015]","HB CH WELLPOINT","1311.58","77.91","","483.51","229.32","1316.08","96","748.29","1683.45","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1683.45","1262.59","CIGNA [1006]","HB CH CIGNA HMO / PPO","998.29","59.3","","439.50","225.34","1872.27","197","841.73","1320.67","percent of total billed charges",""
"SCREW BONE 11X100MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097458","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1683.45","1262.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1320.67","78.45","","385.32","55.36","1815.62","58","841.73","1320.67","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"SCREW BONE 11X2.0MM FIXATION QUICKFIX TITANIUM ALLOY SELF DRILLING MAGENTA","SUP-ITM-10072446","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","AETNA [1001]","HB CH AETNA HMO / PPO","796.55","58.3","","554.95","91.85","1421.75","94","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","997.39","73","","2490.03","2490.03","2490.03","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","796.55","58.3","","750.00","750.00","750.00","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","724.13","53","","1192.50","120.84","4149.90","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1161.35","85","","750.00","75.00","750.00","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1366.29","100","","657.00","121.50","1971.00","14","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1366.29","100","","75.00","75.00","75.00","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1366.29","100","","366.00","144.00","1971.00","45","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","997.39","73","","667.50","667.50","667.50","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","607.32","44.45","","123.77","123.77","123.77","1 through 10","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","both","","","1366.29","1024.72","WELLPOINT [1015]","HB CH WELLPOINT","1064.48","77.91","","483.51","229.32","1316.08","96","607.32","1366.29","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1366.29","1024.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","810.21","59.3","","439.50","225.34","1872.27","197","683.15","1071.85","percent of total billed charges",""
"SCREW BONE 11X85MM FIXATION TITANIUM TROCHANTERIC GOLD","SUP-ITM-10097455","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1366.29","1024.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1071.85","78.45","","385.32","55.36","1815.62","58","683.15","1071.85","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","554.95","91.85","1421.75","94","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","2490.03","2490.03","2490.03","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","750.00","750.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","1192.50","120.84","4149.90","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1083.75","85","","750.00","75.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1275.00","100","","657.00","121.50","1971.00","14","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1275.00","100","","75.00","75.00","75.00","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1275.00","100","","366.00","144.00","1971.00","45","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","667.50","667.50","667.50","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","123.77","123.77","123.77","1 through 10","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","483.51","229.32","1316.08","96","566.74","1275","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","439.50","225.34","1872.27","197","637.5","1000.24","percent of total billed charges",""
"SCREW BONE 12.5X35MM HIP HUMERAL FIXATION HEMICAP COMPONENT ARTICULAR LG","SUP-ITM-10123420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","385.32","55.36","1815.62","58","637.5","1000.24","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","AETNA [1001]","HB CH AETNA HMO / PPO","449.11","58.3","","554.95","91.85","1421.75","94","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","2490.03","2490.03","2490.03","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","449.11","58.3","","750.00","750.00","750.00","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","408.28","53","","1192.50","120.84","4149.90","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","654.79","85","","750.00","75.00","750.00","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","770.34","100","","657.00","121.50","1971.00","14","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","770.34","100","","75.00","75.00","75.00","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","770.34","100","","366.00","144.00","1971.00","45","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","667.50","667.50","667.50","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.42","44.45","","123.77","123.77","123.77","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","WELLPOINT [1015]","HB CH WELLPOINT","600.17","77.91","","483.51","229.32","1316.08","96","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","456.81","59.3","","439.50","225.34","1872.27","197","385.17","604.33","percent of total billed charges",""
"SCREW BONE 12.7X70MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009079","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","604.33","78.45","","385.32","55.36","1815.62","58","385.17","604.33","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","AETNA [1001]","HB CH AETNA HMO / PPO","449.11","58.3","","554.95","91.85","1421.75","94","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","2490.03","2490.03","2490.03","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","449.11","58.3","","750.00","750.00","750.00","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","408.28","53","","1192.50","120.84","4149.90","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","654.79","85","","750.00","75.00","750.00","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","770.34","100","","657.00","121.50","1971.00","14","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","770.34","100","","75.00","75.00","75.00","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","770.34","100","","366.00","144.00","1971.00","45","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","562.35","73","","667.50","667.50","667.50","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","342.42","44.45","","123.77","123.77","123.77","1 through 10","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","both","","","770.34","577.75","WELLPOINT [1015]","HB CH WELLPOINT","600.17","77.91","","483.51","229.32","1316.08","96","342.42","770.34","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","456.81","59.3","","439.50","225.34","1872.27","197","385.17","604.33","percent of total billed charges",""
"SCREW BONE 12.7X80MM LAG DHS DCS ONE STEP SS 22MM THREAD","SUP-ITM-10009081","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","770.34","577.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","604.33","78.45","","385.32","55.36","1815.62","58","385.17","604.33","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","AETNA [1001]","HB CH AETNA HMO / PPO","147.72","58.3","","554.95","91.85","1421.75","94","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","184.97","73","","2490.03","2490.03","2490.03","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","147.72","58.3","","750.00","750.00","750.00","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","134.29","53","","1192.50","120.84","4149.90","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","215.37","85","","750.00","75.00","750.00","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","253.38","100","","657.00","121.50","1971.00","14","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","253.38","100","","75.00","75.00","75.00","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","253.38","100","","366.00","144.00","1971.00","45","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","184.97","73","","667.50","667.50","667.50","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.63","44.45","","123.77","123.77","123.77","1 through 10","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.38","190.03","WELLPOINT [1015]","HB CH WELLPOINT","197.41","77.91","","483.51","229.32","1316.08","96","112.63","253.38","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.38","190.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.25","59.3","","439.50","225.34","1872.27","197","126.69","198.78","percent of total billed charges",""
"SCREW BONE 12X1.5MM ALPS SELF TAPPING SQUARE DRIVE NONLOCKING","SUP-ITM-10056577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.38","190.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.78","78.45","","385.32","55.36","1815.62","58","126.69","198.78","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","AETNA [1001]","HB CH AETNA HMO / PPO","358.55","58.3","","554.95","91.85","1421.75","94","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","448.95","73","","2490.03","2490.03","2490.03","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","358.55","58.3","","750.00","750.00","750.00","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","325.95","53","","1192.50","120.84","4149.90","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","522.75","85","","750.00","75.00","750.00","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","615.00","100","","657.00","121.50","1971.00","14","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","615.00","100","","75.00","75.00","75.00","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","615.00","100","","366.00","144.00","1971.00","45","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","448.95","73","","667.50","667.50","667.50","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","273.37","44.45","","123.77","123.77","123.77","1 through 10","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","both","","","615.00","461.25","WELLPOINT [1015]","HB CH WELLPOINT","479.15","77.91","","483.51","229.32","1316.08","96","273.37","615","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","615.00","461.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","364.70","59.3","","439.50","225.34","1872.27","197","307.5","482.47","percent of total billed charges",""
"SCREW BONE 12X3.0MM LAG HPS CANNULATED TITANIUM","SUP-ITM-10019551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","615.00","461.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","482.47","78.45","","385.32","55.36","1815.62","58","307.5","482.47","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","AETNA [1001]","HB CH AETNA HMO / PPO","181.90","58.3","","554.95","91.85","1421.75","94","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","2490.03","2490.03","2490.03","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","181.90","58.3","","750.00","750.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","165.36","53","","1192.50","120.84","4149.90","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","265.20","85","","750.00","75.00","750.00","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","312.00","100","","657.00","121.50","1971.00","14","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","312.00","100","","75.00","75.00","75.00","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","312.00","100","","366.00","144.00","1971.00","45","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","227.76","73","","667.50","667.50","667.50","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.68","44.45","","123.77","123.77","123.77","1 through 10","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","both","","","312.00","234.00","WELLPOINT [1015]","HB CH WELLPOINT","243.08","77.91","","483.51","229.32","1316.08","96","138.68","312","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","185.02","59.3","","439.50","225.34","1872.27","197","156","244.76","percent of total billed charges",""
"SCREW BONE 12X3.5MM L POLYAXIAL NON LOCKING COMPRESSION CORTICAL GEMINUS TITANIUM FOSSA SPECIFIC PLATING","SUP-ITM-10126426","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","312.00","234.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","244.76","78.45","","385.32","55.36","1815.62","58","156","244.76","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","AETNA [1001]","HB CH AETNA HMO / PPO","124.18","58.3","","554.95","91.85","1421.75","94","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","155.49","73","","2490.03","2490.03","2490.03","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","124.18","58.3","","750.00","750.00","750.00","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","112.89","53","","1192.50","120.84","4149.90","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","181.05","85","","750.00","75.00","750.00","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","213.00","100","","657.00","121.50","1971.00","14","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","213.00","100","","75.00","75.00","75.00","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","213.00","100","","366.00","144.00","1971.00","45","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","155.49","73","","667.50","667.50","667.50","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","94.68","44.45","","123.77","123.77","123.77","1 through 10","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","both","","","213.00","159.75","WELLPOINT [1015]","HB CH WELLPOINT","165.95","77.91","","483.51","229.32","1316.08","96","94.68","213","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.00","159.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","126.31","59.3","","439.50","225.34","1872.27","197","106.5","167.1","percent of total billed charges",""
"SCREW BONE 12X3.5MM RADIUS TAP LOC HEXALOBE TITANIUM VOLAR DISTAL PLATING NONLOCKING FULL THREAD","SUP-ITM-10080139","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","213.00","159.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","167.10","78.45","","385.32","55.36","1815.62","58","106.5","167.1","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","554.95","91.85","1421.75","94","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","2490.03","2490.03","2490.03","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","750.00","750.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","1192.50","120.84","4149.90","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.25","85","","750.00","75.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.00","100","","657.00","121.50","1971.00","14","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.00","100","","75.00","75.00","75.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.00","100","","366.00","144.00","1971.00","45","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","667.50","667.50","667.50","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","123.77","123.77","123.77","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","483.51","229.32","1316.08","96","46.67","105","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","439.50","225.34","1872.27","197","52.5","82.37","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10076866","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","385.32","55.36","1815.62","58","52.5","82.37","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","AETNA [1001]","HB CH AETNA HMO / PPO","138.17","58.3","","554.95","91.85","1421.75","94","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","2490.03","2490.03","2490.03","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.17","58.3","","750.00","750.00","750.00","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.61","53","","1192.50","120.84","4149.90","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.45","85","","750.00","75.00","750.00","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.00","100","","657.00","121.50","1971.00","14","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.00","100","","75.00","75.00","75.00","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.00","100","","366.00","144.00","1971.00","45","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","667.50","667.50","667.50","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","123.77","123.77","123.77","1 through 10","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","WELLPOINT [1015]","HB CH WELLPOINT","184.65","77.91","","483.51","229.32","1316.08","96","105.35","237","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.54","59.3","","439.50","225.34","1872.27","197","118.5","185.93","percent of total billed charges",""
"SCREW BONE 12X4.0MM CANCELLOUS TITANIUM","SUP-ITM-10017010","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","385.32","55.36","1815.62","58","118.5","185.93","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","AETNA [1001]","HB CH AETNA HMO / PPO","265.85","58.3","","554.95","91.85","1421.75","94","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","332.88","73","","2490.03","2490.03","2490.03","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","265.85","58.3","","750.00","750.00","750.00","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","241.68","53","","1192.50","120.84","4149.90","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","387.60","85","","750.00","75.00","750.00","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","456.00","100","","657.00","121.50","1971.00","14","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","456.00","100","","75.00","75.00","75.00","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","456.00","100","","366.00","144.00","1971.00","45","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","332.88","73","","667.50","667.50","667.50","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.69","44.45","","123.77","123.77","123.77","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","WELLPOINT [1015]","HB CH WELLPOINT","355.27","77.91","","483.51","229.32","1316.08","96","202.69","456","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","270.41","59.3","","439.50","225.34","1872.27","197","228","357.73","percent of total billed charges",""
"SCREW BONE 14X2.5MM COMPRESSION DART FIRE TI CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057136","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","357.73","78.45","","385.32","55.36","1815.62","58","228","357.73","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","AETNA [1001]","HB CH AETNA HMO / PPO","84.67","58.3","","554.95","91.85","1421.75","94","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","106.02","73","","2490.03","2490.03","2490.03","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","84.67","58.3","","750.00","750.00","750.00","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.97","53","","1192.50","120.84","4149.90","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","123.45","85","","750.00","75.00","750.00","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","145.23","100","","657.00","121.50","1971.00","14","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","145.23","100","","75.00","75.00","75.00","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","145.23","100","","366.00","144.00","1971.00","45","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","106.02","73","","667.50","667.50","667.50","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.55","44.45","","123.77","123.77","123.77","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","WELLPOINT [1015]","HB CH WELLPOINT","113.15","77.91","","483.51","229.32","1316.08","96","64.55","145.23","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.23","108.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","86.12","59.3","","439.50","225.34","1872.27","197","72.62","113.93","percent of total billed charges",""
"SCREW BONE 14X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10125920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.23","108.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.93","78.45","","385.32","55.36","1815.62","58","72.62","113.93","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","AETNA [1001]","HB CH AETNA HMO / PPO","409.27","58.3","","554.95","91.85","1421.75","94","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","512.46","73","","2490.03","2490.03","2490.03","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","409.27","58.3","","750.00","750.00","750.00","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","372.06","53","","1192.50","120.84","4149.90","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","596.70","85","","750.00","75.00","750.00","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","702.00","100","","657.00","121.50","1971.00","14","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","702.00","100","","75.00","75.00","75.00","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","702.00","100","","366.00","144.00","1971.00","45","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","512.46","73","","667.50","667.50","667.50","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.04","44.45","","123.77","123.77","123.77","1 through 10","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","both","","","702.00","526.50","WELLPOINT [1015]","HB CH WELLPOINT","546.93","77.91","","483.51","229.32","1316.08","96","312.04","702","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","416.29","59.3","","439.50","225.34","1872.27","197","351","550.72","percent of total billed charges",""
"SCREW BONE 14X2MM COMPRESSION TWISTOFF TI ALLOY SELF DRILLING TAPPING","SUP-ITM-10018273","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","702.00","526.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","550.72","78.45","","385.32","55.36","1815.62","58","351","550.72","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","AETNA [1001]","HB CH AETNA HMO / PPO","367.29","58.3","","554.95","91.85","1421.75","94","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","459.90","73","","2490.03","2490.03","2490.03","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","367.29","58.3","","750.00","750.00","750.00","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","333.90","53","","1192.50","120.84","4149.90","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","535.50","85","","750.00","75.00","750.00","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","630.00","100","","657.00","121.50","1971.00","14","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","630.00","100","","75.00","75.00","75.00","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","630.00","100","","366.00","144.00","1971.00","45","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","459.90","73","","667.50","667.50","667.50","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.04","44.45","","123.77","123.77","123.77","1 through 10","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.00","472.50","WELLPOINT [1015]","HB CH WELLPOINT","490.83","77.91","","483.51","229.32","1316.08","96","280.04","630","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","373.59","59.3","","439.50","225.34","1872.27","197","315","494.24","percent of total billed charges",""
"SCREW BONE 14X3.0MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADLESS BROWN","SUP-ITM-10133805","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.00","472.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.24","78.45","","385.32","55.36","1815.62","58","315","494.24","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","554.95","91.85","1421.75","94","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","2490.03","2490.03","2490.03","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","750.00","750.00","750.00","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","1192.50","120.84","4149.90","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","267.75","85","","750.00","75.00","750.00","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","315.00","100","","657.00","121.50","1971.00","14","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","315.00","100","","75.00","75.00","75.00","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","315.00","100","","366.00","144.00","1971.00","45","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","667.50","667.50","667.50","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","123.77","123.77","123.77","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","483.51","229.32","1316.08","96","140.02","315","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","439.50","225.34","1872.27","197","157.5","247.12","percent of total billed charges",""
"SCREW BONE 14X3.2MM CORTICAL SS LOCKING HEXAGONAL","SUP-ITM-10079253","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","385.32","55.36","1815.62","58","157.5","247.12","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","AETNA [1001]","HB CH AETNA HMO / PPO","106.69","58.3","","554.95","91.85","1421.75","94","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","133.59","73","","2490.03","2490.03","2490.03","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","106.69","58.3","","750.00","750.00","750.00","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","96.99","53","","1192.50","120.84","4149.90","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","155.55","85","","750.00","75.00","750.00","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","183.00","100","","657.00","121.50","1971.00","14","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","183.00","100","","75.00","75.00","75.00","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","183.00","100","","366.00","144.00","1971.00","45","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.59","73","","667.50","667.50","667.50","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.34","44.45","","123.77","123.77","123.77","1 through 10","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.00","137.25","WELLPOINT [1015]","HB CH WELLPOINT","142.58","77.91","","483.51","229.32","1316.08","96","81.34","183","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.00","137.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.52","59.3","","439.50","225.34","1872.27","197","91.5","143.56","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM","SUP-ITM-10016510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.00","137.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.56","78.45","","385.32","55.36","1815.62","58","91.5","143.56","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","AETNA [1001]","HB CH AETNA HMO / PPO","227.37","58.3","","554.95","91.85","1421.75","94","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","284.70","73","","2490.03","2490.03","2490.03","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.37","58.3","","750.00","750.00","750.00","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.70","53","","1192.50","120.84","4149.90","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","331.50","85","","750.00","75.00","750.00","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","390.00","100","","657.00","121.50","1971.00","14","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","390.00","100","","75.00","75.00","75.00","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","390.00","100","","366.00","144.00","1971.00","45","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.70","73","","667.50","667.50","667.50","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.36","44.45","","123.77","123.77","123.77","1 through 10","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","both","","","390.00","292.50","WELLPOINT [1015]","HB CH WELLPOINT","303.85","77.91","","483.51","229.32","1316.08","96","173.36","390","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.27","59.3","","439.50","225.34","1872.27","197","195","305.96","percent of total billed charges",""
"SCREW BONE 14X3.5MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING THREAD","SUP-ITM-10017015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.96","78.45","","385.32","55.36","1815.62","58","195","305.96","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","1830.28","315.58","1830.28","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","4170.85","4170.85","4170.85","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","649.55","649.55","649.55","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","8998.38","2542.37","8998.38","20","146.69","330","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","1891.61","1609.14","3664.18","25","165","258.89","percent of total billed charges",""
"SCREW BONE 14X4.0MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF DRILLING GOLD","SUP-ITM-10022861","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","1470.68","1310.06","2481.69","19","165","258.89","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","AETNA [1001]","HB CH AETNA HMO / PPO","631.13","58.3","","554.95","91.85","1421.75","94","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","790.26","73","","2490.03","2490.03","2490.03","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","631.13","58.3","","750.00","750.00","750.00","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","573.75","53","","1192.50","120.84","4149.90","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","920.17","85","","750.00","75.00","750.00","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1082.55","100","","657.00","121.50","1971.00","14","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1082.55","100","","75.00","75.00","75.00","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1082.55","100","","366.00","144.00","1971.00","45","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","790.26","73","","667.50","667.50","667.50","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","481.19","44.45","","123.77","123.77","123.77","1 through 10","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","both","","","1082.55","811.91","WELLPOINT [1015]","HB CH WELLPOINT","843.41","77.91","","483.51","229.32","1316.08","96","481.19","1082.55","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.55","811.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","641.95","59.3","","439.50","225.34","1872.27","197","541.28","849.26","percent of total billed charges",""
"SCREW BONE 14X4.5MM LOCKING HINDFOOT ADVANSYS SURFIX SS","SUP-ITM-10091899","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1082.55","811.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","849.26","78.45","","385.32","55.36","1815.62","58","541.28","849.26","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"SCREW BONE 15X3.0MM QUICKFIX TITANIUM LOW PROFILE SELF DRILLING TAPPING LIGHT BLUE","SUP-ITM-10072451","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","AETNA [1001]","HB CH AETNA HMO / PPO","95.48","58.3","","554.95","91.85","1421.75","94","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","119.55","73","","2490.03","2490.03","2490.03","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","95.48","58.3","","750.00","750.00","750.00","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","86.80","53","","1192.50","120.84","4149.90","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","139.20","85","","750.00","75.00","750.00","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","163.77","100","","657.00","121.50","1971.00","14","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","163.77","100","","75.00","75.00","75.00","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","163.77","100","","366.00","144.00","1971.00","45","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","119.55","73","","667.50","667.50","667.50","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.80","44.45","","123.77","123.77","123.77","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","WELLPOINT [1015]","HB CH WELLPOINT","127.59","77.91","","483.51","229.32","1316.08","96","72.8","163.77","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.12","59.3","","439.50","225.34","1872.27","197","81.89","128.48","percent of total billed charges",""
"SCREW BONE 15X3.5MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071465","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","128.48","78.45","","385.32","55.36","1815.62","58","81.89","128.48","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","AETNA [1001]","HB CH AETNA HMO / PPO","603.41","58.3","","554.95","91.85","1421.75","94","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","755.55","73","","2490.03","2490.03","2490.03","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","603.41","58.3","","750.00","750.00","750.00","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","548.55","53","","1192.50","120.84","4149.90","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","879.75","85","","750.00","75.00","750.00","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1035.00","100","","657.00","121.50","1971.00","14","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1035.00","100","","75.00","75.00","75.00","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1035.00","100","","366.00","144.00","1971.00","45","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","755.55","73","","667.50","667.50","667.50","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","460.06","44.45","","123.77","123.77","123.77","1 through 10","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","both","","","1035.00","776.25","WELLPOINT [1015]","HB CH WELLPOINT","806.37","77.91","","483.51","229.32","1316.08","96","460.06","1035","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","613.76","59.3","","439.50","225.34","1872.27","197","517.5","811.96","percent of total billed charges",""
"SCREW BONE 15X5.5MM INTERFERENCE BIOCOMPOSITE BIO TENODESIS","SUP-ITM-10078884","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1035.00","776.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","811.96","78.45","","385.32","55.36","1815.62","58","517.5","811.96","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","554.95","91.85","1421.75","94","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","2490.03","2490.03","2490.03","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","750.00","750.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","1192.50","120.84","4149.90","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.90","85","","750.00","75.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","114.00","100","","657.00","121.50","1971.00","14","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","114.00","100","","75.00","75.00","75.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","114.00","100","","366.00","144.00","1971.00","45","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","667.50","667.50","667.50","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","123.77","123.77","123.77","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","483.51","229.32","1316.08","96","50.67","114","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","439.50","225.34","1872.27","197","57","89.43","percent of total billed charges",""
"SCREW BONE 15X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10004332","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","385.32","55.36","1815.62","58","57","89.43","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","AETNA [1001]","HB CH AETNA HMO / PPO","138.35","58.3","","554.95","91.85","1421.75","94","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","2490.03","2490.03","2490.03","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.35","58.3","","750.00","750.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.77","53","","1192.50","120.84","4149.90","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.71","85","","750.00","75.00","750.00","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.30","100","","657.00","121.50","1971.00","14","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.30","100","","75.00","75.00","75.00","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.30","100","","366.00","144.00","1971.00","45","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.23","73","","667.50","667.50","667.50","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.48","44.45","","123.77","123.77","123.77","1 through 10","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.30","177.97","WELLPOINT [1015]","HB CH WELLPOINT","184.88","77.91","","483.51","229.32","1316.08","96","105.48","237.3","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.72","59.3","","439.50","225.34","1872.27","197","118.65","186.16","percent of total billed charges",""
"SCREW BONE 16.0X3.5MM CORTICAL DVR TITANIUM ANATOMIC","SUP-ITM-10028125","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.30","177.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.16","78.45","","385.32","55.36","1815.62","58","118.65","186.16","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","1830.28","315.58","1830.28","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","4170.85","4170.85","4170.85","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","649.55","649.55","649.55","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","8998.38","2542.37","8998.38","20","220.03","495","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","1891.61","1609.14","3664.18","25","247.5","388.33","percent of total billed charges",""
"SCREW BONE 16MM CERVICAL ZERO P TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10113209","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","1470.68","1310.06","2481.69","19","247.5","388.33","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","554.95","91.85","1421.75","94","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","188.34","73","","2490.03","2490.03","2490.03","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","150.41","58.3","","750.00","750.00","750.00","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","136.74","53","","1192.50","120.84","4149.90","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","219.30","85","","750.00","75.00","750.00","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","258.00","100","","657.00","121.50","1971.00","14","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","258.00","100","","75.00","75.00","75.00","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","258.00","100","","366.00","144.00","1971.00","45","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","188.34","73","","667.50","667.50","667.50","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.68","44.45","","123.77","123.77","123.77","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB CH WELLPOINT","201.01","77.91","","483.51","229.32","1316.08","96","114.68","258","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.99","59.3","","439.50","225.34","1872.27","197","129","202.4","percent of total billed charges",""
"SCREW BONE 16X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10017018","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","385.32","55.36","1815.62","58","129","202.4","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","AETNA [1001]","HB CH AETNA HMO / PPO","169.34","58.3","","554.95","91.85","1421.75","94","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","2490.03","2490.03","2490.03","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","169.34","58.3","","750.00","750.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","153.94","53","","1192.50","120.84","4149.90","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","246.89","85","","750.00","75.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","290.46","100","","657.00","121.50","1971.00","14","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","290.46","100","","75.00","75.00","75.00","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","290.46","100","","366.00","144.00","1971.00","45","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","667.50","667.50","667.50","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.11","44.45","","123.77","123.77","123.77","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","WELLPOINT [1015]","HB CH WELLPOINT","226.30","77.91","","483.51","229.32","1316.08","96","129.11","290.46","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.24","59.3","","439.50","225.34","1872.27","197","145.23","227.87","percent of total billed charges",""
"SCREW BONE 16X2.7MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10125917","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","227.87","78.45","","385.32","55.36","1815.62","58","145.23","227.87","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","554.95","91.85","1421.75","94","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","2490.03","2490.03","2490.03","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","157.41","58.3","","750.00","750.00","750.00","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","1192.50","120.84","4149.90","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","229.50","85","","750.00","75.00","750.00","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","270.00","100","","657.00","121.50","1971.00","14","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","270.00","100","","75.00","75.00","75.00","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","270.00","100","","366.00","144.00","1971.00","45","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","667.50","667.50","667.50","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","123.77","123.77","123.77","1 through 10","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","483.51","229.32","1316.08","96","120.02","270","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","439.50","225.34","1872.27","197","135","211.82","percent of total billed charges",""
"SCREW BONE 16X3.2MM CORTICAL SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10028336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","385.32","55.36","1815.62","58","135","211.82","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","AETNA [1001]","HB CH AETNA HMO / PPO","190.64","58.3","","554.95","91.85","1421.75","94","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","238.71","73","","2490.03","2490.03","2490.03","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","190.64","58.3","","750.00","750.00","750.00","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","173.31","53","","1192.50","120.84","4149.90","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","277.95","85","","750.00","75.00","750.00","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","327.00","100","","657.00","121.50","1971.00","14","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","327.00","100","","75.00","75.00","75.00","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","327.00","100","","366.00","144.00","1971.00","45","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","238.71","73","","667.50","667.50","667.50","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.35","44.45","","123.77","123.77","123.77","1 through 10","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","both","","","327.00","245.25","WELLPOINT [1015]","HB CH WELLPOINT","254.77","77.91","","483.51","229.32","1316.08","96","145.35","327","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","327.00","245.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.91","59.3","","439.50","225.34","1872.27","197","163.5","256.53","percent of total billed charges",""
"SCREW BONE 16X3.5MM RADIUS ULNA DISTAL CORTICAL","SUP-ITM-10025685","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","327.00","245.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","256.53","78.45","","385.32","55.36","1815.62","58","163.5","256.53","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","AETNA [1001]","HB CH AETNA HMO / PPO","166.16","58.3","","554.95","91.85","1421.75","94","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","208.05","73","","2490.03","2490.03","2490.03","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","166.16","58.3","","750.00","750.00","750.00","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","151.05","53","","1192.50","120.84","4149.90","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","242.25","85","","750.00","75.00","750.00","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","285.00","100","","657.00","121.50","1971.00","14","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","285.00","100","","75.00","75.00","75.00","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","285.00","100","","366.00","144.00","1971.00","45","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","208.05","73","","667.50","667.50","667.50","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.68","44.45","","123.77","123.77","123.77","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","WELLPOINT [1015]","HB CH WELLPOINT","222.04","77.91","","483.51","229.32","1316.08","96","126.68","285","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","169.01","59.3","","439.50","225.34","1872.27","197","142.5","223.58","percent of total billed charges",""
"SCREW BONE 18.0X2.3MM CORTICAL TITANIUM LOW PROFILE FULL THREAD SOLID","SUP-ITM-10018064","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","223.58","78.45","","385.32","55.36","1815.62","58","142.5","223.58","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","554.95","91.85","1421.75","94","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2490.03","2490.03","2490.03","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","750.00","750.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","1192.50","120.84","4149.90","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","750.00","75.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","657.00","121.50","1971.00","14","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","75.00","75.00","75.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","366.00","144.00","1971.00","45","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","667.50","667.50","667.50","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","123.77","123.77","123.77","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","483.51","229.32","1316.08","96","333.38","750","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","439.50","225.34","1872.27","197","375","588.38","percent of total billed charges",""
"SCREW BONE 18MM 6.7X60 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10046551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","385.32","55.36","1815.62","58","375","588.38","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","AETNA [1001]","HB CH AETNA HMO / PPO","218.63","58.3","","554.95","91.85","1421.75","94","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","2490.03","2490.03","2490.03","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","218.63","58.3","","750.00","750.00","750.00","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.75","53","","1192.50","120.84","4149.90","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","318.75","85","","750.00","75.00","750.00","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","375.00","100","","657.00","121.50","1971.00","14","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","375.00","100","","75.00","75.00","75.00","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","375.00","100","","366.00","144.00","1971.00","45","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","667.50","667.50","667.50","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.69","44.45","","123.77","123.77","123.77","1 through 10","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","WELLPOINT [1015]","HB CH WELLPOINT","292.16","77.91","","483.51","229.32","1316.08","96","166.69","375","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","439.50","225.34","1872.27","197","187.5","294.19","percent of total billed charges",""
"SCREW BONE 18X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING LOCKING FULL THREAD GOLD","SUP-ITM-10016518","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","385.32","55.36","1815.62","58","187.5","294.19","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","AETNA [1001]","HB CH AETNA HMO / PPO","325.31","58.3","","554.95","91.85","1421.75","94","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","407.34","73","","2490.03","2490.03","2490.03","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","325.31","58.3","","750.00","750.00","750.00","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","295.74","53","","1192.50","120.84","4149.90","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","474.30","85","","750.00","75.00","750.00","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","558.00","100","","657.00","121.50","1971.00","14","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","558.00","100","","75.00","75.00","75.00","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","558.00","100","","366.00","144.00","1971.00","45","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","407.34","73","","667.50","667.50","667.50","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","248.03","44.45","","123.77","123.77","123.77","1 through 10","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","both","","","558.00","418.50","WELLPOINT [1015]","HB CH WELLPOINT","434.74","77.91","","483.51","229.32","1316.08","96","248.03","558","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.00","418.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","330.89","59.3","","439.50","225.34","1872.27","197","279","437.75","percent of total billed charges",""
"SCREW BONE 18X3.5MM FOOT ORTHOLOC 3DI FIXATION RECONSTRUCTION SYSTEM TITANIUM LOCKING","SUP-ITM-10129728","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","558.00","418.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","437.75","78.45","","385.32","55.36","1815.62","58","279","437.75","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","AETNA [1001]","HB CH AETNA HMO / PPO","93.83","58.3","","554.95","91.85","1421.75","94","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","117.49","73","","2490.03","2490.03","2490.03","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","93.83","58.3","","750.00","750.00","750.00","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.30","53","","1192.50","120.84","4149.90","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","136.81","85","","750.00","75.00","750.00","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","160.95","100","","657.00","121.50","1971.00","14","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","160.95","100","","75.00","75.00","75.00","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","160.95","100","","366.00","144.00","1971.00","45","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","117.49","73","","667.50","667.50","667.50","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.54","44.45","","123.77","123.77","123.77","1 through 10","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.95","120.71","WELLPOINT [1015]","HB CH WELLPOINT","125.40","77.91","","483.51","229.32","1316.08","96","71.54","160.95","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.95","120.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","95.44","59.3","","439.50","225.34","1872.27","197","80.48","126.27","percent of total billed charges",""
"SCREW BONE 1X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037052","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.95","120.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","126.27","78.45","","385.32","55.36","1815.62","58","80.48","126.27","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","AETNA [1001]","HB CH AETNA HMO / PPO","812.66","58.3","","554.95","91.85","1421.75","94","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1017.56","73","","2490.03","2490.03","2490.03","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","812.66","58.3","","750.00","750.00","750.00","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","738.78","53","","1192.50","120.84","4149.90","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1184.83","85","","750.00","75.00","750.00","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1393.92","100","","657.00","121.50","1971.00","14","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1393.92","100","","75.00","75.00","75.00","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1393.92","100","","366.00","144.00","1971.00","45","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1017.56","73","","667.50","667.50","667.50","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","619.60","44.45","","123.77","123.77","123.77","1 through 10","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","both","","","1393.92","1045.44","WELLPOINT [1015]","HB CH WELLPOINT","1086.00","77.91","","483.51","229.32","1316.08","96","619.6","1393.92","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.92","1045.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","826.59","59.3","","439.50","225.34","1872.27","197","696.96","1093.53","percent of total billed charges",""
"SCREW BONE 2.0X30MM COMPRESSION CANNULATED SS TWIN PITCH AUTOFIX","SUP-ITM-10186364","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1393.92","1045.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1093.53","78.45","","385.32","55.36","1815.62","58","696.96","1093.53","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","AETNA [1001]","HB CH AETNA HMO / PPO","291.84","58.3","","554.95","91.85","1421.75","94","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","365.42","73","","2490.03","2490.03","2490.03","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","291.84","58.3","","750.00","750.00","750.00","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.31","53","","1192.50","120.84","4149.90","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","425.49","85","","750.00","75.00","750.00","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","500.58","100","","657.00","121.50","1971.00","14","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","500.58","100","","75.00","75.00","75.00","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","500.58","100","","366.00","144.00","1971.00","45","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","365.42","73","","667.50","667.50","667.50","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.51","44.45","","123.77","123.77","123.77","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","WELLPOINT [1015]","HB CH WELLPOINT","390.00","77.91","","483.51","229.32","1316.08","96","222.51","500.58","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.58","375.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","296.84","59.3","","439.50","225.34","1872.27","197","250.29","392.71","percent of total billed charges",""
"SCREW BONE 2.2MM 3.5X12 LOCKING A.L.P.S. COBALT MULTIDIRECTIONAL SELF TAPPING SQUARE DRIVE","SUP-ITM-10072336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.58","375.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","392.71","78.45","","385.32","55.36","1815.62","58","250.29","392.71","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","AETNA [1001]","HB CH AETNA HMO / PPO","329.56","58.3","","554.95","91.85","1421.75","94","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","412.66","73","","2490.03","2490.03","2490.03","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","329.56","58.3","","750.00","750.00","750.00","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","299.60","53","","1192.50","120.84","4149.90","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","480.50","85","","750.00","75.00","750.00","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","565.29","100","","657.00","121.50","1971.00","14","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","565.29","100","","75.00","75.00","75.00","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","565.29","100","","366.00","144.00","1971.00","45","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","412.66","73","","667.50","667.50","667.50","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","251.27","44.45","","123.77","123.77","123.77","1 through 10","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","both","","","565.29","423.97","WELLPOINT [1015]","HB CH WELLPOINT","440.42","77.91","","483.51","229.32","1316.08","96","251.27","565.29","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.29","423.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","335.22","59.3","","439.50","225.34","1872.27","197","282.65","443.47","percent of total billed charges",""
"SCREW BONE 2.3X10MM VARIAX TITANIUM LOCKING T7 DRIVE","SUP-ITM-10113953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","565.29","423.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","443.47","78.45","","385.32","55.36","1815.62","58","282.65","443.47","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","AETNA [1001]","HB CH AETNA HMO / PPO","278.09","58.3","","554.95","91.85","1421.75","94","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","348.21","73","","2490.03","2490.03","2490.03","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","278.09","58.3","","750.00","750.00","750.00","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","252.81","53","","1192.50","120.84","4149.90","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","405.45","85","","750.00","75.00","750.00","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","477.00","100","","657.00","121.50","1971.00","14","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","477.00","100","","75.00","75.00","75.00","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","477.00","100","","366.00","144.00","1971.00","45","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","348.21","73","","667.50","667.50","667.50","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.03","44.45","","123.77","123.77","123.77","1 through 10","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","both","","","477.00","357.75","WELLPOINT [1015]","HB CH WELLPOINT","371.63","77.91","","483.51","229.32","1316.08","96","212.03","477","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.00","357.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","282.86","59.3","","439.50","225.34","1872.27","197","238.5","374.21","percent of total billed charges",""
"SCREW BONE 2.3X18MM ACU LOC HEXALOBE VARIABLE ANGLE TI LOCKING DISTAL","SUP-ITM-10139166","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","477.00","357.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","374.21","78.45","","385.32","55.36","1815.62","58","238.5","374.21","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","AETNA [1001]","HB CH AETNA HMO / PPO","260.27","58.3","","554.95","91.85","1421.75","94","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","325.89","73","","2490.03","2490.03","2490.03","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","260.27","58.3","","750.00","750.00","750.00","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","236.61","53","","1192.50","120.84","4149.90","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","379.47","85","","750.00","75.00","750.00","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","446.43","100","","657.00","121.50","1971.00","14","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","446.43","100","","75.00","75.00","75.00","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","446.43","100","","366.00","144.00","1971.00","45","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","325.89","73","","667.50","667.50","667.50","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.44","44.45","","123.77","123.77","123.77","1 through 10","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.43","334.82","WELLPOINT [1015]","HB CH WELLPOINT","347.81","77.91","","483.51","229.32","1316.08","96","198.44","446.43","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.43","334.82","CIGNA [1006]","HB CH CIGNA HMO / PPO","264.73","59.3","","439.50","225.34","1872.27","197","223.22","350.22","percent of total billed charges",""
"SCREW BONE 2.3X8MM TI VARIAX SELF TAPPING","SUP-ITM-10143895","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.43","334.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","350.22","78.45","","385.32","55.36","1815.62","58","223.22","350.22","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","AETNA [1001]","HB CH AETNA HMO / PPO","78.30","58.3","","554.95","91.85","1421.75","94","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.05","73","","2490.03","2490.03","2490.03","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.30","58.3","","750.00","750.00","750.00","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.18","53","","1192.50","120.84","4149.90","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.16","85","","750.00","75.00","750.00","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","134.31","100","","657.00","121.50","1971.00","14","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","134.31","100","","75.00","75.00","75.00","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","134.31","100","","366.00","144.00","1971.00","45","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.05","73","","667.50","667.50","667.50","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.70","44.45","","123.77","123.77","123.77","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","WELLPOINT [1015]","HB CH WELLPOINT","104.64","77.91","","483.51","229.32","1316.08","96","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","79.65","59.3","","439.50","225.34","1872.27","197","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X10MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10014404","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.37","78.45","","385.32","55.36","1815.62","58","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","AETNA [1001]","HB CH AETNA HMO / PPO","190.26","58.3","","554.95","91.85","1421.75","94","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","238.23","73","","2490.03","2490.03","2490.03","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","190.26","58.3","","750.00","750.00","750.00","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","172.96","53","","1192.50","120.84","4149.90","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","277.39","85","","750.00","75.00","750.00","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","326.34","100","","657.00","121.50","1971.00","14","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","326.34","100","","75.00","75.00","75.00","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","326.34","100","","366.00","144.00","1971.00","45","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","238.23","73","","667.50","667.50","667.50","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","145.06","44.45","","123.77","123.77","123.77","1 through 10","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","both","","","326.34","244.75","WELLPOINT [1015]","HB CH WELLPOINT","254.25","77.91","","483.51","229.32","1316.08","96","145.06","326.34","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","193.52","59.3","","439.50","225.34","1872.27","197","163.17","256.01","percent of total billed charges",""
"SCREW BONE 2.4X10MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10023235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","326.34","244.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","256.01","78.45","","385.32","55.36","1815.62","58","163.17","256.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","AETNA [1001]","HB CH AETNA HMO / PPO","117.78","58.3","","554.95","91.85","1421.75","94","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","147.47","73","","2490.03","2490.03","2490.03","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.78","58.3","","750.00","750.00","750.00","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","107.07","53","","1192.50","120.84","4149.90","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","171.72","85","","750.00","75.00","750.00","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","202.02","100","","657.00","121.50","1971.00","14","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","202.02","100","","75.00","75.00","75.00","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","202.02","100","","366.00","144.00","1971.00","45","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","147.47","73","","667.50","667.50","667.50","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.80","44.45","","123.77","123.77","123.77","1 through 10","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","both","","","202.02","151.51","WELLPOINT [1015]","HB CH WELLPOINT","157.39","77.91","","483.51","229.32","1316.08","96","89.8","202.02","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.02","151.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.80","59.3","","439.50","225.34","1872.27","197","101.01","158.48","percent of total billed charges",""
"SCREW BONE 2.4X12MM HAND CORTEX TI SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002246","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","202.02","151.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","158.48","78.45","","385.32","55.36","1815.62","58","101.01","158.48","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","AETNA [1001]","HB CH AETNA HMO / PPO","210.32","58.3","","554.95","91.85","1421.75","94","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","263.35","73","","2490.03","2490.03","2490.03","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","210.32","58.3","","750.00","750.00","750.00","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","191.20","53","","1192.50","120.84","4149.90","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","306.64","85","","750.00","75.00","750.00","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","360.75","100","","657.00","121.50","1971.00","14","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","360.75","100","","75.00","75.00","75.00","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","360.75","100","","366.00","144.00","1971.00","45","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","263.35","73","","667.50","667.50","667.50","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","160.35","44.45","","123.77","123.77","123.77","1 through 10","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","both","","","360.75","270.56","WELLPOINT [1015]","HB CH WELLPOINT","281.06","77.91","","483.51","229.32","1316.08","96","160.35","360.75","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.75","270.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","213.92","59.3","","439.50","225.34","1872.27","197","180.38","283.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM TITANIUM VARIABLE ANGLE LOCKING SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10096192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","360.75","270.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","283.01","78.45","","385.32","55.36","1815.62","58","180.38","283.01","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","AETNA [1001]","HB CH AETNA HMO / PPO","269.64","58.3","","554.95","91.85","1421.75","94","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","337.63","73","","2490.03","2490.03","2490.03","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","269.64","58.3","","750.00","750.00","750.00","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.13","53","","1192.50","120.84","4149.90","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","393.13","85","","750.00","75.00","750.00","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","462.51","100","","657.00","121.50","1971.00","14","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","462.51","100","","75.00","75.00","75.00","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","462.51","100","","366.00","144.00","1971.00","45","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","337.63","73","","667.50","667.50","667.50","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.59","44.45","","123.77","123.77","123.77","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","WELLPOINT [1015]","HB CH WELLPOINT","360.34","77.91","","483.51","229.32","1316.08","96","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.27","59.3","","439.50","225.34","1872.27","197","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.4X12MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI","SUP-ITM-10171316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","362.84","78.45","","385.32","55.36","1815.62","58","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","AETNA [1001]","HB CH AETNA HMO / PPO","86.07","58.3","","554.95","91.85","1421.75","94","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","107.77","73","","2490.03","2490.03","2490.03","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","86.07","58.3","","750.00","750.00","750.00","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","78.24","53","","1192.50","120.84","4149.90","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","125.49","85","","750.00","75.00","750.00","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","147.63","100","","657.00","121.50","1971.00","14","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","147.63","100","","75.00","75.00","75.00","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","147.63","100","","366.00","144.00","1971.00","45","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","107.77","73","","667.50","667.50","667.50","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","65.62","44.45","","123.77","123.77","123.77","1 through 10","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","both","","","147.63","110.72","WELLPOINT [1015]","HB CH WELLPOINT","115.02","77.91","","483.51","229.32","1316.08","96","65.62","147.63","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","87.54","59.3","","439.50","225.34","1872.27","197","73.82","115.82","percent of total billed charges",""
"SCREW BONE 2.4X14MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TI","SUP-ITM-10013590","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","147.63","110.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","115.82","78.45","","385.32","55.36","1815.62","58","73.82","115.82","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","AETNA [1001]","HB CH AETNA HMO / PPO","158.55","58.3","","554.95","91.85","1421.75","94","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","198.52","73","","2490.03","2490.03","2490.03","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","158.55","58.3","","750.00","750.00","750.00","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","144.13","53","","1192.50","120.84","4149.90","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","231.16","85","","750.00","75.00","750.00","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","271.95","100","","657.00","121.50","1971.00","14","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","271.95","100","","75.00","75.00","75.00","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","271.95","100","","366.00","144.00","1971.00","45","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","198.52","73","","667.50","667.50","667.50","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.88","44.45","","123.77","123.77","123.77","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","WELLPOINT [1015]","HB CH WELLPOINT","211.88","77.91","","483.51","229.32","1316.08","96","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","161.27","59.3","","439.50","225.34","1872.27","197","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X14MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016577","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","213.34","78.45","","385.32","55.36","1815.62","58","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","AETNA [1001]","HB CH AETNA HMO / PPO","223.31","58.3","","554.95","91.85","1421.75","94","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","279.62","73","","2490.03","2490.03","2490.03","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","223.31","58.3","","750.00","750.00","750.00","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","203.01","53","","1192.50","120.84","4149.90","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","325.58","85","","750.00","75.00","750.00","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","383.04","100","","657.00","121.50","1971.00","14","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","383.04","100","","75.00","75.00","75.00","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","383.04","100","","366.00","144.00","1971.00","45","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","279.62","73","","667.50","667.50","667.50","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","170.26","44.45","","123.77","123.77","123.77","1 through 10","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","both","","","383.04","287.28","WELLPOINT [1015]","HB CH WELLPOINT","298.43","77.91","","483.51","229.32","1316.08","96","170.26","383.04","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","383.04","287.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","227.14","59.3","","439.50","225.34","1872.27","197","191.52","300.49","percent of total billed charges",""
"SCREW BONE 2.4X15MM CANNULATED SS LONG THREAD","SUP-ITM-10019174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","383.04","287.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","300.49","78.45","","385.32","55.36","1815.62","58","191.52","300.49","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","554.95","91.85","1421.75","94","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","2490.03","2490.03","2490.03","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","253.61","58.3","","750.00","750.00","750.00","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","230.55","53","","1192.50","120.84","4149.90","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","369.75","85","","750.00","75.00","750.00","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","435.00","100","","657.00","121.50","1971.00","14","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","435.00","100","","75.00","75.00","75.00","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","435.00","100","","366.00","144.00","1971.00","45","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","667.50","667.50","667.50","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","123.77","123.77","123.77","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","483.51","229.32","1316.08","96","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","439.50","225.34","1872.27","197","217.5","341.26","percent of total billed charges",""
"SCREW BONE 2.4X16MM QUICKFIX CANNULATED TI FIXATION SELF DRILLING PARTIAL THREAD PROXIMAL HEAD LOW PROFILE","SUP-ITM-10153923","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","385.32","55.36","1815.62","58","217.5","341.26","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","AETNA [1001]","HB CH AETNA HMO / PPO","365.47","58.3","","554.95","91.85","1421.75","94","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","457.62","73","","2490.03","2490.03","2490.03","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","365.47","58.3","","750.00","750.00","750.00","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","332.25","53","","1192.50","120.84","4149.90","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","532.85","85","","750.00","75.00","750.00","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","626.88","100","","657.00","121.50","1971.00","14","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","626.88","100","","75.00","75.00","75.00","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","626.88","100","","366.00","144.00","1971.00","45","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","457.62","73","","667.50","667.50","667.50","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.65","44.45","","123.77","123.77","123.77","1 through 10","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","both","","","626.88","470.16","WELLPOINT [1015]","HB CH WELLPOINT","488.40","77.91","","483.51","229.32","1316.08","96","278.65","626.88","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.88","470.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.74","59.3","","439.50","225.34","1872.27","197","313.44","491.79","percent of total billed charges",""
"SCREW BONE 2.4X18MM SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10046826","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","626.88","470.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.79","78.45","","385.32","55.36","1815.62","58","313.44","491.79","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","AETNA [1001]","HB CH AETNA HMO / PPO","460.63","58.3","","554.95","91.85","1421.75","94","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","576.78","73","","2490.03","2490.03","2490.03","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","460.63","58.3","","750.00","750.00","750.00","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","418.76","53","","1192.50","120.84","4149.90","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","671.59","85","","750.00","75.00","750.00","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","790.11","100","","657.00","121.50","1971.00","14","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","790.11","100","","75.00","75.00","75.00","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","790.11","100","","366.00","144.00","1971.00","45","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","576.78","73","","667.50","667.50","667.50","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.20","44.45","","123.77","123.77","123.77","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","WELLPOINT [1015]","HB CH WELLPOINT","615.57","77.91","","483.51","229.32","1316.08","96","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","468.54","59.3","","439.50","225.34","1872.27","197","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.4X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10168023","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","619.84","78.45","","385.32","55.36","1815.62","58","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","554.95","91.85","1421.75","94","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","2490.03","2490.03","2490.03","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","253.61","58.3","","750.00","750.00","750.00","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","230.55","53","","1192.50","120.84","4149.90","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","369.75","85","","750.00","75.00","750.00","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","435.00","100","","657.00","121.50","1971.00","14","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","435.00","100","","75.00","75.00","75.00","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","435.00","100","","366.00","144.00","1971.00","45","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","667.50","667.50","667.50","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","123.77","123.77","123.77","1 through 10","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","483.51","229.32","1316.08","96","193.36","435","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","439.50","225.34","1872.27","197","217.5","341.26","percent of total billed charges",""
"SCREW BONE 2.4X22MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10100405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","385.32","55.36","1815.62","58","217.5","341.26","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","AETNA [1001]","HB CH AETNA HMO / PPO","158.55","58.3","","554.95","91.85","1421.75","94","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","198.52","73","","2490.03","2490.03","2490.03","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","158.55","58.3","","750.00","750.00","750.00","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","144.13","53","","1192.50","120.84","4149.90","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","231.16","85","","750.00","75.00","750.00","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","271.95","100","","657.00","121.50","1971.00","14","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","271.95","100","","75.00","75.00","75.00","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","271.95","100","","366.00","144.00","1971.00","45","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","198.52","73","","667.50","667.50","667.50","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.88","44.45","","123.77","123.77","123.77","1 through 10","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","both","","","271.95","203.96","WELLPOINT [1015]","HB CH WELLPOINT","211.88","77.91","","483.51","229.32","1316.08","96","120.88","271.95","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","161.27","59.3","","439.50","225.34","1872.27","197","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X22MM SS LOCKING SELF TAPPING FULLY THREADED T8 STARDRIVE RECESS","SUP-ITM-10016498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","271.95","203.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","213.34","78.45","","385.32","55.36","1815.62","58","135.98","213.34","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","554.95","91.85","1421.75","94","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","88.32","73","","2490.03","2490.03","2490.03","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","70.54","58.3","","750.00","750.00","750.00","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","64.12","53","","1192.50","120.84","4149.90","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.84","85","","750.00","75.00","750.00","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.99","100","","657.00","121.50","1971.00","14","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.99","100","","75.00","75.00","75.00","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.99","100","","366.00","144.00","1971.00","45","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","88.32","73","","667.50","667.50","667.50","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","123.77","123.77","123.77","1 through 10","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.99","90.74","WELLPOINT [1015]","HB CH WELLPOINT","94.26","77.91","","483.51","229.32","1316.08","96","53.78","120.99","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.99","90.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","439.50","225.34","1872.27","197","60.5","94.92","percent of total billed charges",""
"SCREW BONE 2.4X3.5X6MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037090","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.99","90.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","385.32","55.36","1815.62","58","60.5","94.92","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","AETNA [1001]","HB CH AETNA HMO / PPO","78.30","58.3","","554.95","91.85","1421.75","94","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.05","73","","2490.03","2490.03","2490.03","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.30","58.3","","750.00","750.00","750.00","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.18","53","","1192.50","120.84","4149.90","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.16","85","","750.00","75.00","750.00","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","134.31","100","","657.00","121.50","1971.00","14","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","134.31","100","","75.00","75.00","75.00","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","134.31","100","","366.00","144.00","1971.00","45","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.05","73","","667.50","667.50","667.50","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.70","44.45","","123.77","123.77","123.77","1 through 10","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","both","","","134.31","100.73","WELLPOINT [1015]","HB CH WELLPOINT","104.64","77.91","","483.51","229.32","1316.08","96","59.7","134.31","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","79.65","59.3","","439.50","225.34","1872.27","197","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X6MM CORTEX SS SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10016499","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","134.31","100.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.37","78.45","","385.32","55.36","1815.62","58","67.16","105.37","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","AETNA [1001]","HB CH AETNA HMO / PPO","68.60","58.3","","554.95","91.85","1421.75","94","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","85.89","73","","2490.03","2490.03","2490.03","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","68.60","58.3","","750.00","750.00","750.00","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","62.36","53","","1192.50","120.84","4149.90","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","100.01","85","","750.00","75.00","750.00","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","117.66","100","","657.00","121.50","1971.00","14","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","117.66","100","","75.00","75.00","75.00","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","117.66","100","","366.00","144.00","1971.00","45","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","85.89","73","","667.50","667.50","667.50","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.30","44.45","","123.77","123.77","123.77","1 through 10","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.66","88.24","WELLPOINT [1015]","HB CH WELLPOINT","91.67","77.91","","483.51","229.32","1316.08","96","52.3","117.66","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.66","88.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.77","59.3","","439.50","225.34","1872.27","197","58.83","92.3","percent of total billed charges",""
"SCREW BONE 2.4X8MM CORTEX SS SELF TAPPING FULL THREAD CRUCIFORM RECESS","SUP-ITM-10037092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.66","88.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.30","78.45","","385.32","55.36","1815.62","58","58.83","92.3","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","AETNA [1001]","HB CH AETNA HMO / PPO","549.01","58.3","","554.95","91.85","1421.75","94","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","2490.03","2490.03","2490.03","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","549.01","58.3","","750.00","750.00","750.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","499.10","53","","1192.50","120.84","4149.90","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","800.45","85","","750.00","75.00","750.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","941.70","100","","657.00","121.50","1971.00","14","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","941.70","100","","75.00","75.00","75.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","941.70","100","","366.00","144.00","1971.00","45","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","667.50","667.50","667.50","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.59","44.45","","123.77","123.77","123.77","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","WELLPOINT [1015]","HB CH WELLPOINT","733.68","77.91","","483.51","229.32","1316.08","96","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","558.43","59.3","","439.50","225.34","1872.27","197","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2.5X14MM TI COMPRESSION CANNULATED HEADLESS","SUP-ITM-10274356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","738.76","78.45","","385.32","55.36","1815.62","58","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","AETNA [1001]","HB CH AETNA HMO / PPO","336.68","58.3","","554.95","91.85","1421.75","94","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","421.58","73","","2490.03","2490.03","2490.03","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","336.68","58.3","","750.00","750.00","750.00","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","306.08","53","","1192.50","120.84","4149.90","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","490.88","85","","750.00","75.00","750.00","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","577.50","100","","657.00","121.50","1971.00","14","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","577.50","100","","75.00","75.00","75.00","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","577.50","100","","366.00","144.00","1971.00","45","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","421.58","73","","667.50","667.50","667.50","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.70","44.45","","123.77","123.77","123.77","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB CH WELLPOINT","449.93","77.91","","483.51","229.32","1316.08","96","256.7","577.5","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","342.46","59.3","","439.50","225.34","1872.27","197","288.75","453.05","percent of total billed charges",""
"SCREW BONE 2.5X22MM CANNULATED MINI-MONSTER SHORT THREAD HEADED","SUP-ITM-10240741","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","453.05","78.45","","385.32","55.36","1815.62","58","288.75","453.05","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","AETNA [1001]","HB CH AETNA HMO / PPO","819.44","58.3","","554.95","91.85","1421.75","94","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","2490.03","2490.03","2490.03","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","819.44","58.3","","750.00","750.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.95","53","","1192.50","120.84","4149.90","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1194.73","85","","750.00","75.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1405.56","100","","657.00","121.50","1971.00","14","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1405.56","100","","75.00","75.00","75.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1405.56","100","","366.00","144.00","1971.00","45","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","667.50","667.50","667.50","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","123.77","123.77","123.77","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","WELLPOINT [1015]","HB CH WELLPOINT","1095.07","77.91","","483.51","229.32","1316.08","96","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","833.50","59.3","","439.50","225.34","1872.27","197","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X26MM MINI HEADLESS CANNULATED","SUP-ITM-10232429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","385.32","55.36","1815.62","58","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","554.95","91.85","1421.75","94","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","2490.03","2490.03","2490.03","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","750.00","750.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","1192.50","120.84","4149.90","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.20","85","","750.00","75.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.24","100","","657.00","121.50","1971.00","14","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.24","100","","75.00","75.00","75.00","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.24","100","","366.00","144.00","1971.00","45","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","667.50","667.50","667.50","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","123.77","123.77","123.77","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","483.51","229.32","1316.08","96","186.8","420.24","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","439.50","225.34","1872.27","197","210.12","329.68","percent of total billed charges",""
"SCREW BONE 2.5X30MM PEG A.L.P.S. COBALT MULTIDIRECTIONAL LOCKING THREADED SQUARE DRIVE","SUP-ITM-10071445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","385.32","55.36","1815.62","58","210.12","329.68","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","AETNA [1001]","HB CH AETNA HMO / PPO","380.11","58.3","","554.95","91.85","1421.75","94","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","475.95","73","","2490.03","2490.03","2490.03","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","380.11","58.3","","750.00","750.00","750.00","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.55","53","","1192.50","120.84","4149.90","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","554.19","85","","750.00","75.00","750.00","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.99","100","","657.00","121.50","1971.00","14","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","651.99","100","","75.00","75.00","75.00","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.99","100","","366.00","144.00","1971.00","45","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.95","73","","667.50","667.50","667.50","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.81","44.45","","123.77","123.77","123.77","1 through 10","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.99","488.99","WELLPOINT [1015]","HB CH WELLPOINT","507.97","77.91","","483.51","229.32","1316.08","96","289.81","651.99","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.99","488.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.63","59.3","","439.50","225.34","1872.27","197","326","511.49","percent of total billed charges",""
"SCREW BONE 2.7 TO 3.5MM COUNTERSINK","SUP-ITM-10130376","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.99","488.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.49","78.45","","385.32","55.36","1815.62","58","326","511.49","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","AETNA [1001]","HB CH AETNA HMO / PPO","75.21","58.3","","554.95","91.85","1421.75","94","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","94.17","73","","2490.03","2490.03","2490.03","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.21","58.3","","750.00","750.00","750.00","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.37","53","","1192.50","120.84","4149.90","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","109.65","85","","750.00","75.00","750.00","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","129.00","100","","657.00","121.50","1971.00","14","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","129.00","100","","75.00","75.00","75.00","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","129.00","100","","366.00","144.00","1971.00","45","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.17","73","","667.50","667.50","667.50","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.34","44.45","","123.77","123.77","123.77","1 through 10","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.00","96.75","WELLPOINT [1015]","HB CH WELLPOINT","100.50","77.91","","483.51","229.32","1316.08","96","57.34","129","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.00","96.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.50","59.3","","439.50","225.34","1872.27","197","64.5","101.2","percent of total billed charges",""
"SCREW BONE 2.7MMX10MM NON LOCKING CORTICAL FULLY THREADED STD CANNULATEDCRUCIFORM DRIVE SS","SUP-ITM-10017366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.00","96.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.20","78.45","","385.32","55.36","1815.62","58","64.5","101.2","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","AETNA [1001]","HB CH AETNA HMO / PPO","690.86","58.3","","554.95","91.85","1421.75","94","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","865.05","73","","2490.03","2490.03","2490.03","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","690.86","58.3","","750.00","750.00","750.00","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","628.05","53","","1192.50","120.84","4149.90","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1007.25","85","","750.00","75.00","750.00","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1185.00","100","","657.00","121.50","1971.00","14","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1185.00","100","","75.00","75.00","75.00","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1185.00","100","","366.00","144.00","1971.00","45","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","865.05","73","","667.50","667.50","667.50","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","526.73","44.45","","123.77","123.77","123.77","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","WELLPOINT [1015]","HB CH WELLPOINT","923.23","77.91","","483.51","229.32","1316.08","96","526.73","1185","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","702.71","59.3","","439.50","225.34","1872.27","197","592.5","929.63","percent of total billed charges",""
"SCREW BONE 2.7MMX20MM ELBOW INTERFERENCE CANNULATED ABSORBABLE POLY L LACTIC ACID BIOCOMPOSITE","SUP-ITM-10025565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","929.63","78.45","","385.32","55.36","1815.62","58","592.5","929.63","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","AETNA [1001]","HB CH AETNA HMO / PPO","201.76","58.3","","554.95","91.85","1421.75","94","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","252.64","73","","2490.03","2490.03","2490.03","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.76","58.3","","750.00","750.00","750.00","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","183.42","53","","1192.50","120.84","4149.90","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","294.17","85","","750.00","75.00","750.00","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","346.08","100","","657.00","121.50","1971.00","14","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","346.08","100","","75.00","75.00","75.00","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","346.08","100","","366.00","144.00","1971.00","45","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","252.64","73","","667.50","667.50","667.50","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.83","44.45","","123.77","123.77","123.77","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","WELLPOINT [1015]","HB CH WELLPOINT","269.63","77.91","","483.51","229.32","1316.08","96","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.08","259.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","205.23","59.3","","439.50","225.34","1872.27","197","173.04","271.5","percent of total billed charges",""
"SCREW BONE 2.7X10MM CORTICAL LOCKING","SUP-ITM-10075967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.08","259.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","271.50","78.45","","385.32","55.36","1815.62","58","173.04","271.5","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","AETNA [1001]","HB CH AETNA HMO / PPO","279.00","58.3","","554.95","91.85","1421.75","94","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","2490.03","2490.03","2490.03","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","279.00","58.3","","750.00","750.00","750.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","253.64","53","","1192.50","120.84","4149.90","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","406.78","85","","750.00","75.00","750.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","478.56","100","","657.00","121.50","1971.00","14","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","478.56","100","","75.00","75.00","75.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","478.56","100","","366.00","144.00","1971.00","45","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","667.50","667.50","667.50","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","123.77","123.77","123.77","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","WELLPOINT [1015]","HB CH WELLPOINT","372.85","77.91","","483.51","229.32","1316.08","96","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.79","59.3","","439.50","225.34","1872.27","197","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X10MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10171314","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","385.32","55.36","1815.62","58","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","AETNA [1001]","HB CH AETNA HMO / PPO","84.67","58.3","","554.95","91.85","1421.75","94","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","106.02","73","","2490.03","2490.03","2490.03","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","84.67","58.3","","750.00","750.00","750.00","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.97","53","","1192.50","120.84","4149.90","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","123.45","85","","750.00","75.00","750.00","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","145.23","100","","657.00","121.50","1971.00","14","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","145.23","100","","75.00","75.00","75.00","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","145.23","100","","366.00","144.00","1971.00","45","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","106.02","73","","667.50","667.50","667.50","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.55","44.45","","123.77","123.77","123.77","1 through 10","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.23","108.92","WELLPOINT [1015]","HB CH WELLPOINT","113.15","77.91","","483.51","229.32","1316.08","96","64.55","145.23","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.23","108.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","86.12","59.3","","439.50","225.34","1872.27","197","72.62","113.93","percent of total billed charges",""
"SCREW BONE 2.7X11MM RADIUS DVR CROSSLOCK COBALT CHROME NONLOCKING TRIPLE THREAD TAPERED HEAD DISTAL","SUP-ITM-10151243","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.23","108.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.93","78.45","","385.32","55.36","1815.62","58","72.62","113.93","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","AETNA [1001]","HB CH AETNA HMO / PPO","515.96","58.3","","554.95","91.85","1421.75","94","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","2490.03","2490.03","2490.03","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","515.96","58.3","","750.00","750.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","469.05","53","","1192.50","120.84","4149.90","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","752.25","85","","750.00","75.00","750.00","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","885.00","100","","657.00","121.50","1971.00","14","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","885.00","100","","75.00","75.00","75.00","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","885.00","100","","366.00","144.00","1971.00","45","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","646.05","73","","667.50","667.50","667.50","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","393.38","44.45","","123.77","123.77","123.77","1 through 10","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","both","","","885.00","663.75","WELLPOINT [1015]","HB CH WELLPOINT","689.50","77.91","","483.51","229.32","1316.08","96","393.38","885","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","524.81","59.3","","439.50","225.34","1872.27","197","442.5","694.28","percent of total billed charges",""
"SCREW BONE 2.7X12MM COMPRESSION SS KRELOCK","SUP-ITM-10310220","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","885.00","663.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","694.28","78.45","","385.32","55.36","1815.62","58","442.5","694.28","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","AETNA [1001]","HB CH AETNA HMO / PPO","61.48","58.3","","554.95","91.85","1421.75","94","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.98","73","","2490.03","2490.03","2490.03","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.48","58.3","","750.00","750.00","750.00","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.89","53","","1192.50","120.84","4149.90","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.63","85","","750.00","75.00","750.00","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.45","100","","657.00","121.50","1971.00","14","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.45","100","","75.00","75.00","75.00","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.45","100","","366.00","144.00","1971.00","45","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.98","73","","667.50","667.50","667.50","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.87","44.45","","123.77","123.77","123.77","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","WELLPOINT [1015]","HB CH WELLPOINT","82.16","77.91","","483.51","229.32","1316.08","96","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.53","59.3","","439.50","225.34","1872.27","197","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM CORTICAL SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.73","78.45","","385.32","55.36","1815.62","58","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","AETNA [1001]","HB CH AETNA HMO / PPO","284.63","58.3","","554.95","91.85","1421.75","94","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","356.40","73","","2490.03","2490.03","2490.03","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.63","58.3","","750.00","750.00","750.00","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.76","53","","1192.50","120.84","4149.90","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","414.99","85","","750.00","75.00","750.00","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","488.22","100","","657.00","121.50","1971.00","14","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","488.22","100","","75.00","75.00","75.00","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","488.22","100","","366.00","144.00","1971.00","45","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","356.40","73","","667.50","667.50","667.50","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.01","44.45","","123.77","123.77","123.77","1 through 10","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.22","366.16","WELLPOINT [1015]","HB CH WELLPOINT","380.37","77.91","","483.51","229.32","1316.08","96","217.01","488.22","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.22","366.16","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.51","59.3","","439.50","225.34","1872.27","197","244.11","383.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM RADIUS DVR CROSSLOCK COBALT CHROME MULTIDIRECTIONAL","SUP-ITM-10148307","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.22","366.16","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","383.01","78.45","","385.32","55.36","1815.62","58","244.11","383.01","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","AETNA [1001]","HB CH AETNA HMO / PPO","586.30","58.3","","554.95","91.85","1421.75","94","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","734.13","73","","2490.03","2490.03","2490.03","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","586.30","58.3","","750.00","750.00","750.00","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","533.00","53","","1192.50","120.84","4149.90","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","854.81","85","","750.00","75.00","750.00","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1005.66","100","","657.00","121.50","1971.00","14","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1005.66","100","","75.00","75.00","75.00","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1005.66","100","","366.00","144.00","1971.00","45","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","734.13","73","","667.50","667.50","667.50","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","447.02","44.45","","123.77","123.77","123.77","1 through 10","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.66","754.24","WELLPOINT [1015]","HB CH WELLPOINT","783.51","77.91","","483.51","229.32","1316.08","96","447.02","1005.66","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.66","754.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","596.36","59.3","","439.50","225.34","1872.27","197","502.83","788.94","percent of total billed charges",""
"SCREW BONE 2.7X12MM SNAP OFF","SUP-ITM-10043008","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.66","754.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.94","78.45","","385.32","55.36","1815.62","58","502.83","788.94","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","AETNA [1001]","HB CH AETNA HMO / PPO","75.66","58.3","","554.95","91.85","1421.75","94","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","94.74","73","","2490.03","2490.03","2490.03","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.66","58.3","","750.00","750.00","750.00","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.78","53","","1192.50","120.84","4149.90","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","110.31","85","","750.00","75.00","750.00","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","129.78","100","","657.00","121.50","1971.00","14","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","129.78","100","","75.00","75.00","75.00","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","129.78","100","","366.00","144.00","1971.00","45","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.74","73","","667.50","667.50","667.50","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.69","44.45","","123.77","123.77","123.77","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","WELLPOINT [1015]","HB CH WELLPOINT","101.11","77.91","","483.51","229.32","1316.08","96","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.96","59.3","","439.50","225.34","1872.27","197","64.89","101.81","percent of total billed charges",""
"SCREW BONE 2.7X12MM TI CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10018198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.81","78.45","","385.32","55.36","1815.62","58","64.89","101.81","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","AETNA [1001]","HB CH AETNA HMO / PPO","56.95","58.3","","554.95","91.85","1421.75","94","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","71.31","73","","2490.03","2490.03","2490.03","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","56.95","58.3","","750.00","750.00","750.00","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.77","53","","1192.50","120.84","4149.90","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","83.03","85","","750.00","75.00","750.00","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","97.68","100","","657.00","121.50","1971.00","14","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","97.68","100","","75.00","75.00","75.00","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","97.68","100","","366.00","144.00","1971.00","45","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","71.31","73","","667.50","667.50","667.50","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","43.42","44.45","","123.77","123.77","123.77","1 through 10","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","both","","","97.68","73.26","WELLPOINT [1015]","HB CH WELLPOINT","76.10","77.91","","483.51","229.32","1316.08","96","43.42","97.68","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.68","73.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","57.92","59.3","","439.50","225.34","1872.27","197","48.84","76.63","percent of total billed charges",""
"SCREW BONE 2.7X14MM CORTICAL LOCKING SELF TAPPING T8 STARDRIVE RECESS SS","SUP-ITM-10016583","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","97.68","73.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.63","78.45","","385.32","55.36","1815.62","58","48.84","76.63","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","AETNA [1001]","HB CH AETNA HMO / PPO","232.62","58.3","","554.95","91.85","1421.75","94","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","291.27","73","","2490.03","2490.03","2490.03","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","232.62","58.3","","750.00","750.00","750.00","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","211.47","53","","1192.50","120.84","4149.90","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","339.15","85","","750.00","75.00","750.00","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","399.00","100","","657.00","121.50","1971.00","14","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","399.00","100","","75.00","75.00","75.00","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","399.00","100","","366.00","144.00","1971.00","45","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","291.27","73","","667.50","667.50","667.50","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","177.36","44.45","","123.77","123.77","123.77","1 through 10","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","both","","","399.00","299.25","WELLPOINT [1015]","HB CH WELLPOINT","310.86","77.91","","483.51","229.32","1316.08","96","177.36","399","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","236.61","59.3","","439.50","225.34","1872.27","197","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X14MM RAYHACK CORTICAL LOCKING SS 40100774","SUP-ITM-10051730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","399.00","299.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","313.02","78.45","","385.32","55.36","1815.62","58","199.5","313.02","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","AETNA [1001]","HB CH AETNA HMO / PPO","177.31","58.3","","554.95","91.85","1421.75","94","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","222.02","73","","2490.03","2490.03","2490.03","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","177.31","58.3","","750.00","750.00","750.00","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","161.19","53","","1192.50","120.84","4149.90","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","258.52","85","","750.00","75.00","750.00","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","304.14","100","","657.00","121.50","1971.00","14","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","304.14","100","","75.00","75.00","75.00","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","304.14","100","","366.00","144.00","1971.00","45","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","222.02","73","","667.50","667.50","667.50","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","135.19","44.45","","123.77","123.77","123.77","1 through 10","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","both","","","304.14","228.10","WELLPOINT [1015]","HB CH WELLPOINT","236.96","77.91","","483.51","229.32","1316.08","96","135.19","304.14","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.14","228.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","180.36","59.3","","439.50","225.34","1872.27","197","152.07","238.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM SS VARIABLE ANGLE LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10082258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","304.14","228.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","238.60","78.45","","385.32","55.36","1815.62","58","152.07","238.6","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","AETNA [1001]","HB CH AETNA HMO / PPO","279.00","58.3","","554.95","91.85","1421.75","94","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","2490.03","2490.03","2490.03","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","279.00","58.3","","750.00","750.00","750.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","253.64","53","","1192.50","120.84","4149.90","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","406.78","85","","750.00","75.00","750.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","478.56","100","","657.00","121.50","1971.00","14","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","478.56","100","","75.00","75.00","75.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","478.56","100","","366.00","144.00","1971.00","45","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","667.50","667.50","667.50","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","123.77","123.77","123.77","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","WELLPOINT [1015]","HB CH WELLPOINT","372.85","77.91","","483.51","229.32","1316.08","96","212.72","478.56","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.79","59.3","","439.50","225.34","1872.27","197","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10152748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","385.32","55.36","1815.62","58","239.28","375.43","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","AETNA [1001]","HB CH AETNA HMO / PPO","269.64","58.3","","554.95","91.85","1421.75","94","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","337.63","73","","2490.03","2490.03","2490.03","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","269.64","58.3","","750.00","750.00","750.00","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.13","53","","1192.50","120.84","4149.90","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","393.13","85","","750.00","75.00","750.00","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","462.51","100","","657.00","121.50","1971.00","14","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","462.51","100","","75.00","75.00","75.00","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","462.51","100","","366.00","144.00","1971.00","45","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","337.63","73","","667.50","667.50","667.50","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.59","44.45","","123.77","123.77","123.77","1 through 10","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","both","","","462.51","346.88","WELLPOINT [1015]","HB CH WELLPOINT","360.34","77.91","","483.51","229.32","1316.08","96","205.59","462.51","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.27","59.3","","439.50","225.34","1872.27","197","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.7X16MM VARIAX 2 T8 NON LOCKING FULLY THREADED MINI 656416","SUP-ITM-10168025","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","462.51","346.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","362.84","78.45","","385.32","55.36","1815.62","58","231.26","362.84","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","AETNA [1001]","HB CH AETNA HMO / PPO","62.77","58.3","","554.95","91.85","1421.75","94","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","78.60","73","","2490.03","2490.03","2490.03","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","62.77","58.3","","750.00","750.00","750.00","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.07","53","","1192.50","120.84","4149.90","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","91.52","85","","750.00","75.00","750.00","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","107.67","100","","657.00","121.50","1971.00","14","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","107.67","100","","75.00","75.00","75.00","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","107.67","100","","366.00","144.00","1971.00","45","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","78.60","73","","667.50","667.50","667.50","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.86","44.45","","123.77","123.77","123.77","1 through 10","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.67","80.75","WELLPOINT [1015]","HB CH WELLPOINT","83.89","77.91","","483.51","229.32","1316.08","96","47.86","107.67","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.67","80.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.85","59.3","","439.50","225.34","1872.27","197","53.84","84.47","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL SELF TAPPING WITH T8 STARDRIVE RECESS TITANIUM","SUP-ITM-10024293","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.67","80.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.47","78.45","","385.32","55.36","1815.62","58","53.84","84.47","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","AETNA [1001]","HB CH AETNA HMO / PPO","117.18","58.3","","554.95","91.85","1421.75","94","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","146.73","73","","2490.03","2490.03","2490.03","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","117.18","58.3","","750.00","750.00","750.00","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","106.53","53","","1192.50","120.84","4149.90","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","170.85","85","","750.00","75.00","750.00","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","201.00","100","","657.00","121.50","1971.00","14","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","201.00","100","","75.00","75.00","75.00","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","201.00","100","","366.00","144.00","1971.00","45","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","146.73","73","","667.50","667.50","667.50","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","89.34","44.45","","123.77","123.77","123.77","1 through 10","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","both","","","201.00","150.75","WELLPOINT [1015]","HB CH WELLPOINT","156.60","77.91","","483.51","229.32","1316.08","96","89.34","201","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","119.19","59.3","","439.50","225.34","1872.27","197","100.5","157.68","percent of total billed charges",""
"SCREW BONE 2.7X18MM CORTICAL TITANIUM FULL THREAD DISTAL ROUNDED HEAD NONLOCKING","SUP-ITM-10018416","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","201.00","150.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","157.68","78.45","","385.32","55.36","1815.62","58","100.5","157.68","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","AETNA [1001]","HB CH AETNA HMO / PPO","460.63","58.3","","554.95","91.85","1421.75","94","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","576.78","73","","2490.03","2490.03","2490.03","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","460.63","58.3","","750.00","750.00","750.00","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","418.76","53","","1192.50","120.84","4149.90","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","671.59","85","","750.00","75.00","750.00","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","790.11","100","","657.00","121.50","1971.00","14","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","790.11","100","","75.00","75.00","75.00","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","790.11","100","","366.00","144.00","1971.00","45","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","576.78","73","","667.50","667.50","667.50","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","351.20","44.45","","123.77","123.77","123.77","1 through 10","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","both","","","790.11","592.58","WELLPOINT [1015]","HB CH WELLPOINT","615.57","77.91","","483.51","229.32","1316.08","96","351.2","790.11","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","468.54","59.3","","439.50","225.34","1872.27","197","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X18MM VARIAX 2 T8 LOCKING FULLY THREADED MINI","SUP-ITM-10174743","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","790.11","592.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","619.84","78.45","","385.32","55.36","1815.62","58","395.06","619.84","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","AETNA [1001]","HB CH AETNA HMO / PPO","201.76","58.3","","554.95","91.85","1421.75","94","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","252.64","73","","2490.03","2490.03","2490.03","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","201.76","58.3","","750.00","750.00","750.00","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","183.42","53","","1192.50","120.84","4149.90","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","294.17","85","","750.00","75.00","750.00","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","346.08","100","","657.00","121.50","1971.00","14","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","346.08","100","","75.00","75.00","75.00","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","346.08","100","","366.00","144.00","1971.00","45","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","252.64","73","","667.50","667.50","667.50","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","153.83","44.45","","123.77","123.77","123.77","1 through 10","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.08","259.56","WELLPOINT [1015]","HB CH WELLPOINT","269.63","77.91","","483.51","229.32","1316.08","96","153.83","346.08","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.08","259.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","205.23","59.3","","439.50","225.34","1872.27","197","173.04","271.5","percent of total billed charges",""
"SCREW BONE 2.7X20MM CORTICAL LOCKING","SUP-ITM-10075972","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.08","259.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","271.50","78.45","","385.32","55.36","1815.62","58","173.04","271.5","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","AETNA [1001]","HB CH AETNA HMO / PPO","295.58","58.3","","554.95","91.85","1421.75","94","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","370.11","73","","2490.03","2490.03","2490.03","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","295.58","58.3","","750.00","750.00","750.00","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","268.71","53","","1192.50","120.84","4149.90","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","430.95","85","","750.00","75.00","750.00","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","507.00","100","","657.00","121.50","1971.00","14","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","507.00","100","","75.00","75.00","75.00","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","507.00","100","","366.00","144.00","1971.00","45","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","370.11","73","","667.50","667.50","667.50","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","225.36","44.45","","123.77","123.77","123.77","1 through 10","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","both","","","507.00","380.25","WELLPOINT [1015]","HB CH WELLPOINT","395.00","77.91","","483.51","229.32","1316.08","96","225.36","507","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.00","380.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","300.65","59.3","","439.50","225.34","1872.27","197","253.5","397.74","percent of total billed charges",""
"SCREW BONE 2.7X24MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING","SUP-ITM-10019638","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","507.00","380.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","397.74","78.45","","385.32","55.36","1815.62","58","253.5","397.74","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","AETNA [1001]","HB CH AETNA HMO / PPO","147.55","58.3","","554.95","91.85","1421.75","94","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","184.75","73","","2490.03","2490.03","2490.03","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","147.55","58.3","","750.00","750.00","750.00","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","134.13","53","","1192.50","120.84","4149.90","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","215.12","85","","750.00","75.00","750.00","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","253.08","100","","657.00","121.50","1971.00","14","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","253.08","100","","75.00","75.00","75.00","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","253.08","100","","366.00","144.00","1971.00","45","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","184.75","73","","667.50","667.50","667.50","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.49","44.45","","123.77","123.77","123.77","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","WELLPOINT [1015]","HB CH WELLPOINT","197.17","77.91","","483.51","229.32","1316.08","96","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.08","59.3","","439.50","225.34","1872.27","197","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X24MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013257","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.54","78.45","","385.32","55.36","1815.62","58","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","AETNA [1001]","HB CH AETNA HMO / PPO","147.55","58.3","","554.95","91.85","1421.75","94","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","184.75","73","","2490.03","2490.03","2490.03","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","147.55","58.3","","750.00","750.00","750.00","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","134.13","53","","1192.50","120.84","4149.90","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","215.12","85","","750.00","75.00","750.00","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","253.08","100","","657.00","121.50","1971.00","14","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","253.08","100","","75.00","75.00","75.00","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","253.08","100","","366.00","144.00","1971.00","45","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","184.75","73","","667.50","667.50","667.50","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","112.49","44.45","","123.77","123.77","123.77","1 through 10","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","both","","","253.08","189.81","WELLPOINT [1015]","HB CH WELLPOINT","197.17","77.91","","483.51","229.32","1316.08","96","112.49","253.08","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","150.08","59.3","","439.50","225.34","1872.27","197","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM CORTEX SS LOCKING SELF TAPPING FULL THREAD T8 STARDRIVE RECESS","SUP-ITM-10013258","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","253.08","189.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","198.54","78.45","","385.32","55.36","1815.62","58","126.54","198.54","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","AETNA [1001]","HB CH AETNA HMO / PPO","102.89","58.3","","554.95","91.85","1421.75","94","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","128.84","73","","2490.03","2490.03","2490.03","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","102.89","58.3","","750.00","750.00","750.00","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","93.54","53","","1192.50","120.84","4149.90","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","150.02","85","","750.00","75.00","750.00","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","176.49","100","","657.00","121.50","1971.00","14","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","176.49","100","","75.00","75.00","75.00","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","176.49","100","","366.00","144.00","1971.00","45","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","128.84","73","","667.50","667.50","667.50","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.45","44.45","","123.77","123.77","123.77","1 through 10","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","both","","","176.49","132.37","WELLPOINT [1015]","HB CH WELLPOINT","137.50","77.91","","483.51","229.32","1316.08","96","78.45","176.49","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.66","59.3","","439.50","225.34","1872.27","197","88.25","138.46","percent of total billed charges",""
"SCREW BONE 2.7X28MM METAPHYSEAL LCP SS SELF TAPPING T8 STARDRIVE RECESS","SUP-ITM-10103952","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","176.49","132.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.46","78.45","","385.32","55.36","1815.62","58","88.25","138.46","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","AETNA [1001]","HB CH AETNA HMO / PPO","75.66","58.3","","554.95","91.85","1421.75","94","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","94.74","73","","2490.03","2490.03","2490.03","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.66","58.3","","750.00","750.00","750.00","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.78","53","","1192.50","120.84","4149.90","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","110.31","85","","750.00","75.00","750.00","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","129.78","100","","657.00","121.50","1971.00","14","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","129.78","100","","75.00","75.00","75.00","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","129.78","100","","366.00","144.00","1971.00","45","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.74","73","","667.50","667.50","667.50","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.69","44.45","","123.77","123.77","123.77","1 through 10","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.78","97.33","WELLPOINT [1015]","HB CH WELLPOINT","101.11","77.91","","483.51","229.32","1316.08","96","57.69","129.78","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","76.96","59.3","","439.50","225.34","1872.27","197","64.89","101.81","percent of total billed charges",""
"SCREW BONE 2.7X44MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072009","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.78","97.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.81","78.45","","385.32","55.36","1815.62","58","64.89","101.81","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","AETNA [1001]","HB CH AETNA HMO / PPO","61.48","58.3","","554.95","91.85","1421.75","94","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.98","73","","2490.03","2490.03","2490.03","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.48","58.3","","750.00","750.00","750.00","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.89","53","","1192.50","120.84","4149.90","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.63","85","","750.00","75.00","750.00","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.45","100","","657.00","121.50","1971.00","14","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.45","100","","75.00","75.00","75.00","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.45","100","","366.00","144.00","1971.00","45","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.98","73","","667.50","667.50","667.50","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.87","44.45","","123.77","123.77","123.77","1 through 10","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.45","79.09","WELLPOINT [1015]","HB CH WELLPOINT","82.16","77.91","","483.51","229.32","1316.08","96","46.87","105.45","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.53","59.3","","439.50","225.34","1872.27","197","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X45MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019113","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.45","79.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.73","78.45","","385.32","55.36","1815.62","58","52.73","82.73","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","AETNA [1001]","HB CH AETNA HMO / PPO","71.18","58.3","","554.95","91.85","1421.75","94","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","89.13","73","","2490.03","2490.03","2490.03","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","71.18","58.3","","750.00","750.00","750.00","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","64.71","53","","1192.50","120.84","4149.90","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","103.79","85","","750.00","75.00","750.00","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","122.10","100","","657.00","121.50","1971.00","14","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","122.10","100","","75.00","75.00","75.00","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","122.10","100","","366.00","144.00","1971.00","45","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","89.13","73","","667.50","667.50","667.50","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","54.27","44.45","","123.77","123.77","123.77","1 through 10","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","both","","","122.10","91.57","WELLPOINT [1015]","HB CH WELLPOINT","95.13","77.91","","483.51","229.32","1316.08","96","54.27","122.1","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","72.41","59.3","","439.50","225.34","1872.27","197","61.05","95.79","percent of total billed charges",""
"SCREW BONE 2.7X55MM CORTEX SS HEXAGONAL SOCKET SELF TAPPING SPHERICAL HEAD SM","SUP-ITM-10019183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","122.10","91.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","95.79","78.45","","385.32","55.36","1815.62","58","61.05","95.79","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","AETNA [1001]","HB CH AETNA HMO / PPO","169.34","58.3","","554.95","91.85","1421.75","94","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","2490.03","2490.03","2490.03","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","169.34","58.3","","750.00","750.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","153.94","53","","1192.50","120.84","4149.90","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","246.89","85","","750.00","75.00","750.00","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","290.46","100","","657.00","121.50","1971.00","14","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","290.46","100","","75.00","75.00","75.00","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","290.46","100","","366.00","144.00","1971.00","45","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","212.04","73","","667.50","667.50","667.50","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.11","44.45","","123.77","123.77","123.77","1 through 10","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","both","","","290.46","217.84","WELLPOINT [1015]","HB CH WELLPOINT","226.30","77.91","","483.51","229.32","1316.08","96","129.11","290.46","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.24","59.3","","439.50","225.34","1872.27","197","145.23","227.87","percent of total billed charges",""
"SCREW BONE 2.7X9MM RADIUS DVR CROSSLOCK COBALT CHROME LOCKING TRIPLE THREAD DISTAL TAPERED HEAD","SUP-ITM-10151254","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","290.46","217.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","227.87","78.45","","385.32","55.36","1815.62","58","145.23","227.87","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","554.95","91.85","1421.75","94","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2490.03","2490.03","2490.03","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","750.00","750.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","1192.50","120.84","4149.90","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","750.00","75.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","657.00","121.50","1971.00","14","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","75.00","75.00","75.00","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","366.00","144.00","1971.00","45","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","667.50","667.50","667.50","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","123.77","123.77","123.77","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","483.51","229.32","1316.08","96","800.1","1800","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","439.50","225.34","1872.27","197","900","1412.1","percent of total billed charges",""
"SCREW BONE 20MM CENTRAL MODULAR","SUP-ITM-10233532","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","385.32","55.36","1815.62","58","900","1412.1","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","AETNA [1001]","HB CH AETNA HMO / PPO","606.83","58.3","","554.95","91.85","1421.75","94","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","759.84","73","","2490.03","2490.03","2490.03","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","606.83","58.3","","750.00","750.00","750.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","551.67","53","","1192.50","120.84","4149.90","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","884.75","85","","750.00","75.00","750.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1040.88","100","","657.00","121.50","1971.00","14","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1040.88","100","","75.00","75.00","75.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1040.88","100","","366.00","144.00","1971.00","45","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","759.84","73","","667.50","667.50","667.50","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","462.67","44.45","","123.77","123.77","123.77","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","WELLPOINT [1015]","HB CH WELLPOINT","810.95","77.91","","483.51","229.32","1316.08","96","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1040.88","780.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","617.24","59.3","","439.50","225.34","1872.27","197","520.44","816.57","percent of total billed charges",""
"SCREW BONE 20X3.5MM SS MIDFOOT LOCKING SURFIX","SUP-ITM-10080379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1040.88","780.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","816.57","78.45","","385.32","55.36","1815.62","58","520.44","816.57","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","AETNA [1001]","HB CH AETNA HMO / PPO","679.68","58.3","","554.95","91.85","1421.75","94","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","851.06","73","","2490.03","2490.03","2490.03","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","679.68","58.3","","750.00","750.00","750.00","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","617.89","53","","1192.50","120.84","4149.90","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","990.96","85","","750.00","75.00","750.00","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1165.83","100","","657.00","121.50","1971.00","14","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1165.83","100","","75.00","75.00","75.00","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1165.83","100","","366.00","144.00","1971.00","45","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","851.06","73","","667.50","667.50","667.50","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","518.21","44.45","","123.77","123.77","123.77","1 through 10","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","both","","","1165.83","874.37","WELLPOINT [1015]","HB CH WELLPOINT","908.30","77.91","","483.51","229.32","1316.08","96","518.21","1165.83","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.83","874.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","691.34","59.3","","439.50","225.34","1872.27","197","582.92","914.59","percent of total billed charges",""
"SCREW BONE 20X6.5MM FOOT LOCKING FLEXIBLE STABLE ADVANSYS SURFIX","SUP-ITM-10091915","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1165.83","874.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","914.59","78.45","","385.32","55.36","1815.62","58","582.92","914.59","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","554.95","91.85","1421.75","94","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","2490.03","2490.03","2490.03","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","750.00","750.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","1192.50","120.84","4149.90","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","280.50","85","","750.00","75.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","330.00","100","","657.00","121.50","1971.00","14","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","330.00","100","","75.00","75.00","75.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","330.00","100","","366.00","144.00","1971.00","45","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","667.50","667.50","667.50","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","123.77","123.77","123.77","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","483.51","229.32","1316.08","96","146.69","330","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","439.50","225.34","1872.27","197","165","258.89","percent of total billed charges",""
"SCREW BONE 22.0X2.4MM CORTEX TITANIUM LOW PROFILE SOLID","SUP-ITM-10148117","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","385.32","55.36","1815.62","58","165","258.89","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","AETNA [1001]","HB CH AETNA HMO / PPO","846.36","58.3","","554.95","91.85","1421.75","94","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1059.76","73","","2490.03","2490.03","2490.03","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","846.36","58.3","","750.00","750.00","750.00","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","769.42","53","","1192.50","120.84","4149.90","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1233.97","85","","750.00","75.00","750.00","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1451.73","100","","657.00","121.50","1971.00","14","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1451.73","100","","75.00","75.00","75.00","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1451.73","100","","366.00","144.00","1971.00","45","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1059.76","73","","667.50","667.50","667.50","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","645.29","44.45","","123.77","123.77","123.77","1 through 10","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","both","","","1451.73","1088.80","WELLPOINT [1015]","HB CH WELLPOINT","1131.04","77.91","","483.51","229.32","1316.08","96","645.29","1451.73","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.73","1088.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","860.88","59.3","","439.50","225.34","1872.27","197","725.87","1138.88","percent of total billed charges",""
"SCREW BONE 22MM 13X80 LAG OMEGA 2 SS THREAD","SUP-ITM-10034181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1451.73","1088.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1138.88","78.45","","385.32","55.36","1815.62","58","725.87","1138.88","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","AETNA [1001]","HB CH AETNA HMO / PPO","84.63","58.3","","554.95","91.85","1421.75","94","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","105.97","73","","2490.03","2490.03","2490.03","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","84.63","58.3","","750.00","750.00","750.00","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.94","53","","1192.50","120.84","4149.90","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","123.39","85","","750.00","75.00","750.00","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","145.17","100","","657.00","121.50","1971.00","14","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","145.17","100","","75.00","75.00","75.00","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","145.17","100","","366.00","144.00","1971.00","45","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.97","73","","667.50","667.50","667.50","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.53","44.45","","123.77","123.77","123.77","1 through 10","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","both","","","145.17","108.88","WELLPOINT [1015]","HB CH WELLPOINT","113.10","77.91","","483.51","229.32","1316.08","96","64.53","145.17","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.17","108.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","86.09","59.3","","439.50","225.34","1872.27","197","72.59","113.89","percent of total billed charges",""
"SCREW BONE 22MM 13X85 LAG OMEGA 2 SS THREAD","SUP-ITM-10034182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","145.17","108.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.89","78.45","","385.32","55.36","1815.62","58","72.59","113.89","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","AETNA [1001]","HB CH AETNA HMO / PPO","376.04","58.3","","554.95","91.85","1421.75","94","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","470.85","73","","2490.03","2490.03","2490.03","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","376.04","58.3","","750.00","750.00","750.00","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","341.85","53","","1192.50","120.84","4149.90","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","548.25","85","","750.00","75.00","750.00","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","645.00","100","","657.00","121.50","1971.00","14","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","645.00","100","","75.00","75.00","75.00","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","645.00","100","","366.00","144.00","1971.00","45","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","470.85","73","","667.50","667.50","667.50","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.70","44.45","","123.77","123.77","123.77","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","WELLPOINT [1015]","HB CH WELLPOINT","502.52","77.91","","483.51","229.32","1316.08","96","286.7","645","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","382.49","59.3","","439.50","225.34","1872.27","197","322.5","506","percent of total billed charges",""
"SCREW BONE 22MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10024933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","506.00","78.45","","385.32","55.36","1815.62","58","322.5","506","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","AETNA [1001]","HB CH AETNA HMO / PPO","61.25","58.3","","554.95","91.85","1421.75","94","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.69","73","","2490.03","2490.03","2490.03","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.25","58.3","","750.00","750.00","750.00","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.68","53","","1192.50","120.84","4149.90","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.30","85","","750.00","75.00","750.00","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.06","100","","657.00","121.50","1971.00","14","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.06","100","","75.00","75.00","75.00","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.06","100","","366.00","144.00","1971.00","45","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.69","73","","667.50","667.50","667.50","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.70","44.45","","123.77","123.77","123.77","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","WELLPOINT [1015]","HB CH WELLPOINT","81.85","77.91","","483.51","229.32","1316.08","96","46.7","105.06","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.30","59.3","","439.50","225.34","1872.27","197","52.53","82.42","percent of total billed charges",""
"SCREW BONE 22MMX4MM CANCELLOUS A.L.P.S. TITANIUM SELF TAPPING FULL THREAD T 15 DRIVE","SUP-ITM-10017520","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.42","78.45","","385.32","55.36","1815.62","58","52.53","82.42","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","AETNA [1001]","HB CH AETNA HMO / PPO","183.65","58.3","","554.95","91.85","1421.75","94","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","2490.03","2490.03","2490.03","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","183.65","58.3","","750.00","750.00","750.00","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","166.95","53","","1192.50","120.84","4149.90","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","267.75","85","","750.00","75.00","750.00","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","315.00","100","","657.00","121.50","1971.00","14","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","315.00","100","","75.00","75.00","75.00","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","315.00","100","","366.00","144.00","1971.00","45","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","229.95","73","","667.50","667.50","667.50","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","140.02","44.45","","123.77","123.77","123.77","1 through 10","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","both","","","315.00","236.25","WELLPOINT [1015]","HB CH WELLPOINT","245.42","77.91","","483.51","229.32","1316.08","96","140.02","315","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","186.80","59.3","","439.50","225.34","1872.27","197","157.5","247.12","percent of total billed charges",""
"SCREW BONE 22X3.2MM CORTICAL LAG SS FIXED ANGLE NONLOCKING HEXAGONAL SOCKET","SUP-ITM-10071375","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","315.00","236.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","247.12","78.45","","385.32","55.36","1815.62","58","157.5","247.12","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","AETNA [1001]","HB CH AETNA HMO / PPO","166.16","58.3","","554.95","91.85","1421.75","94","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","208.05","73","","2490.03","2490.03","2490.03","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","166.16","58.3","","750.00","750.00","750.00","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","151.05","53","","1192.50","120.84","4149.90","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","242.25","85","","750.00","75.00","750.00","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","285.00","100","","657.00","121.50","1971.00","14","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","285.00","100","","75.00","75.00","75.00","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","285.00","100","","366.00","144.00","1971.00","45","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","208.05","73","","667.50","667.50","667.50","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.68","44.45","","123.77","123.77","123.77","1 through 10","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.00","213.75","WELLPOINT [1015]","HB CH WELLPOINT","222.04","77.91","","483.51","229.32","1316.08","96","126.68","285","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","169.01","59.3","","439.50","225.34","1872.27","197","142.5","223.58","percent of total billed charges",""
"SCREW BONE 22X3.5MM ORTHOLOC 3DI TI NONLOCKING LOW PROFILE CORTICAL","SUP-ITM-10124568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.00","213.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","223.58","78.45","","385.32","55.36","1815.62","58","142.5","223.58","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","554.95","91.85","1421.75","94","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2490.03","2490.03","2490.03","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","750.00","750.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","1192.50","120.84","4149.90","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","750.00","75.00","750.00","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","657.00","121.50","1971.00","14","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","75.00","75.00","75.00","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","366.00","144.00","1971.00","45","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","667.50","667.50","667.50","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","800.10","44.45","","123.77","123.77","123.77","1 through 10","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","483.51","229.32","1316.08","96","800.1","1800","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","439.50","225.34","1872.27","197","900","1412.1","percent of total billed charges",""
"SCREW BONE 25MM CENTRAL MODULAR","SUP-ITM-10233530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","385.32","55.36","1815.62","58","900","1412.1","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","554.95","91.85","1421.75","94","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2490.03","2490.03","2490.03","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","750.00","750.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","1192.50","120.84","4149.90","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","750.00","75.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","657.00","121.50","1971.00","14","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","75.00","75.00","75.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","366.00","144.00","1971.00","45","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","667.50","667.50","667.50","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","123.77","123.77","123.77","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","483.51","229.32","1316.08","96","72.01","162","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","439.50","225.34","1872.27","197","81","127.09","percent of total billed charges",""
"SCREW BONE 25X6.5MM HIP CANCELLOUS PINNACLE SS DOME","SUP-ITM-10007287","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","385.32","55.36","1815.62","58","81","127.09","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","AETNA [1001]","HB CH AETNA HMO / PPO","150.41","58.3","","554.95","91.85","1421.75","94","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","188.34","73","","2490.03","2490.03","2490.03","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","150.41","58.3","","750.00","750.00","750.00","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","136.74","53","","1192.50","120.84","4149.90","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","219.30","85","","750.00","75.00","750.00","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","258.00","100","","657.00","121.50","1971.00","14","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","258.00","100","","75.00","75.00","75.00","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","258.00","100","","366.00","144.00","1971.00","45","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","188.34","73","","667.50","667.50","667.50","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","114.68","44.45","","123.77","123.77","123.77","1 through 10","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","both","","","258.00","193.50","WELLPOINT [1015]","HB CH WELLPOINT","201.01","77.91","","483.51","229.32","1316.08","96","114.68","258","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","152.99","59.3","","439.50","225.34","1872.27","197","129","202.4","percent of total billed charges",""
"SCREW BONE 26X2.3MM CORTICAL ACU LOC 2 TITANIUM VOLAR DISTAL PLATING NONTOGGLING","SUP-ITM-10026988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","202.40","78.45","","385.32","55.36","1815.62","58","129","202.4","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","AETNA [1001]","HB CH AETNA HMO / PPO","45.47","58.3","","554.95","91.85","1421.75","94","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","2490.03","2490.03","2490.03","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.47","58.3","","750.00","750.00","750.00","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.34","53","","1192.50","120.84","4149.90","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","66.30","85","","750.00","75.00","750.00","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","78.00","100","","657.00","121.50","1971.00","14","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","78.00","100","","75.00","75.00","75.00","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","78.00","100","","366.00","144.00","1971.00","45","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","667.50","667.50","667.50","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","123.77","123.77","123.77","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","WELLPOINT [1015]","HB CH WELLPOINT","60.77","77.91","","483.51","229.32","1316.08","96","34.67","78","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.25","59.3","","439.50","225.34","1872.27","197","39","61.19","percent of total billed charges",""
"SCREW BONE 26X4.5MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULL THREAD","SUP-ITM-10020235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","385.32","55.36","1815.62","58","39","61.19","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","554.95","91.85","1421.75","94","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","2490.03","2490.03","2490.03","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","750.00","750.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","1192.50","120.84","4149.90","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","153.00","85","","750.00","75.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","180.00","100","","657.00","121.50","1971.00","14","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","180.00","100","","75.00","75.00","75.00","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","180.00","100","","366.00","144.00","1971.00","45","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","667.50","667.50","667.50","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","123.77","123.77","123.77","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","483.51","229.32","1316.08","96","80.01","180","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","439.50","225.34","1872.27","197","90","141.21","percent of total billed charges",""
"SCREW BONE 26X4.5MM SHOULDER COMPRESSION AEQUALIS TITANIUM SELF TAPPING HEMISPHERICAL HEAD","SUP-ITM-10017352","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","385.32","55.36","1815.62","58","90","141.21","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","AETNA [1001]","HB CH AETNA HMO / PPO","479.91","58.3","","554.95","91.85","1421.75","94","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","600.91","73","","2490.03","2490.03","2490.03","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","479.91","58.3","","750.00","750.00","750.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","436.28","53","","1192.50","120.84","4149.90","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","699.69","85","","750.00","75.00","750.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","823.17","100","","657.00","121.50","1971.00","14","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","823.17","100","","75.00","75.00","75.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","823.17","100","","366.00","144.00","1971.00","45","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","600.91","73","","667.50","667.50","667.50","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","365.90","44.45","","123.77","123.77","123.77","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","WELLPOINT [1015]","HB CH WELLPOINT","641.33","77.91","","483.51","229.32","1316.08","96","365.9","823.17","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","823.17","617.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","488.14","59.3","","439.50","225.34","1872.27","197","411.59","645.78","percent of total billed charges",""
"SCREW BONE 26X5MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072690","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","823.17","617.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","645.78","78.45","","385.32","55.36","1815.62","58","411.59","645.78","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","AETNA [1001]","HB CH AETNA HMO / PPO","66.01","58.3","","554.95","91.85","1421.75","94","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","82.65","73","","2490.03","2490.03","2490.03","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.01","58.3","","750.00","750.00","750.00","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.01","53","","1192.50","120.84","4149.90","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.24","85","","750.00","75.00","750.00","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","113.22","100","","657.00","121.50","1971.00","14","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","113.22","100","","75.00","75.00","75.00","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","113.22","100","","366.00","144.00","1971.00","45","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","82.65","73","","667.50","667.50","667.50","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.33","44.45","","123.77","123.77","123.77","1 through 10","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","both","","","113.22","84.91","WELLPOINT [1015]","HB CH WELLPOINT","88.21","77.91","","483.51","229.32","1316.08","96","50.33","113.22","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.22","84.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.14","59.3","","439.50","225.34","1872.27","197","56.61","88.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING CRUCIFORM RECESS","SUP-ITM-10019167","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","113.22","84.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","88.82","78.45","","385.32","55.36","1815.62","58","56.61","88.82","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","AETNA [1001]","HB CH AETNA HMO / PPO","75.71","58.3","","554.95","91.85","1421.75","94","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","94.81","73","","2490.03","2490.03","2490.03","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","75.71","58.3","","750.00","750.00","750.00","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","68.83","53","","1192.50","120.84","4149.90","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","110.39","85","","750.00","75.00","750.00","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","129.87","100","","657.00","121.50","1971.00","14","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","129.87","100","","75.00","75.00","75.00","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","129.87","100","","366.00","144.00","1971.00","45","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","94.81","73","","667.50","667.50","667.50","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","57.73","44.45","","123.77","123.77","123.77","1 through 10","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","both","","","129.87","97.40","WELLPOINT [1015]","HB CH WELLPOINT","101.18","77.91","","483.51","229.32","1316.08","96","57.73","129.87","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.87","97.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","77.01","59.3","","439.50","225.34","1872.27","197","64.94","101.88","percent of total billed charges",""
"SCREW BONE 2X10MM CORTEX SS SELF TAPPING FULL THREAD T6 STARDRIVE RECESS","SUP-ITM-10022567","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","129.87","97.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","101.88","78.45","","385.32","55.36","1815.62","58","64.94","101.88","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"SCREW BONE 2X10MM SMALL JOINT SELF DRILL TAP QUICK FIX CLEAR","SUP-ITM-10072445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","AETNA [1001]","HB CH AETNA HMO / PPO","553.05","58.3","","554.95","91.85","1421.75","94","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","692.50","73","","2490.03","2490.03","2490.03","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","553.05","58.3","","750.00","750.00","750.00","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","502.77","53","","1192.50","120.84","4149.90","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","806.34","85","","750.00","75.00","750.00","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","948.63","100","","657.00","121.50","1971.00","14","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","948.63","100","","75.00","75.00","75.00","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","948.63","100","","366.00","144.00","1971.00","45","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","692.50","73","","667.50","667.50","667.50","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","421.67","44.45","","123.77","123.77","123.77","1 through 10","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","both","","","948.63","711.47","WELLPOINT [1015]","HB CH WELLPOINT","739.08","77.91","","483.51","229.32","1316.08","96","421.67","948.63","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","CIGNA [1006]","HB CH CIGNA HMO / PPO","562.54","59.3","","439.50","225.34","1872.27","197","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X11MM TWIST-OFF NON STERILE","SUP-ITM-10230358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","948.63","711.47","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","744.20","78.45","","385.32","55.36","1815.62","58","474.32","744.2","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","AETNA [1001]","HB CH AETNA HMO / PPO","121.21","58.3","","554.95","91.85","1421.75","94","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","151.77","73","","2490.03","2490.03","2490.03","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","121.21","58.3","","750.00","750.00","750.00","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","110.19","53","","1192.50","120.84","4149.90","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","176.72","85","","750.00","75.00","750.00","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","207.91","100","","657.00","121.50","1971.00","14","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","207.91","100","","75.00","75.00","75.00","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","207.91","100","","366.00","144.00","1971.00","45","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","151.77","73","","667.50","667.50","667.50","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.42","44.45","","123.77","123.77","123.77","1 through 10","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.91","155.93","WELLPOINT [1015]","HB CH WELLPOINT","161.98","77.91","","483.51","229.32","1316.08","96","92.42","207.91","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.91","155.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","123.29","59.3","","439.50","225.34","1872.27","197","103.96","163.11","percent of total billed charges",""
"SCREW BONE 2X12MM CORTICAL SS SELF DRILLING FULL THREAD PK/5EA","SUP-ITM-10020247","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.91","155.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","163.11","78.45","","385.32","55.36","1815.62","58","103.96","163.11","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","AETNA [1001]","HB CH AETNA HMO / PPO","549.01","58.3","","554.95","91.85","1421.75","94","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","2490.03","2490.03","2490.03","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","549.01","58.3","","750.00","750.00","750.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","499.10","53","","1192.50","120.84","4149.90","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","800.45","85","","750.00","75.00","750.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","941.70","100","","657.00","121.50","1971.00","14","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","941.70","100","","75.00","75.00","75.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","941.70","100","","366.00","144.00","1971.00","45","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","667.50","667.50","667.50","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.59","44.45","","123.77","123.77","123.77","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","WELLPOINT [1015]","HB CH WELLPOINT","733.68","77.91","","483.51","229.32","1316.08","96","418.59","941.7","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","558.43","59.3","","439.50","225.34","1872.27","197","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2X12MM QUICK INSERTION TI","SUP-ITM-10277014","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","738.76","78.45","","385.32","55.36","1815.62","58","470.85","738.76","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","AETNA [1001]","HB CH AETNA HMO / PPO","244.86","58.3","","554.95","91.85","1421.75","94","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","2490.03","2490.03","2490.03","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","244.86","58.3","","750.00","750.00","750.00","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.60","53","","1192.50","120.84","4149.90","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.00","85","","750.00","75.00","750.00","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.00","100","","657.00","121.50","1971.00","14","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.00","100","","75.00","75.00","75.00","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.00","100","","366.00","144.00","1971.00","45","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","667.50","667.50","667.50","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","123.77","123.77","123.77","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB CH WELLPOINT","327.22","77.91","","483.51","229.32","1316.08","96","186.69","420","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.06","59.3","","439.50","225.34","1872.27","197","210","329.49","percent of total billed charges",""
"SCREW BONE 2X12MM QUICKFIX CANNULATED TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10117450","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","385.32","55.36","1815.62","58","210","329.49","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","AETNA [1001]","HB CH AETNA HMO / PPO","166.31","58.3","","554.95","91.85","1421.75","94","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","208.25","73","","2490.03","2490.03","2490.03","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","166.31","58.3","","750.00","750.00","750.00","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","151.19","53","","1192.50","120.84","4149.90","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","242.48","85","","750.00","75.00","750.00","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","285.27","100","","657.00","121.50","1971.00","14","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","285.27","100","","75.00","75.00","75.00","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","285.27","100","","366.00","144.00","1971.00","45","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","208.25","73","","667.50","667.50","667.50","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","126.80","44.45","","123.77","123.77","123.77","1 through 10","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","both","","","285.27","213.95","WELLPOINT [1015]","HB CH WELLPOINT","222.25","77.91","","483.51","229.32","1316.08","96","126.8","285.27","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.27","213.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","169.17","59.3","","439.50","225.34","1872.27","197","142.64","223.79","percent of total billed charges",""
"SCREW BONE 2X13MM VARIABLE ANGLE LOCKING SELF TAPPING SS","SUP-ITM-10164601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","285.27","213.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","223.79","78.45","","385.32","55.36","1815.62","58","142.64","223.79","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","AETNA [1001]","HB CH AETNA HMO / PPO","72.48","58.3","","554.95","91.85","1421.75","94","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","90.75","73","","2490.03","2490.03","2490.03","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","72.48","58.3","","750.00","750.00","750.00","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","65.89","53","","1192.50","120.84","4149.90","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","105.67","85","","750.00","75.00","750.00","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","124.32","100","","657.00","121.50","1971.00","14","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","124.32","100","","75.00","75.00","75.00","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","124.32","100","","366.00","144.00","1971.00","45","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","90.75","73","","667.50","667.50","667.50","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.26","44.45","","123.77","123.77","123.77","1 through 10","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.32","93.24","WELLPOINT [1015]","HB CH WELLPOINT","96.86","77.91","","483.51","229.32","1316.08","96","55.26","124.32","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.32","93.24","CIGNA [1006]","HB CH CIGNA HMO / PPO","73.72","59.3","","439.50","225.34","1872.27","197","62.16","97.53","percent of total billed charges",""
"SCREW BONE 2X14MM CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10039721","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.32","93.24","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","97.53","78.45","","385.32","55.36","1815.62","58","62.16","97.53","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","AETNA [1001]","HB CH AETNA HMO / PPO","244.86","58.3","","554.95","91.85","1421.75","94","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","2490.03","2490.03","2490.03","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","244.86","58.3","","750.00","750.00","750.00","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.60","53","","1192.50","120.84","4149.90","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.00","85","","750.00","75.00","750.00","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.00","100","","657.00","121.50","1971.00","14","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.00","100","","75.00","75.00","75.00","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.00","100","","366.00","144.00","1971.00","45","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.60","73","","667.50","667.50","667.50","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.69","44.45","","123.77","123.77","123.77","1 through 10","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.00","315.00","WELLPOINT [1015]","HB CH WELLPOINT","327.22","77.91","","483.51","229.32","1316.08","96","186.69","420","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.06","59.3","","439.50","225.34","1872.27","197","210","329.49","percent of total billed charges",""
"SCREW BONE 2X26MM QUICKFIX CANNULATED TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153916","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.00","315.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.49","78.45","","385.32","55.36","1815.62","58","210","329.49","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","554.95","91.85","1421.75","94","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","2490.03","2490.03","2490.03","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","89.20","58.3","","750.00","750.00","750.00","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.09","53","","1192.50","120.84","4149.90","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","130.05","85","","750.00","75.00","750.00","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","153.00","100","","657.00","121.50","1971.00","14","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","153.00","100","","75.00","75.00","75.00","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","153.00","100","","366.00","144.00","1971.00","45","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","667.50","667.50","667.50","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","123.77","123.77","123.77","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","WELLPOINT [1015]","HB CH WELLPOINT","119.20","77.91","","483.51","229.32","1316.08","96","68.01","153","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","439.50","225.34","1872.27","197","76.5","120.03","percent of total billed charges",""
"SCREW BONE 2X28MM DEPUY TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10071999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","385.32","55.36","1815.62","58","76.5","120.03","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","AETNA [1001]","HB CH AETNA HMO / PPO","68.22","58.3","","554.95","91.85","1421.75","94","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","85.42","73","","2490.03","2490.03","2490.03","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","68.22","58.3","","750.00","750.00","750.00","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","62.02","53","","1192.50","120.84","4149.90","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","99.47","85","","750.00","75.00","750.00","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","117.02","100","","657.00","121.50","1971.00","14","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","117.02","100","","75.00","75.00","75.00","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","117.02","100","","366.00","144.00","1971.00","45","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","85.42","73","","667.50","667.50","667.50","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","52.02","44.45","","123.77","123.77","123.77","1 through 10","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","both","","","117.02","87.76","WELLPOINT [1015]","HB CH WELLPOINT","91.17","77.91","","483.51","229.32","1316.08","96","52.02","117.02","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.02","87.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.39","59.3","","439.50","225.34","1872.27","197","58.51","91.8","percent of total billed charges",""
"SCREW BONE 2X4MM PLUSDRIVE TITANIUM EMERGENCY SELF TAPPING RECESS PK/5EA","SUP-ITM-10075732","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","117.02","87.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","91.80","78.45","","385.32","55.36","1815.62","58","58.51","91.8","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","AETNA [1001]","HB CH AETNA HMO / PPO","122.43","58.3","","554.95","91.85","1421.75","94","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","153.30","73","","2490.03","2490.03","2490.03","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","122.43","58.3","","750.00","750.00","750.00","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","111.30","53","","1192.50","120.84","4149.90","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","178.50","85","","750.00","75.00","750.00","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","210.00","100","","657.00","121.50","1971.00","14","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","210.00","100","","75.00","75.00","75.00","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","210.00","100","","366.00","144.00","1971.00","45","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","153.30","73","","667.50","667.50","667.50","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.35","44.45","","123.77","123.77","123.77","1 through 10","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","both","","","210.00","157.50","WELLPOINT [1015]","HB CH WELLPOINT","163.61","77.91","","483.51","229.32","1316.08","96","93.35","210","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","124.53","59.3","","439.50","225.34","1872.27","197","105","164.75","percent of total billed charges",""
"SCREW BONE 2X6MM SPINE CORTICAL SELF DRILLING WITH STARDRIVE RECESS TITANIUM","SUP-ITM-10013613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","210.00","157.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","164.75","78.45","","385.32","55.36","1815.62","58","105","164.75","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","AETNA [1001]","HB CH AETNA HMO / PPO","139.13","58.3","","554.95","91.85","1421.75","94","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","174.21","73","","2490.03","2490.03","2490.03","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.13","58.3","","750.00","750.00","750.00","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.48","53","","1192.50","120.84","4149.90","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","202.85","85","","750.00","75.00","750.00","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","238.65","100","","657.00","121.50","1971.00","14","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","238.65","100","","75.00","75.00","75.00","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","238.65","100","","366.00","144.00","1971.00","45","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","174.21","73","","667.50","667.50","667.50","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.08","44.45","","123.77","123.77","123.77","1 through 10","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","both","","","238.65","178.99","WELLPOINT [1015]","HB CH WELLPOINT","185.93","77.91","","483.51","229.32","1316.08","96","106.08","238.65","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.65","178.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.52","59.3","","439.50","225.34","1872.27","197","119.33","187.22","percent of total billed charges",""
"SCREW BONE 2X8MM CORTEX SS LOCKING SELF TAPPING STARDRIVE RECESS","SUP-ITM-10022568","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","238.65","178.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","187.22","78.45","","385.32","55.36","1815.62","58","119.33","187.22","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","AETNA [1001]","HB CH AETNA HMO / PPO","58.24","58.3","","554.95","91.85","1421.75","94","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","72.93","73","","2490.03","2490.03","2490.03","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","58.24","58.3","","750.00","750.00","750.00","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","52.95","53","","1192.50","120.84","4149.90","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","84.92","85","","750.00","75.00","750.00","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","99.90","100","","657.00","121.50","1971.00","14","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","99.90","100","","75.00","75.00","75.00","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","99.90","100","","366.00","144.00","1971.00","45","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","72.93","73","","667.50","667.50","667.50","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.41","44.45","","123.77","123.77","123.77","1 through 10","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","both","","","99.90","74.92","WELLPOINT [1015]","HB CH WELLPOINT","77.83","77.91","","483.51","229.32","1316.08","96","44.41","99.9","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.90","74.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.24","59.3","","439.50","225.34","1872.27","197","49.95","78.37","percent of total billed charges",""
"SCREW BONE 2X8MM HAND CORTEX TITANIUM SELF TAPPING CRUCIFORM STARDRIVE RECESS","SUP-ITM-10002235","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","99.90","74.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","78.37","78.45","","385.32","55.36","1815.62","58","49.95","78.37","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","AETNA [1001]","HB CH AETNA HMO / PPO","304.33","58.3","","554.95","91.85","1421.75","94","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","381.06","73","","2490.03","2490.03","2490.03","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","304.33","58.3","","750.00","750.00","750.00","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.66","53","","1192.50","120.84","4149.90","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","443.70","85","","750.00","75.00","750.00","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","522.00","100","","657.00","121.50","1971.00","14","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","522.00","100","","75.00","75.00","75.00","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","522.00","100","","366.00","144.00","1971.00","45","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","381.06","73","","667.50","667.50","667.50","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.03","44.45","","123.77","123.77","123.77","1 through 10","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","both","","","522.00","391.50","WELLPOINT [1015]","HB CH WELLPOINT","406.69","77.91","","483.51","229.32","1316.08","96","232.03","522","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","309.55","59.3","","439.50","225.34","1872.27","197","261","409.51","percent of total billed charges",""
"SCREW BONE 2X9MM CORTICAL APTUS TI HEXADRIVE 6","SUP-ITM-10028198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","409.51","78.45","","385.32","55.36","1815.62","58","261","409.51","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","AETNA [1001]","HB CH AETNA HMO / PPO","629.64","58.3","","554.95","91.85","1421.75","94","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","788.40","73","","2490.03","2490.03","2490.03","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","629.64","58.3","","750.00","750.00","750.00","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","572.40","53","","1192.50","120.84","4149.90","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","918.00","85","","750.00","75.00","750.00","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1080.00","100","","657.00","121.50","1971.00","14","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1080.00","100","","75.00","75.00","75.00","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1080.00","100","","366.00","144.00","1971.00","45","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","788.40","73","","667.50","667.50","667.50","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","480.06","44.45","","123.77","123.77","123.77","1 through 10","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","both","","","1080.00","810.00","WELLPOINT [1015]","HB CH WELLPOINT","841.43","77.91","","483.51","229.32","1316.08","96","480.06","1080","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","640.44","59.3","","439.50","225.34","1872.27","197","540","847.26","percent of total billed charges",""
"SCREW BONE 3 4MM COUNTERSINK CANNULATED TI","SUP-ITM-10019547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1080.00","810.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","847.26","78.45","","385.32","55.36","1815.62","58","540","847.26","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","AETNA [1001]","HB CH AETNA HMO / PPO","274.59","58.3","","554.95","91.85","1421.75","94","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","343.83","73","","2490.03","2490.03","2490.03","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","274.59","58.3","","750.00","750.00","750.00","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","249.63","53","","1192.50","120.84","4149.90","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","400.35","85","","750.00","75.00","750.00","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","471.00","100","","657.00","121.50","1971.00","14","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","471.00","100","","75.00","75.00","75.00","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","471.00","100","","366.00","144.00","1971.00","45","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","343.83","73","","667.50","667.50","667.50","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","209.36","44.45","","123.77","123.77","123.77","1 through 10","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","both","","","471.00","353.25","WELLPOINT [1015]","HB CH WELLPOINT","366.96","77.91","","483.51","229.32","1316.08","96","209.36","471","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.00","353.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","279.30","59.3","","439.50","225.34","1872.27","197","235.5","369.5","percent of total billed charges",""
"SCREW BONE 3.0X14MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED MAGENTA","SUP-ITM-10057150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","471.00","353.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","369.50","78.45","","385.32","55.36","1815.62","58","235.5","369.5","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","AETNA [1001]","HB CH AETNA HMO / PPO","489.72","58.3","","554.95","91.85","1421.75","94","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","2490.03","2490.03","2490.03","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","489.72","58.3","","750.00","750.00","750.00","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","445.20","53","","1192.50","120.84","4149.90","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","714.00","85","","750.00","75.00","750.00","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","840.00","100","","657.00","121.50","1971.00","14","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","840.00","100","","75.00","75.00","75.00","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","840.00","100","","366.00","144.00","1971.00","45","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","613.20","73","","667.50","667.50","667.50","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","373.38","44.45","","123.77","123.77","123.77","1 through 10","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","both","","","840.00","630.00","WELLPOINT [1015]","HB CH WELLPOINT","654.44","77.91","","483.51","229.32","1316.08","96","373.38","840","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","498.12","59.3","","439.50","225.34","1872.27","197","420","658.98","percent of total billed charges",""
"SCREW BONE 3.0X26MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10198158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","840.00","630.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","658.98","78.45","","385.32","55.36","1815.62","58","420","658.98","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","AETNA [1001]","HB CH AETNA HMO / PPO","265.85","58.3","","554.95","91.85","1421.75","94","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","332.88","73","","2490.03","2490.03","2490.03","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","265.85","58.3","","750.00","750.00","750.00","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","241.68","53","","1192.50","120.84","4149.90","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","387.60","85","","750.00","75.00","750.00","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","456.00","100","","657.00","121.50","1971.00","14","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","456.00","100","","75.00","75.00","75.00","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","456.00","100","","366.00","144.00","1971.00","45","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","332.88","73","","667.50","667.50","667.50","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.69","44.45","","123.77","123.77","123.77","1 through 10","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","both","","","456.00","342.00","WELLPOINT [1015]","HB CH WELLPOINT","355.27","77.91","","483.51","229.32","1316.08","96","202.69","456","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","270.41","59.3","","439.50","225.34","1872.27","197","228","357.73","percent of total billed charges",""
"SCREW BONE 3.5MM 22 COMPRESSION DARCO TITANIUM ALLOY CANNULATED SELF DRILLING TAPPING COUNTERSINK HEX THREAD BX/5EA","SUP-ITM-10026174","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","456.00","342.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","357.73","78.45","","385.32","55.36","1815.62","58","228","357.73","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","554.95","91.85","1421.75","94","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","2490.03","2490.03","2490.03","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","750.00","750.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","1192.50","120.84","4149.90","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","227.59","85","","750.00","75.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","267.75","100","","657.00","121.50","1971.00","14","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","267.75","100","","75.00","75.00","75.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","267.75","100","","366.00","144.00","1971.00","45","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","667.50","667.50","667.50","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","123.77","123.77","123.77","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","483.51","229.32","1316.08","96","119.01","267.75","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","439.50","225.34","1872.27","197","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM 35X6.5 CENTRAL COMPREHENSIVE REVERSE SHOULDER TITANIUM HEX","SUP-ITM-10146778","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","385.32","55.36","1815.62","58","133.88","210.05","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","AETNA [1001]","HB CH AETNA HMO / PPO","270.06","58.3","","554.95","91.85","1421.75","94","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","338.16","73","","2490.03","2490.03","2490.03","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","270.06","58.3","","750.00","750.00","750.00","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.51","53","","1192.50","120.84","4149.90","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","393.75","85","","750.00","75.00","750.00","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","463.23","100","","657.00","121.50","1971.00","14","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","463.23","100","","75.00","75.00","75.00","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","463.23","100","","366.00","144.00","1971.00","45","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.16","73","","667.50","667.50","667.50","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.91","44.45","","123.77","123.77","123.77","1 through 10","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.23","347.42","WELLPOINT [1015]","HB CH WELLPOINT","360.90","77.91","","483.51","229.32","1316.08","96","205.91","463.23","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.23","347.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.70","59.3","","439.50","225.34","1872.27","197","231.62","363.4","percent of total billed charges",""
"SCREW BONE 3.5MM SURFIX TITANIUM LOCKING","SUP-ITM-10075193","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.23","347.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","363.40","78.45","","385.32","55.36","1815.62","58","231.62","363.4","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","AETNA [1001]","HB CH AETNA HMO / PPO","225.62","58.3","","554.95","91.85","1421.75","94","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","282.51","73","","2490.03","2490.03","2490.03","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","225.62","58.3","","750.00","750.00","750.00","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","205.11","53","","1192.50","120.84","4149.90","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","328.95","85","","750.00","75.00","750.00","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","387.00","100","","657.00","121.50","1971.00","14","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","387.00","100","","75.00","75.00","75.00","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","387.00","100","","366.00","144.00","1971.00","45","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","282.51","73","","667.50","667.50","667.50","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.02","44.45","","123.77","123.77","123.77","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","WELLPOINT [1015]","HB CH WELLPOINT","301.51","77.91","","483.51","229.32","1316.08","96","172.02","387","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","229.49","59.3","","439.50","225.34","1872.27","197","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3.5MM TAP SURGICAL LOCKING FOREFOOT PLATING SYSTEM CORTICAL HARD","SUP-ITM-10088539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","385.32","55.36","1815.62","58","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","554.95","91.85","1421.75","94","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","2490.03","2490.03","2490.03","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","89.20","58.3","","750.00","750.00","750.00","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.09","53","","1192.50","120.84","4149.90","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","130.05","85","","750.00","75.00","750.00","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","153.00","100","","657.00","121.50","1971.00","14","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","153.00","100","","75.00","75.00","75.00","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","153.00","100","","366.00","144.00","1971.00","45","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","667.50","667.50","667.50","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","123.77","123.77","123.77","1 through 10","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","WELLPOINT [1015]","HB CH WELLPOINT","119.20","77.91","","483.51","229.32","1316.08","96","68.01","153","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","439.50","225.34","1872.27","197","76.5","120.03","percent of total billed charges",""
"SCREW BONE 3.5X100MM TITANIUM CORTICAL SELF TAPPING FULL THREAD","SUP-ITM-10072046","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","385.32","55.36","1815.62","58","76.5","120.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","AETNA [1001]","HB CH AETNA HMO / PPO","209.32","58.3","","554.95","91.85","1421.75","94","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","2490.03","2490.03","2490.03","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.32","58.3","","750.00","750.00","750.00","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.29","53","","1192.50","120.84","4149.90","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","305.18","85","","750.00","75.00","750.00","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","359.04","100","","657.00","121.50","1971.00","14","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","359.04","100","","75.00","75.00","75.00","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","359.04","100","","366.00","144.00","1971.00","45","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","667.50","667.50","667.50","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","123.77","123.77","123.77","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","WELLPOINT [1015]","HB CH WELLPOINT","279.73","77.91","","483.51","229.32","1316.08","96","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.91","59.3","","439.50","225.34","1872.27","197","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X10MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","385.32","55.36","1815.62","58","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","AETNA [1001]","HB CH AETNA HMO / PPO","41.42","58.3","","554.95","91.85","1421.75","94","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","51.86","73","","2490.03","2490.03","2490.03","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","41.42","58.3","","750.00","750.00","750.00","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","37.65","53","","1192.50","120.84","4149.90","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","60.38","85","","750.00","75.00","750.00","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","71.04","100","","657.00","121.50","1971.00","14","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","71.04","100","","75.00","75.00","75.00","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","71.04","100","","366.00","144.00","1971.00","45","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","51.86","73","","667.50","667.50","667.50","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","31.58","44.45","","123.77","123.77","123.77","1 through 10","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","both","","","71.04","53.28","WELLPOINT [1015]","HB CH WELLPOINT","55.35","77.91","","483.51","229.32","1316.08","96","31.58","71.04","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.04","53.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.13","59.3","","439.50","225.34","1872.27","197","35.52","55.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006718","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","71.04","53.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","55.73","78.45","","385.32","55.36","1815.62","58","35.52","55.73","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","AETNA [1001]","HB CH AETNA HMO / PPO","202.04","58.3","","554.95","91.85","1421.75","94","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","252.99","73","","2490.03","2490.03","2490.03","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","202.04","58.3","","750.00","750.00","750.00","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","183.68","53","","1192.50","120.84","4149.90","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","294.58","85","","750.00","75.00","750.00","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","346.56","100","","657.00","121.50","1971.00","14","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","346.56","100","","75.00","75.00","75.00","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","346.56","100","","366.00","144.00","1971.00","45","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","252.99","73","","667.50","667.50","667.50","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","154.05","44.45","","123.77","123.77","123.77","1 through 10","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","both","","","346.56","259.92","WELLPOINT [1015]","HB CH WELLPOINT","270.00","77.91","","483.51","229.32","1316.08","96","154.05","346.56","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.56","259.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","205.51","59.3","","439.50","225.34","1872.27","197","173.28","271.88","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTEX SS CANNULATED PARTIAL THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10019192","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","346.56","259.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","271.88","78.45","","385.32","55.36","1815.62","58","173.28","271.88","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.84","58.3","","554.95","91.85","1421.75","94","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","2490.03","2490.03","2490.03","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.84","58.3","","750.00","750.00","750.00","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.58","53","","1192.50","120.84","4149.90","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","68.29","85","","750.00","75.00","750.00","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","80.34","100","","657.00","121.50","1971.00","14","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","80.34","100","","75.00","75.00","75.00","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","80.34","100","","366.00","144.00","1971.00","45","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","667.50","667.50","667.50","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","123.77","123.77","123.77","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","WELLPOINT [1015]","HB CH WELLPOINT","62.59","77.91","","483.51","229.32","1316.08","96","35.71","80.34","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.64","59.3","","439.50","225.34","1872.27","197","40.17","63.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM CORTICAL A.L.P.S. TITANIUM NONLOCKING","SUP-ITM-10020945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","385.32","55.36","1815.62","58","40.17","63.03","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","AETNA [1001]","HB CH AETNA HMO / PPO","203.57","58.3","","554.95","91.85","1421.75","94","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","254.89","73","","2490.03","2490.03","2490.03","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","203.57","58.3","","750.00","750.00","750.00","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","185.06","53","","1192.50","120.84","4149.90","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","296.79","85","","750.00","75.00","750.00","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","349.17","100","","657.00","121.50","1971.00","14","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","349.17","100","","75.00","75.00","75.00","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","349.17","100","","366.00","144.00","1971.00","45","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","254.89","73","","667.50","667.50","667.50","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.21","44.45","","123.77","123.77","123.77","1 through 10","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","both","","","349.17","261.88","WELLPOINT [1015]","HB CH WELLPOINT","272.04","77.91","","483.51","229.32","1316.08","96","155.21","349.17","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.17","261.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","207.06","59.3","","439.50","225.34","1872.27","197","174.59","273.92","percent of total billed charges",""
"SCREW BONE 3.5X10MM LOCKING SQUARE","SUP-ITM-10230388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","349.17","261.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","273.92","78.45","","385.32","55.36","1815.62","58","174.59","273.92","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","AETNA [1001]","HB CH AETNA HMO / PPO","126.82","58.3","","554.95","91.85","1421.75","94","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","158.80","73","","2490.03","2490.03","2490.03","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","126.82","58.3","","750.00","750.00","750.00","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","115.29","53","","1192.50","120.84","4149.90","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","184.90","85","","750.00","75.00","750.00","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","217.53","100","","657.00","121.50","1971.00","14","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","217.53","100","","75.00","75.00","75.00","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","217.53","100","","366.00","144.00","1971.00","45","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","158.80","73","","667.50","667.50","667.50","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.69","44.45","","123.77","123.77","123.77","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","WELLPOINT [1015]","HB CH WELLPOINT","169.48","77.91","","483.51","229.32","1316.08","96","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.00","59.3","","439.50","225.34","1872.27","197","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X10MM TITANIUM CORTICAL SELF TAPPING LOW PROFILE","SUP-ITM-10071463","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","170.65","78.45","","385.32","55.36","1815.62","58","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","AETNA [1001]","HB CH AETNA HMO / PPO","101.11","58.3","","554.95","91.85","1421.75","94","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","126.60","73","","2490.03","2490.03","2490.03","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","101.11","58.3","","750.00","750.00","750.00","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.92","53","","1192.50","120.84","4149.90","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","147.42","85","","750.00","75.00","750.00","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","173.43","100","","657.00","121.50","1971.00","14","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","173.43","100","","75.00","75.00","75.00","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","173.43","100","","366.00","144.00","1971.00","45","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.60","73","","667.50","667.50","667.50","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.09","44.45","","123.77","123.77","123.77","1 through 10","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","WELLPOINT [1015]","HB CH WELLPOINT","135.12","77.91","","483.51","229.32","1316.08","96","77.09","173.43","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.84","59.3","","439.50","225.34","1872.27","197","86.72","136.06","percent of total billed charges",""
"SCREW BONE 3.5X110MM TITANIUM CORTICAL","SUP-ITM-10185882","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.06","78.45","","385.32","55.36","1815.62","58","86.72","136.06","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","AETNA [1001]","HB CH AETNA HMO / PPO","126.82","58.3","","554.95","91.85","1421.75","94","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","158.80","73","","2490.03","2490.03","2490.03","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","126.82","58.3","","750.00","750.00","750.00","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","115.29","53","","1192.50","120.84","4149.90","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","184.90","85","","750.00","75.00","750.00","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","217.53","100","","657.00","121.50","1971.00","14","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","217.53","100","","75.00","75.00","75.00","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","217.53","100","","366.00","144.00","1971.00","45","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","158.80","73","","667.50","667.50","667.50","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","96.69","44.45","","123.77","123.77","123.77","1 through 10","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","both","","","217.53","163.15","WELLPOINT [1015]","HB CH WELLPOINT","169.48","77.91","","483.51","229.32","1316.08","96","96.69","217.53","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","129.00","59.3","","439.50","225.34","1872.27","197","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X12MM A.L.P.S. TITANIUM CORTICAL DISTAL LOW PROFILE SELF TAPPING NONLOCKING FULL THREAD SQUARE SOCKET","SUP-ITM-10071464","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","217.53","163.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","170.65","78.45","","385.32","55.36","1815.62","58","108.77","170.65","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","AETNA [1001]","HB CH AETNA HMO / PPO","30.10","58.3","","554.95","91.85","1421.75","94","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","37.69","73","","2490.03","2490.03","2490.03","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","30.10","58.3","","750.00","750.00","750.00","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","27.36","53","","1192.50","120.84","4149.90","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","43.89","85","","750.00","75.00","750.00","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","51.63","100","","657.00","121.50","1971.00","14","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","51.63","100","","75.00","75.00","75.00","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","51.63","100","","366.00","144.00","1971.00","45","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","37.69","73","","667.50","667.50","667.50","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","22.95","44.45","","123.77","123.77","123.77","1 through 10","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.63","38.72","WELLPOINT [1015]","HB CH WELLPOINT","40.22","77.91","","483.51","229.32","1316.08","96","22.95","51.63","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.63","38.72","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.62","59.3","","439.50","225.34","1872.27","197","25.82","40.5","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX SELF TAPPING FULLY THREADED HEX HEAD SS","SUP-ITM-10006719","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.63","38.72","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","40.50","78.45","","385.32","55.36","1815.62","58","25.82","40.5","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","AETNA [1001]","HB CH AETNA HMO / PPO","42.06","58.3","","554.95","91.85","1421.75","94","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","52.67","73","","2490.03","2490.03","2490.03","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","42.06","58.3","","750.00","750.00","750.00","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","38.24","53","","1192.50","120.84","4149.90","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","61.33","85","","750.00","75.00","750.00","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","72.15","100","","657.00","121.50","1971.00","14","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","72.15","100","","75.00","75.00","75.00","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","72.15","100","","366.00","144.00","1971.00","45","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","52.67","73","","667.50","667.50","667.50","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.07","44.45","","123.77","123.77","123.77","1 through 10","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","both","","","72.15","54.11","WELLPOINT [1015]","HB CH WELLPOINT","56.21","77.91","","483.51","229.32","1316.08","96","32.07","72.15","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.15","54.11","CIGNA [1006]","HB CH CIGNA HMO / PPO","42.78","59.3","","439.50","225.34","1872.27","197","36.08","56.6","percent of total billed charges",""
"SCREW BONE 3.5X12MM CORTEX STAINLESS STEEL SELF-TAPPING T15 STARDRIVE RECESS","SUP-ITM-10037545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","72.15","54.11","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","56.60","78.45","","385.32","55.36","1815.62","58","36.08","56.6","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","554.95","91.85","1421.75","94","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","151.11","73","","2490.03","2490.03","2490.03","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","120.68","58.3","","750.00","750.00","750.00","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","109.71","53","","1192.50","120.84","4149.90","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","175.95","85","","750.00","75.00","750.00","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","207.00","100","","657.00","121.50","1971.00","14","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","207.00","100","","75.00","75.00","75.00","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","207.00","100","","366.00","144.00","1971.00","45","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","151.11","73","","667.50","667.50","667.50","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","92.01","44.45","","123.77","123.77","123.77","1 through 10","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","both","","","207.00","155.25","WELLPOINT [1015]","HB CH WELLPOINT","161.27","77.91","","483.51","229.32","1316.08","96","92.01","207","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","122.75","59.3","","439.50","225.34","1872.27","197","103.5","162.39","percent of total billed charges",""
"SCREW BONE 3.5X14MM RAYHACK CORTICAL LOCKING SS","SUP-ITM-10051724","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","385.32","55.36","1815.62","58","103.5","162.39","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","554.95","91.85","1421.75","94","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2490.03","2490.03","2490.03","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","750.00","750.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","1192.50","120.84","4149.90","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","750.00","75.00","750.00","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","657.00","121.50","1971.00","14","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","75.00","75.00","75.00","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","366.00","144.00","1971.00","45","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","667.50","667.50","667.50","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","123.77","123.77","123.77","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","483.51","229.32","1316.08","96","666.75","1500","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","439.50","225.34","1872.27","197","750","1176.75","percent of total billed charges",""
"SCREW BONE 3.5X14MM SPINE VUEPOINT II MULTIAXIAL PARTIAL THREAD","SUP-ITM-10187230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","385.32","55.36","1815.62","58","750","1176.75","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","AETNA [1001]","HB CH AETNA HMO / PPO","291.84","58.3","","554.95","91.85","1421.75","94","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","365.42","73","","2490.03","2490.03","2490.03","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","291.84","58.3","","750.00","750.00","750.00","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.31","53","","1192.50","120.84","4149.90","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","425.49","85","","750.00","75.00","750.00","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","500.58","100","","657.00","121.50","1971.00","14","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","500.58","100","","75.00","75.00","75.00","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","500.58","100","","366.00","144.00","1971.00","45","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","365.42","73","","667.50","667.50","667.50","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.51","44.45","","123.77","123.77","123.77","1 through 10","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","both","","","500.58","375.43","WELLPOINT [1015]","HB CH WELLPOINT","390.00","77.91","","483.51","229.32","1316.08","96","222.51","500.58","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.58","375.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","296.84","59.3","","439.50","225.34","1872.27","197","250.29","392.71","percent of total billed charges",""
"SCREW BONE 3.5X16MM CHROME MULTIDIRECTIONAL LOCKING SELF TAPPING COBALT","SUP-ITM-10072338","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","500.58","375.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","392.71","78.45","","385.32","55.36","1815.62","58","250.29","392.71","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","AETNA [1001]","HB CH AETNA HMO / PPO","98.87","58.3","","554.95","91.85","1421.75","94","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","123.80","73","","2490.03","2490.03","2490.03","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","98.87","58.3","","750.00","750.00","750.00","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.88","53","","1192.50","120.84","4149.90","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","144.15","85","","750.00","75.00","750.00","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","169.59","100","","657.00","121.50","1971.00","14","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","169.59","100","","75.00","75.00","75.00","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","169.59","100","","366.00","144.00","1971.00","45","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","123.80","73","","667.50","667.50","667.50","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.38","44.45","","123.77","123.77","123.77","1 through 10","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","both","","","169.59","127.19","WELLPOINT [1015]","HB CH WELLPOINT","132.13","77.91","","483.51","229.32","1316.08","96","75.38","169.59","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.59","127.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.57","59.3","","439.50","225.34","1872.27","197","84.8","133.04","percent of total billed charges",""
"SCREW BONE 3.5X16MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090985","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","169.59","127.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.04","78.45","","385.32","55.36","1815.62","58","84.8","133.04","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","AETNA [1001]","HB CH AETNA HMO / PPO","95.48","58.3","","554.95","91.85","1421.75","94","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","119.55","73","","2490.03","2490.03","2490.03","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","95.48","58.3","","750.00","750.00","750.00","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","86.80","53","","1192.50","120.84","4149.90","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","139.20","85","","750.00","75.00","750.00","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","163.77","100","","657.00","121.50","1971.00","14","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","163.77","100","","75.00","75.00","75.00","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","163.77","100","","366.00","144.00","1971.00","45","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","119.55","73","","667.50","667.50","667.50","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.80","44.45","","123.77","123.77","123.77","1 through 10","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","both","","","163.77","122.83","WELLPOINT [1015]","HB CH WELLPOINT","127.59","77.91","","483.51","229.32","1316.08","96","72.8","163.77","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","97.12","59.3","","439.50","225.34","1872.27","197","81.89","128.48","percent of total billed charges",""
"SCREW BONE 3.5X18MM CORTICAL A.L.P.S. TITANIUM NONLOCKING SELF TAPPING LOW PROFILE FULL THREAD DISTAL","SUP-ITM-10071467","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","163.77","122.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","128.48","78.45","","385.32","55.36","1815.62","58","81.89","128.48","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","AETNA [1001]","HB CH AETNA HMO / PPO","481.22","58.3","","554.95","91.85","1421.75","94","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","602.56","73","","2490.03","2490.03","2490.03","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","481.22","58.3","","750.00","750.00","750.00","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","437.47","53","","1192.50","120.84","4149.90","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","701.61","85","","750.00","75.00","750.00","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","825.42","100","","657.00","121.50","1971.00","14","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","825.42","100","","75.00","75.00","75.00","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","825.42","100","","366.00","144.00","1971.00","45","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","602.56","73","","667.50","667.50","667.50","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","366.90","44.45","","123.77","123.77","123.77","1 through 10","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","both","","","825.42","619.06","WELLPOINT [1015]","HB CH WELLPOINT","643.08","77.91","","483.51","229.32","1316.08","96","366.9","825.42","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.42","619.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.47","59.3","","439.50","225.34","1872.27","197","412.71","647.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING","SUP-ITM-10082695","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","825.42","619.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","647.54","78.45","","385.32","55.36","1815.62","58","412.71","647.54","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","AETNA [1001]","HB CH AETNA HMO / PPO","494.34","58.3","","554.95","91.85","1421.75","94","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","618.98","73","","2490.03","2490.03","2490.03","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","494.34","58.3","","750.00","750.00","750.00","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","449.40","53","","1192.50","120.84","4149.90","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","720.73","85","","750.00","75.00","750.00","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","847.92","100","","657.00","121.50","1971.00","14","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","847.92","100","","75.00","75.00","75.00","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","847.92","100","","366.00","144.00","1971.00","45","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","618.98","73","","667.50","667.50","667.50","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.90","44.45","","123.77","123.77","123.77","1 through 10","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.92","635.94","WELLPOINT [1015]","HB CH WELLPOINT","660.61","77.91","","483.51","229.32","1316.08","96","376.9","847.92","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.92","635.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","502.82","59.3","","439.50","225.34","1872.27","197","423.96","665.19","percent of total billed charges",""
"SCREW BONE 3.5X18MM VARIAX TITANIUM LOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10090984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.92","635.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","665.19","78.45","","385.32","55.36","1815.62","58","423.96","665.19","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","554.95","91.85","1421.75","94","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","2490.03","2490.03","2490.03","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","750.00","750.00","750.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","1192.50","120.84","4149.90","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","750.77","85","","750.00","75.00","750.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","883.26","100","","657.00","121.50","1971.00","14","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","883.26","100","","75.00","75.00","75.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","883.26","100","","366.00","144.00","1971.00","45","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","667.50","667.50","667.50","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","123.77","123.77","123.77","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","483.51","229.32","1316.08","96","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","439.50","225.34","1872.27","197","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10152749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","385.32","55.36","1815.62","58","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","AETNA [1001]","HB CH AETNA HMO / PPO","279.00","58.3","","554.95","91.85","1421.75","94","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","2490.03","2490.03","2490.03","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","279.00","58.3","","750.00","750.00","750.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","253.64","53","","1192.50","120.84","4149.90","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","406.78","85","","750.00","75.00","750.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","478.56","100","","657.00","121.50","1971.00","14","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","478.56","100","","75.00","75.00","75.00","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","478.56","100","","366.00","144.00","1971.00","45","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","349.35","73","","667.50","667.50","667.50","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","212.72","44.45","","123.77","123.77","123.77","1 through 10","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","both","","","478.56","358.92","WELLPOINT [1015]","HB CH WELLPOINT","372.85","77.91","","483.51","229.32","1316.08","96","212.72","478.56","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","283.79","59.3","","439.50","225.34","1872.27","197","239.28","375.43","percent of total billed charges",""
"SCREW BONE 3.5X20MM VARIAX 2 T10 NON LOCKING FULLY THREADED SMALL","SUP-ITM-10166611","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","478.56","358.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","375.43","78.45","","385.32","55.36","1815.62","58","239.28","375.43","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","AETNA [1001]","HB CH AETNA HMO / PPO","549.01","58.3","","554.95","91.85","1421.75","94","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","2490.03","2490.03","2490.03","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","549.01","58.3","","750.00","750.00","750.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","499.10","53","","1192.50","120.84","4149.90","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","800.45","85","","750.00","75.00","750.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","941.70","100","","657.00","121.50","1971.00","14","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","941.70","100","","75.00","75.00","75.00","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","941.70","100","","366.00","144.00","1971.00","45","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","687.44","73","","667.50","667.50","667.50","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","418.59","44.45","","123.77","123.77","123.77","1 through 10","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","both","","","941.70","706.27","WELLPOINT [1015]","HB CH WELLPOINT","733.68","77.91","","483.51","229.32","1316.08","96","418.59","941.7","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","558.43","59.3","","439.50","225.34","1872.27","197","470.85","738.76","percent of total billed charges",""
"SCREW BONE 3.5X22MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10277478","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","941.70","706.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","738.76","78.45","","385.32","55.36","1815.62","58","470.85","738.76","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","AETNA [1001]","HB CH AETNA HMO / PPO","170.20","58.3","","554.95","91.85","1421.75","94","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","213.11","73","","2490.03","2490.03","2490.03","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","170.20","58.3","","750.00","750.00","750.00","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.72","53","","1192.50","120.84","4149.90","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","248.14","85","","750.00","75.00","750.00","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","291.93","100","","657.00","121.50","1971.00","14","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","291.93","100","","75.00","75.00","75.00","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","291.93","100","","366.00","144.00","1971.00","45","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","213.11","73","","667.50","667.50","667.50","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.76","44.45","","123.77","123.77","123.77","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","WELLPOINT [1015]","HB CH WELLPOINT","227.44","77.91","","483.51","229.32","1316.08","96","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.11","59.3","","439.50","225.34","1872.27","197","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X24MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10007730","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.02","78.45","","385.32","55.36","1815.62","58","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","AETNA [1001]","HB CH AETNA HMO / PPO","606.83","58.3","","554.95","91.85","1421.75","94","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","759.84","73","","2490.03","2490.03","2490.03","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","606.83","58.3","","750.00","750.00","750.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","551.67","53","","1192.50","120.84","4149.90","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","884.75","85","","750.00","75.00","750.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1040.88","100","","657.00","121.50","1971.00","14","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1040.88","100","","75.00","75.00","75.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1040.88","100","","366.00","144.00","1971.00","45","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","759.84","73","","667.50","667.50","667.50","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","462.67","44.45","","123.77","123.77","123.77","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","WELLPOINT [1015]","HB CH WELLPOINT","810.95","77.91","","483.51","229.32","1316.08","96","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1040.88","780.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","617.24","59.3","","439.50","225.34","1872.27","197","520.44","816.57","percent of total billed charges",""
"SCREW BONE 3.5X24MM SURFIX SS LOCKING","SUP-ITM-10082312","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1040.88","780.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","816.57","78.45","","385.32","55.36","1815.62","58","520.44","816.57","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","AETNA [1001]","HB CH AETNA HMO / PPO","249.04","58.3","","554.95","91.85","1421.75","94","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","311.83","73","","2490.03","2490.03","2490.03","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","249.04","58.3","","750.00","750.00","750.00","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","226.40","53","","1192.50","120.84","4149.90","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","363.09","85","","750.00","75.00","750.00","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","427.17","100","","657.00","121.50","1971.00","14","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","427.17","100","","75.00","75.00","75.00","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","427.17","100","","366.00","144.00","1971.00","45","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","311.83","73","","667.50","667.50","667.50","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","189.88","44.45","","123.77","123.77","123.77","1 through 10","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","both","","","427.17","320.38","WELLPOINT [1015]","HB CH WELLPOINT","332.81","77.91","","483.51","229.32","1316.08","96","189.88","427.17","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.17","320.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","253.31","59.3","","439.50","225.34","1872.27","197","213.59","335.11","percent of total billed charges",""
"SCREW BONE 3.5X24MM VARIAX TITANIUM SELF TAPPING","SUP-ITM-10094586","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","427.17","320.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","335.11","78.45","","385.32","55.36","1815.62","58","213.59","335.11","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","AETNA [1001]","HB CH AETNA HMO / PPO","45.30","58.3","","554.95","91.85","1421.75","94","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","56.72","73","","2490.03","2490.03","2490.03","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.30","58.3","","750.00","750.00","750.00","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.18","53","","1192.50","120.84","4149.90","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","66.05","85","","750.00","75.00","750.00","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","77.70","100","","657.00","121.50","1971.00","14","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","77.70","100","","75.00","75.00","75.00","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","77.70","100","","366.00","144.00","1971.00","45","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.72","73","","667.50","667.50","667.50","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.54","44.45","","123.77","123.77","123.77","1 through 10","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","both","","","77.70","58.27","WELLPOINT [1015]","HB CH WELLPOINT","60.54","77.91","","483.51","229.32","1316.08","96","34.54","77.7","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.70","58.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.08","59.3","","439.50","225.34","1872.27","197","38.85","60.96","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTEX TITANIUM SELF TAPPING FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10019226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","77.70","58.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","60.96","78.45","","385.32","55.36","1815.62","58","38.85","60.96","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","AETNA [1001]","HB CH AETNA HMO / PPO","104.66","58.3","","554.95","91.85","1421.75","94","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.05","73","","2490.03","2490.03","2490.03","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.66","58.3","","750.00","750.00","750.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.15","53","","1192.50","120.84","4149.90","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","152.59","85","","750.00","75.00","750.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","179.52","100","","657.00","121.50","1971.00","14","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","179.52","100","","75.00","75.00","75.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","179.52","100","","366.00","144.00","1971.00","45","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.05","73","","667.50","667.50","667.50","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.80","44.45","","123.77","123.77","123.77","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","WELLPOINT [1015]","HB CH WELLPOINT","139.86","77.91","","483.51","229.32","1316.08","96","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.52","134.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.46","59.3","","439.50","225.34","1872.27","197","89.76","140.83","percent of total billed charges",""
"SCREW BONE 3.5X26MM CORTICAL 110017726","SUP-ITM-10174753","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.52","134.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.83","78.45","","385.32","55.36","1815.62","58","89.76","140.83","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","554.95","91.85","1421.75","94","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","2490.03","2490.03","2490.03","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","750.00","750.00","750.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","1192.50","120.84","4149.90","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","750.77","85","","750.00","75.00","750.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","883.26","100","","657.00","121.50","1971.00","14","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","883.26","100","","75.00","75.00","75.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","883.26","100","","366.00","144.00","1971.00","45","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","667.50","667.50","667.50","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","123.77","123.77","123.77","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","483.51","229.32","1316.08","96","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","439.50","225.34","1872.27","197","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X26MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10157661","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","385.32","55.36","1815.62","58","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB CH AETNA HMO / PPO","384.78","58.3","","554.95","91.85","1421.75","94","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","481.80","73","","2490.03","2490.03","2490.03","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","384.78","58.3","","750.00","750.00","750.00","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","349.80","53","","1192.50","120.84","4149.90","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","561.00","85","","750.00","75.00","750.00","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","660.00","100","","657.00","121.50","1971.00","14","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","660.00","100","","75.00","75.00","75.00","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","660.00","100","","366.00","144.00","1971.00","45","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","481.80","73","","667.50","667.50","667.50","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.37","44.45","","123.77","123.77","123.77","1 through 10","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","both","","","660.00","495.00","WELLPOINT [1015]","HB CH WELLPOINT","514.21","77.91","","483.51","229.32","1316.08","96","293.37","660","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","439.50","225.34","1872.27","197","330","517.77","percent of total billed charges",""
"SCREW BONE 3.5X28MM CHARLOTTE CLAW SS COMPRESSION CANNULATED LOCKING HEX HEAD","SUP-ITM-10031101","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","385.32","55.36","1815.62","58","330","517.77","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","AETNA [1001]","HB CH AETNA HMO / PPO","31.06","58.3","","554.95","91.85","1421.75","94","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","38.89","73","","2490.03","2490.03","2490.03","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.06","58.3","","750.00","750.00","750.00","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.24","53","","1192.50","120.84","4149.90","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","45.29","85","","750.00","75.00","750.00","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","53.28","100","","657.00","121.50","1971.00","14","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","53.28","100","","75.00","75.00","75.00","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","53.28","100","","366.00","144.00","1971.00","45","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","38.89","73","","667.50","667.50","667.50","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.68","44.45","","123.77","123.77","123.77","1 through 10","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","both","","","53.28","39.96","WELLPOINT [1015]","HB CH WELLPOINT","41.51","77.91","","483.51","229.32","1316.08","96","23.68","53.28","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.28","39.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","31.60","59.3","","439.50","225.34","1872.27","197","26.64","41.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTEX SS SHAFT HEXAGONAL SOCKET PARTIAL THREAD FLAT HEAD","SUP-ITM-10002162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","53.28","39.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","41.80","78.45","","385.32","55.36","1815.62","58","26.64","41.8","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","AETNA [1001]","HB CH AETNA HMO / PPO","104.66","58.3","","554.95","91.85","1421.75","94","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.05","73","","2490.03","2490.03","2490.03","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.66","58.3","","750.00","750.00","750.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.15","53","","1192.50","120.84","4149.90","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","152.59","85","","750.00","75.00","750.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","179.52","100","","657.00","121.50","1971.00","14","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","179.52","100","","75.00","75.00","75.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","179.52","100","","366.00","144.00","1971.00","45","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.05","73","","667.50","667.50","667.50","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.80","44.45","","123.77","123.77","123.77","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","WELLPOINT [1015]","HB CH WELLPOINT","139.86","77.91","","483.51","229.32","1316.08","96","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.52","134.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.46","59.3","","439.50","225.34","1872.27","197","89.76","140.83","percent of total billed charges",""
"SCREW BONE 3.5X28MM CORTICAL 110017728","SUP-ITM-10174748","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.52","134.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.83","78.45","","385.32","55.36","1815.62","58","89.76","140.83","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","AETNA [1001]","HB CH AETNA HMO / PPO","228.63","58.3","","554.95","91.85","1421.75","94","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","286.28","73","","2490.03","2490.03","2490.03","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","228.63","58.3","","750.00","750.00","750.00","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","207.84","53","","1192.50","120.84","4149.90","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","333.34","85","","750.00","75.00","750.00","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","392.16","100","","657.00","121.50","1971.00","14","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","392.16","100","","75.00","75.00","75.00","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","392.16","100","","366.00","144.00","1971.00","45","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","286.28","73","","667.50","667.50","667.50","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","174.32","44.45","","123.77","123.77","123.77","1 through 10","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","both","","","392.16","294.12","WELLPOINT [1015]","HB CH WELLPOINT","305.53","77.91","","483.51","229.32","1316.08","96","174.32","392.16","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.16","294.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.55","59.3","","439.50","225.34","1872.27","197","196.08","307.65","percent of total billed charges",""
"SCREW BONE 3.5X28MM SELF-TAPPING VA LOCKING STARDRIVE RECESS SD/28","SUP-ITM-10125050","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","392.16","294.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.65","78.45","","385.32","55.36","1815.62","58","196.08","307.65","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","AETNA [1001]","HB CH AETNA HMO / PPO","1252.28","58.3","","554.95","91.85","1421.75","94","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1568.04","73","","2490.03","2490.03","2490.03","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1252.28","58.3","","750.00","750.00","750.00","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1138.44","53","","1192.50","120.84","4149.90","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1825.80","85","","750.00","75.00","750.00","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2148.00","100","","657.00","121.50","1971.00","14","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2148.00","100","","75.00","75.00","75.00","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2148.00","100","","366.00","144.00","1971.00","45","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1568.04","73","","667.50","667.50","667.50","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","954.79","44.45","","123.77","123.77","123.77","1 through 10","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","both","","","2148.00","1611.00","WELLPOINT [1015]","HB CH WELLPOINT","1673.51","77.91","","483.51","229.32","1316.08","96","954.79","2148","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2148.00","1611.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1273.76","59.3","","439.50","225.34","1872.27","197","1074","1685.11","percent of total billed charges",""
"SCREW BONE 3.5X30MM REDUCT COMPRESSION TITANIUM HEADLESS","SUP-ITM-10157800","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2148.00","1611.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1685.11","78.45","","385.32","55.36","1815.62","58","1074","1685.11","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","AETNA [1001]","HB CH AETNA HMO / PPO","606.83","58.3","","554.95","91.85","1421.75","94","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","759.84","73","","2490.03","2490.03","2490.03","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","606.83","58.3","","750.00","750.00","750.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","551.67","53","","1192.50","120.84","4149.90","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","884.75","85","","750.00","75.00","750.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1040.88","100","","657.00","121.50","1971.00","14","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1040.88","100","","75.00","75.00","75.00","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1040.88","100","","366.00","144.00","1971.00","45","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","759.84","73","","667.50","667.50","667.50","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","462.67","44.45","","123.77","123.77","123.77","1 through 10","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","both","","","1040.88","780.66","WELLPOINT [1015]","HB CH WELLPOINT","810.95","77.91","","483.51","229.32","1316.08","96","462.67","1040.88","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1040.88","780.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","617.24","59.3","","439.50","225.34","1872.27","197","520.44","816.57","percent of total billed charges",""
"SCREW BONE 3.5X30MM SURFIX SS LOCKING","SUP-ITM-10075189","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1040.88","780.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","816.57","78.45","","385.32","55.36","1815.62","58","520.44","816.57","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","AETNA [1001]","HB CH AETNA HMO / PPO","285.09","58.3","","554.95","91.85","1421.75","94","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","356.97","73","","2490.03","2490.03","2490.03","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","285.09","58.3","","750.00","750.00","750.00","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","259.17","53","","1192.50","120.84","4149.90","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","415.65","85","","750.00","75.00","750.00","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","489.00","100","","657.00","121.50","1971.00","14","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","489.00","100","","75.00","75.00","75.00","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","489.00","100","","366.00","144.00","1971.00","45","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","356.97","73","","667.50","667.50","667.50","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.36","44.45","","123.77","123.77","123.77","1 through 10","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","both","","","489.00","366.75","WELLPOINT [1015]","HB CH WELLPOINT","380.98","77.91","","483.51","229.32","1316.08","96","217.36","489","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.00","366.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.98","59.3","","439.50","225.34","1872.27","197","244.5","383.62","percent of total billed charges",""
"SCREW BONE 3.5X32MM COMPRESSION DART FIRE TITANIUM CANNULATED SELF DRILLING TAPPING HEADED GOLD","SUP-ITM-10057175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","489.00","366.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","383.62","78.45","","385.32","55.36","1815.62","58","244.5","383.62","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","AETNA [1001]","HB CH AETNA HMO / PPO","346.30","58.3","","554.95","91.85","1421.75","94","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","433.62","73","","2490.03","2490.03","2490.03","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","346.30","58.3","","750.00","750.00","750.00","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","314.82","53","","1192.50","120.84","4149.90","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","504.90","85","","750.00","75.00","750.00","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","594.00","100","","657.00","121.50","1971.00","14","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","594.00","100","","75.00","75.00","75.00","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","594.00","100","","366.00","144.00","1971.00","45","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","433.62","73","","667.50","667.50","667.50","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","264.03","44.45","","123.77","123.77","123.77","1 through 10","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","both","","","594.00","445.50","WELLPOINT [1015]","HB CH WELLPOINT","462.79","77.91","","483.51","229.32","1316.08","96","264.03","594","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","352.24","59.3","","439.50","225.34","1872.27","197","297","465.99","percent of total billed charges",""
"SCREW BONE 3.5X34MM DARCO TI COMPRESSION FULL","SUP-ITM-10133548","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","594.00","445.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","465.99","78.45","","385.32","55.36","1815.62","58","297","465.99","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","AETNA [1001]","HB CH AETNA HMO / PPO","209.32","58.3","","554.95","91.85","1421.75","94","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","2490.03","2490.03","2490.03","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","209.32","58.3","","750.00","750.00","750.00","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","190.29","53","","1192.50","120.84","4149.90","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","305.18","85","","750.00","75.00","750.00","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","359.04","100","","657.00","121.50","1971.00","14","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","359.04","100","","75.00","75.00","75.00","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","359.04","100","","366.00","144.00","1971.00","45","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","262.10","73","","667.50","667.50","667.50","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.59","44.45","","123.77","123.77","123.77","1 through 10","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","both","","","359.04","269.28","WELLPOINT [1015]","HB CH WELLPOINT","279.73","77.91","","483.51","229.32","1316.08","96","159.59","359.04","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.91","59.3","","439.50","225.34","1872.27","197","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X36MM CANNULATED SS FULL THREAD HEXAGONAL SOCKET","SUP-ITM-10001559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","359.04","269.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.67","78.45","","385.32","55.36","1815.62","58","179.52","281.67","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","AETNA [1001]","HB CH AETNA HMO / PPO","272.84","58.3","","554.95","91.85","1421.75","94","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","341.64","73","","2490.03","2490.03","2490.03","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","272.84","58.3","","750.00","750.00","750.00","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","248.04","53","","1192.50","120.84","4149.90","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","397.80","85","","750.00","75.00","750.00","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","468.00","100","","657.00","121.50","1971.00","14","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","468.00","100","","75.00","75.00","75.00","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","468.00","100","","366.00","144.00","1971.00","45","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","341.64","73","","667.50","667.50","667.50","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","208.03","44.45","","123.77","123.77","123.77","1 through 10","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","both","","","468.00","351.00","WELLPOINT [1015]","HB CH WELLPOINT","364.62","77.91","","483.51","229.32","1316.08","96","208.03","468","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.00","351.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","277.52","59.3","","439.50","225.34","1872.27","197","234","367.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM CORTITANIUM CAL NON LOCKING TITANIUM","SUP-ITM-10198128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","468.00","351.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","367.15","78.45","","385.32","55.36","1815.62","58","234","367.15","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","AETNA [1001]","HB CH AETNA HMO / PPO","514.94","58.3","","554.95","91.85","1421.75","94","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","2490.03","2490.03","2490.03","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.94","58.3","","750.00","750.00","750.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","468.13","53","","1192.50","120.84","4149.90","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","750.77","85","","750.00","75.00","750.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","883.26","100","","657.00","121.50","1971.00","14","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","883.26","100","","75.00","75.00","75.00","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","883.26","100","","366.00","144.00","1971.00","45","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","644.78","73","","667.50","667.50","667.50","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","392.61","44.45","","123.77","123.77","123.77","1 through 10","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","both","","","883.26","662.44","WELLPOINT [1015]","HB CH WELLPOINT","688.15","77.91","","483.51","229.32","1316.08","96","392.61","883.26","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.77","59.3","","439.50","225.34","1872.27","197","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X36MM VARIAX 2 T10 LOCKING FULLY THREADED SMALL","SUP-ITM-10166606","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","883.26","662.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","692.92","78.45","","385.32","55.36","1815.62","58","441.63","692.92","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","AETNA [1001]","HB CH AETNA HMO / PPO","104.66","58.3","","554.95","91.85","1421.75","94","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.05","73","","2490.03","2490.03","2490.03","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.66","58.3","","750.00","750.00","750.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.15","53","","1192.50","120.84","4149.90","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","152.59","85","","750.00","75.00","750.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","179.52","100","","657.00","121.50","1971.00","14","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","179.52","100","","75.00","75.00","75.00","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","179.52","100","","366.00","144.00","1971.00","45","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.05","73","","667.50","667.50","667.50","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","79.80","44.45","","123.77","123.77","123.77","1 through 10","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","both","","","179.52","134.64","WELLPOINT [1015]","HB CH WELLPOINT","139.86","77.91","","483.51","229.32","1316.08","96","79.8","179.52","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.52","134.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.46","59.3","","439.50","225.34","1872.27","197","89.76","140.83","percent of total billed charges",""
"SCREW BONE 3.5X38MM CORTICAL 110017738","SUP-ITM-10175227","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","179.52","134.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","140.83","78.45","","385.32","55.36","1815.62","58","89.76","140.83","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","AETNA [1001]","HB CH AETNA HMO / PPO","198.16","58.3","","554.95","91.85","1421.75","94","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","248.13","73","","2490.03","2490.03","2490.03","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.16","58.3","","750.00","750.00","750.00","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.15","53","","1192.50","120.84","4149.90","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","288.92","85","","750.00","75.00","750.00","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","339.90","100","","657.00","121.50","1971.00","14","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","339.90","100","","75.00","75.00","75.00","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","339.90","100","","366.00","144.00","1971.00","45","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.13","73","","667.50","667.50","667.50","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.09","44.45","","123.77","123.77","123.77","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","WELLPOINT [1015]","HB CH WELLPOINT","264.82","77.91","","483.51","229.32","1316.08","96","151.09","339.9","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.56","59.3","","439.50","225.34","1872.27","197","169.95","266.65","percent of total billed charges",""
"SCREW BONE 3.5X40MM A.L.P.S. TITANIUM CORTICAL LOCKING SELF TAPPING T 15 DRIVE","SUP-ITM-10030116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","266.65","78.45","","385.32","55.36","1815.62","58","169.95","266.65","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","AETNA [1001]","HB CH AETNA HMO / PPO","327.06","58.3","","554.95","91.85","1421.75","94","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","409.53","73","","2490.03","2490.03","2490.03","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","327.06","58.3","","750.00","750.00","750.00","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","297.33","53","","1192.50","120.84","4149.90","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","476.85","85","","750.00","75.00","750.00","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","561.00","100","","657.00","121.50","1971.00","14","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","561.00","100","","75.00","75.00","75.00","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","561.00","100","","366.00","144.00","1971.00","45","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","409.53","73","","667.50","667.50","667.50","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","249.36","44.45","","123.77","123.77","123.77","1 through 10","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","both","","","561.00","420.75","WELLPOINT [1015]","HB CH WELLPOINT","437.08","77.91","","483.51","229.32","1316.08","96","249.36","561","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","332.67","59.3","","439.50","225.34","1872.27","197","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.5X45MM THREAD MULTITANIUM LOCKING TITANIUM","SUP-ITM-10198188","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","561.00","420.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","440.10","78.45","","385.32","55.36","1815.62","58","280.5","440.1","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","AETNA [1001]","HB CH AETNA HMO / PPO","363.62","58.3","","554.95","91.85","1421.75","94","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","455.30","73","","2490.03","2490.03","2490.03","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.62","58.3","","750.00","750.00","750.00","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.56","53","","1192.50","120.84","4149.90","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","530.15","85","","750.00","75.00","750.00","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","623.70","100","","657.00","121.50","1971.00","14","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","623.70","100","","75.00","75.00","75.00","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","623.70","100","","366.00","144.00","1971.00","45","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.30","73","","667.50","667.50","667.50","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.23","44.45","","123.77","123.77","123.77","1 through 10","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","both","","","623.70","467.77","WELLPOINT [1015]","HB CH WELLPOINT","485.92","77.91","","483.51","229.32","1316.08","96","277.23","623.7","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.70","467.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","369.85","59.3","","439.50","225.34","1872.27","197","311.85","489.29","percent of total billed charges",""
"SCREW BONE 3.5X48MM PERSONA REVISION HEX HEADED","SUP-ITM-10283078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","623.70","467.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.29","78.45","","385.32","55.36","1815.62","58","311.85","489.29","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","AETNA [1001]","HB CH AETNA HMO / PPO","350.57","58.3","","554.95","91.85","1421.75","94","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.96","73","","2490.03","2490.03","2490.03","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","350.57","58.3","","750.00","750.00","750.00","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.70","53","","1192.50","120.84","4149.90","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","511.12","85","","750.00","75.00","750.00","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","601.32","100","","657.00","121.50","1971.00","14","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","601.32","100","","75.00","75.00","75.00","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","601.32","100","","366.00","144.00","1971.00","45","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.96","73","","667.50","667.50","667.50","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","267.29","44.45","","123.77","123.77","123.77","1 through 10","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","both","","","601.32","450.99","WELLPOINT [1015]","HB CH WELLPOINT","468.49","77.91","","483.51","229.32","1316.08","96","267.29","601.32","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","601.32","450.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","356.58","59.3","","439.50","225.34","1872.27","197","300.66","471.74","percent of total billed charges",""
"SCREW BONE 3.5X50MM MULTIDIRECTIONAL","SUP-ITM-10175198","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","601.32","450.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","471.74","78.45","","385.32","55.36","1815.62","58","300.66","471.74","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","AETNA [1001]","HB CH AETNA HMO / PPO","227.13","58.3","","554.95","91.85","1421.75","94","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","284.39","73","","2490.03","2490.03","2490.03","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.13","58.3","","750.00","750.00","750.00","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.48","53","","1192.50","120.84","4149.90","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","331.14","85","","750.00","75.00","750.00","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","389.58","100","","657.00","121.50","1971.00","14","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","389.58","100","","75.00","75.00","75.00","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","389.58","100","","366.00","144.00","1971.00","45","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.39","73","","667.50","667.50","667.50","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.17","44.45","","123.77","123.77","123.77","1 through 10","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.58","292.18","WELLPOINT [1015]","HB CH WELLPOINT","303.52","77.91","","483.51","229.32","1316.08","96","173.17","389.58","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.58","292.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.02","59.3","","439.50","225.34","1872.27","197","194.79","305.63","percent of total billed charges",""
"SCREW BONE 3.5X65MM CONICAL SS SELF TAPPING PARTIALLY THREADED T15 STARDRIVE RECESS","SUP-ITM-10025156","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.58","292.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.63","78.45","","385.32","55.36","1815.62","58","194.79","305.63","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","AETNA [1001]","HB CH AETNA HMO / PPO","62.74","58.3","","554.95","91.85","1421.75","94","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","78.56","73","","2490.03","2490.03","2490.03","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","62.74","58.3","","750.00","750.00","750.00","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.03","53","","1192.50","120.84","4149.90","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","91.47","85","","750.00","75.00","750.00","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","107.61","100","","657.00","121.50","1971.00","14","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","107.61","100","","75.00","75.00","75.00","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","107.61","100","","366.00","144.00","1971.00","45","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","78.56","73","","667.50","667.50","667.50","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.83","44.45","","123.77","123.77","123.77","1 through 10","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","both","","","107.61","80.71","WELLPOINT [1015]","HB CH WELLPOINT","83.84","77.91","","483.51","229.32","1316.08","96","47.83","107.61","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.61","80.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","63.81","59.3","","439.50","225.34","1872.27","197","53.81","84.42","percent of total billed charges",""
"SCREW BONE 3.5X65MM VARIAX TITANIUM POLYAXIAL NONLOCKING SELF TAPPING T10 DRIVE","SUP-ITM-10080943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","107.61","80.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.42","78.45","","385.32","55.36","1815.62","58","53.81","84.42","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","AETNA [1001]","HB CH AETNA HMO / PPO","289.67","58.3","","554.95","91.85","1421.75","94","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","362.71","73","","2490.03","2490.03","2490.03","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","289.67","58.3","","750.00","750.00","750.00","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","263.34","53","","1192.50","120.84","4149.90","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","422.33","85","","750.00","75.00","750.00","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","496.86","100","","657.00","121.50","1971.00","14","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","496.86","100","","75.00","75.00","75.00","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","496.86","100","","366.00","144.00","1971.00","45","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","362.71","73","","667.50","667.50","667.50","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.85","44.45","","123.77","123.77","123.77","1 through 10","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","both","","","496.86","372.64","WELLPOINT [1015]","HB CH WELLPOINT","387.10","77.91","","483.51","229.32","1316.08","96","220.85","496.86","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.86","372.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","294.64","59.3","","439.50","225.34","1872.27","197","248.43","389.79","percent of total billed charges",""
"SCREW BONE 3.5X75MM TITANIUM CORTICAL LOCKING SELF TAPPING","SUP-ITM-10075960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","496.86","372.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","389.79","78.45","","385.32","55.36","1815.62","58","248.43","389.79","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","AETNA [1001]","HB CH AETNA HMO / PPO","170.20","58.3","","554.95","91.85","1421.75","94","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","213.11","73","","2490.03","2490.03","2490.03","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","170.20","58.3","","750.00","750.00","750.00","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.72","53","","1192.50","120.84","4149.90","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","248.14","85","","750.00","75.00","750.00","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","291.93","100","","657.00","121.50","1971.00","14","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","291.93","100","","75.00","75.00","75.00","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","291.93","100","","366.00","144.00","1971.00","45","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","213.11","73","","667.50","667.50","667.50","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","129.76","44.45","","123.77","123.77","123.77","1 through 10","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","both","","","291.93","218.95","WELLPOINT [1015]","HB CH WELLPOINT","227.44","77.91","","483.51","229.32","1316.08","96","129.76","291.93","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","173.11","59.3","","439.50","225.34","1872.27","197","145.97","229.02","percent of total billed charges",""
"SCREW BONE 3.5X80MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10018933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","291.93","218.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","229.02","78.45","","385.32","55.36","1815.62","58","145.97","229.02","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","AETNA [1001]","HB CH AETNA HMO / PPO","376.04","58.3","","554.95","91.85","1421.75","94","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","470.85","73","","2490.03","2490.03","2490.03","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","376.04","58.3","","750.00","750.00","750.00","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","341.85","53","","1192.50","120.84","4149.90","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","548.25","85","","750.00","75.00","750.00","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","645.00","100","","657.00","121.50","1971.00","14","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","645.00","100","","75.00","75.00","75.00","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","645.00","100","","366.00","144.00","1971.00","45","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","470.85","73","","667.50","667.50","667.50","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","286.70","44.45","","123.77","123.77","123.77","1 through 10","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","both","","","645.00","483.75","WELLPOINT [1015]","HB CH WELLPOINT","502.52","77.91","","483.51","229.32","1316.08","96","286.7","645","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","382.49","59.3","","439.50","225.34","1872.27","197","322.5","506","percent of total billed charges",""
"SCREW BONE 30MM HAND WRIST ANKLE FOOT COMP FULLY THREADED HEADLESS SNAP OFF GROOVE TITANIUM ACUTRAK ACUTWIST","SUP-ITM-10022267","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","645.00","483.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","506.00","78.45","","385.32","55.36","1815.62","58","322.5","506","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","554.95","91.85","1421.75","94","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","2490.03","2490.03","2490.03","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","288.59","58.3","","750.00","750.00","750.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","1192.50","120.84","4149.90","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","420.75","85","","750.00","75.00","750.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","495.00","100","","657.00","121.50","1971.00","14","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","495.00","100","","75.00","75.00","75.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","495.00","100","","366.00","144.00","1971.00","45","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","667.50","667.50","667.50","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","123.77","123.77","123.77","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","483.51","229.32","1316.08","96","220.03","495","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","439.50","225.34","1872.27","197","247.5","388.33","percent of total billed charges",""
"SCREW BONE 30X4.0MM CANNULATED SS LOW PROFILE LONG THREAD","SUP-ITM-10076858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","385.32","55.36","1815.62","58","247.5","388.33","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","AETNA [1001]","HB CH AETNA HMO / PPO","69.79","58.3","","554.95","91.85","1421.75","94","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","2490.03","2490.03","2490.03","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.79","58.3","","750.00","750.00","750.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.44","53","","1192.50","120.84","4149.90","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","101.75","85","","750.00","75.00","750.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","119.70","100","","657.00","121.50","1971.00","14","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","119.70","100","","75.00","75.00","75.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","119.70","100","","366.00","144.00","1971.00","45","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","667.50","667.50","667.50","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","123.77","123.77","123.77","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","WELLPOINT [1015]","HB CH WELLPOINT","93.26","77.91","","483.51","229.32","1316.08","96","53.21","119.7","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.98","59.3","","439.50","225.34","1872.27","197","59.85","93.9","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS HGP II TITANIUM ALLOY SELF TAPPING ACETABULAR CUP","SUP-ITM-10003921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","385.32","55.36","1815.62","58","59.85","93.9","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","554.95","91.85","1421.75","94","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","2490.03","2490.03","2490.03","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","750.00","750.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","1192.50","120.84","4149.90","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.90","85","","750.00","75.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","114.00","100","","657.00","121.50","1971.00","14","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","114.00","100","","75.00","75.00","75.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","114.00","100","","366.00","144.00","1971.00","45","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","667.50","667.50","667.50","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","123.77","123.77","123.77","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","483.51","229.32","1316.08","96","50.67","114","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","439.50","225.34","1872.27","197","57","89.43","percent of total billed charges",""
"SCREW BONE 30X6.5MM HIP CANCELLOUS SPHERICAL HEAD FOR REFLECTION SYSTEM 16A CS/1BX/1EA","SUP-ITM-10015385","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","385.32","55.36","1815.62","58","57","89.43","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","AETNA [1001]","HB CH AETNA HMO / PPO","188.96","58.3","","554.95","91.85","1421.75","94","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","236.61","73","","2490.03","2490.03","2490.03","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","188.96","58.3","","750.00","750.00","750.00","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","171.78","53","","1192.50","120.84","4149.90","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","275.50","85","","750.00","75.00","750.00","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","324.12","100","","657.00","121.50","1971.00","14","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","324.12","100","","75.00","75.00","75.00","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","324.12","100","","366.00","144.00","1971.00","45","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","236.61","73","","667.50","667.50","667.50","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","144.07","44.45","","123.77","123.77","123.77","1 through 10","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","both","","","324.12","243.09","WELLPOINT [1015]","HB CH WELLPOINT","252.52","77.91","","483.51","229.32","1316.08","96","144.07","324.12","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.12","243.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","192.20","59.3","","439.50","225.34","1872.27","197","162.06","254.27","percent of total billed charges",""
"SCREW BONE 32X3.5MM TITANIUM LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10040109","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","324.12","243.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","254.27","78.45","","385.32","55.36","1815.62","58","162.06","254.27","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","AETNA [1001]","HB CH AETNA HMO / PPO","479.91","58.3","","554.95","91.85","1421.75","94","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","600.91","73","","2490.03","2490.03","2490.03","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","479.91","58.3","","750.00","750.00","750.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","436.28","53","","1192.50","120.84","4149.90","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","699.69","85","","750.00","75.00","750.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","823.17","100","","657.00","121.50","1971.00","14","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","823.17","100","","75.00","75.00","75.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","823.17","100","","366.00","144.00","1971.00","45","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","600.91","73","","667.50","667.50","667.50","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","365.90","44.45","","123.77","123.77","123.77","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","WELLPOINT [1015]","HB CH WELLPOINT","641.33","77.91","","483.51","229.32","1316.08","96","365.9","823.17","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","823.17","617.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","488.14","59.3","","439.50","225.34","1872.27","197","411.59","645.78","percent of total billed charges",""
"SCREW BONE 32X5.0MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10072693","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","823.17","617.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","645.78","78.45","","385.32","55.36","1815.62","58","411.59","645.78","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","554.95","91.85","1421.75","94","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","2490.03","2490.03","2490.03","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","750.00","750.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","1192.50","120.84","4149.90","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","153.00","85","","750.00","75.00","750.00","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","180.00","100","","657.00","121.50","1971.00","14","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","180.00","100","","75.00","75.00","75.00","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","180.00","100","","366.00","144.00","1971.00","45","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","667.50","667.50","667.50","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","80.01","44.45","","123.77","123.77","123.77","1 through 10","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","483.51","229.32","1316.08","96","80.01","180","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","439.50","225.34","1872.27","197","90","141.21","percent of total billed charges",""
"SCREW BONE 34MM PERFORM REVERSE","SUP-ITM-10211833","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","385.32","55.36","1815.62","58","90","141.21","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","AETNA [1001]","HB CH AETNA HMO / PPO","471.36","58.3","","554.95","91.85","1421.75","94","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","590.21","73","","2490.03","2490.03","2490.03","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","471.36","58.3","","750.00","750.00","750.00","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.51","53","","1192.50","120.84","4149.90","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","687.23","85","","750.00","75.00","750.00","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","808.50","100","","657.00","121.50","1971.00","14","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","808.50","100","","75.00","75.00","75.00","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","808.50","100","","366.00","144.00","1971.00","45","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","590.21","73","","667.50","667.50","667.50","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.38","44.45","","123.77","123.77","123.77","1 through 10","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","both","","","808.50","606.37","WELLPOINT [1015]","HB CH WELLPOINT","629.90","77.91","","483.51","229.32","1316.08","96","359.38","808.5","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","808.50","606.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.44","59.3","","439.50","225.34","1872.27","197","404.25","634.27","percent of total billed charges",""
"SCREW BONE 3MM INTERNAL COMPRESSION PHANTOM HINDFOOT NAIL","SUP-ITM-10285944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","808.50","606.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.27","78.45","","385.32","55.36","1815.62","58","404.25","634.27","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","AETNA [1001]","HB CH AETNA HMO / PPO","884.99","58.3","","554.95","91.85","1421.75","94","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1108.14","73","","2490.03","2490.03","2490.03","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","884.99","58.3","","750.00","750.00","750.00","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","804.54","53","","1192.50","120.84","4149.90","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1290.30","85","","750.00","75.00","750.00","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1518.00","100","","657.00","121.50","1971.00","14","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1518.00","100","","75.00","75.00","75.00","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1518.00","100","","366.00","144.00","1971.00","45","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1108.14","73","","667.50","667.50","667.50","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.75","44.45","","123.77","123.77","123.77","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","WELLPOINT [1015]","HB CH WELLPOINT","1182.67","77.91","","483.51","229.32","1316.08","96","674.75","1518","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","900.17","59.3","","439.50","225.34","1872.27","197","759","1190.87","percent of total billed charges",""
"SCREW BONE 3MMX20MM ARTHROSOPIC NON LOCKING CANNULATEDNON SELF TAPPING DRILLING HEADLESS HEX DRIVE TITANIUM","SUP-ITM-10017835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1190.87","78.45","","385.32","55.36","1815.62","58","759","1190.87","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","AETNA [1001]","HB CH AETNA HMO / PPO","239.61","58.3","","554.95","91.85","1421.75","94","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","300.03","73","","2490.03","2490.03","2490.03","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","239.61","58.3","","750.00","750.00","750.00","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","217.83","53","","1192.50","120.84","4149.90","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","349.35","85","","750.00","75.00","750.00","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","411.00","100","","657.00","121.50","1971.00","14","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","411.00","100","","75.00","75.00","75.00","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","411.00","100","","366.00","144.00","1971.00","45","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","300.03","73","","667.50","667.50","667.50","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","182.69","44.45","","123.77","123.77","123.77","1 through 10","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","both","","","411.00","308.25","WELLPOINT [1015]","HB CH WELLPOINT","320.21","77.91","","483.51","229.32","1316.08","96","182.69","411","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.00","308.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","243.72","59.3","","439.50","225.34","1872.27","197","205.5","322.43","percent of total billed charges",""
"SCREW BONE 3X12MM TITANIUM LOCKING MULTI THREAD","SUP-ITM-10157795","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","411.00","308.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","322.43","78.45","","385.32","55.36","1815.62","58","205.5","322.43","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","AETNA [1001]","HB CH AETNA HMO / PPO","594.90","58.3","","554.95","91.85","1421.75","94","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","744.91","73","","2490.03","2490.03","2490.03","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","594.90","58.3","","750.00","750.00","750.00","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","540.82","53","","1192.50","120.84","4149.90","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","867.36","85","","750.00","75.00","750.00","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1020.42","100","","657.00","121.50","1971.00","14","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1020.42","100","","75.00","75.00","75.00","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1020.42","100","","366.00","144.00","1971.00","45","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","744.91","73","","667.50","667.50","667.50","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.58","44.45","","123.77","123.77","123.77","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","WELLPOINT [1015]","HB CH WELLPOINT","795.01","77.91","","483.51","229.32","1316.08","96","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","605.11","59.3","","439.50","225.34","1872.27","197","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X14MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10050597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","800.52","78.45","","385.32","55.36","1815.62","58","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","AETNA [1001]","HB CH AETNA HMO / PPO","227.23","58.3","","554.95","91.85","1421.75","94","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","284.52","73","","2490.03","2490.03","2490.03","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.23","58.3","","750.00","750.00","750.00","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.57","53","","1192.50","120.84","4149.90","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","331.30","85","","750.00","75.00","750.00","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","389.76","100","","657.00","121.50","1971.00","14","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","389.76","100","","75.00","75.00","75.00","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","389.76","100","","366.00","144.00","1971.00","45","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.52","73","","667.50","667.50","667.50","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.25","44.45","","123.77","123.77","123.77","1 through 10","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","both","","","389.76","292.32","WELLPOINT [1015]","HB CH WELLPOINT","303.66","77.91","","483.51","229.32","1316.08","96","173.25","389.76","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.76","292.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.13","59.3","","439.50","225.34","1872.27","197","194.88","305.77","percent of total billed charges",""
"SCREW BONE 3X18MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD CRUCIFORM RECESS","SUP-ITM-10002120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","389.76","292.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.77","78.45","","385.32","55.36","1815.62","58","194.88","305.77","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","AETNA [1001]","HB CH AETNA HMO / PPO","402.97","58.3","","554.95","91.85","1421.75","94","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","504.58","73","","2490.03","2490.03","2490.03","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","402.97","58.3","","750.00","750.00","750.00","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","366.34","53","","1192.50","120.84","4149.90","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","587.52","85","","750.00","75.00","750.00","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","691.20","100","","657.00","121.50","1971.00","14","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","691.20","100","","75.00","75.00","75.00","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","691.20","100","","366.00","144.00","1971.00","45","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","504.58","73","","667.50","667.50","667.50","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","307.24","44.45","","123.77","123.77","123.77","1 through 10","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","both","","","691.20","518.40","WELLPOINT [1015]","HB CH WELLPOINT","538.51","77.91","","483.51","229.32","1316.08","96","307.24","691.2","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.20","518.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","409.88","59.3","","439.50","225.34","1872.27","197","345.6","542.25","percent of total billed charges",""
"SCREW BONE 3X20MM COMPRESSION CANNULATED TITANIUM LONG THREAD T8 STARDRIVE RECESS","SUP-ITM-10040427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","691.20","518.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","542.25","78.45","","385.32","55.36","1815.62","58","345.6","542.25","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","AETNA [1001]","HB CH AETNA HMO / PPO","225.62","58.3","","554.95","91.85","1421.75","94","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","282.51","73","","2490.03","2490.03","2490.03","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","225.62","58.3","","750.00","750.00","750.00","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","205.11","53","","1192.50","120.84","4149.90","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","328.95","85","","750.00","75.00","750.00","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","387.00","100","","657.00","121.50","1971.00","14","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","387.00","100","","75.00","75.00","75.00","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","387.00","100","","366.00","144.00","1971.00","45","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","282.51","73","","667.50","667.50","667.50","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.02","44.45","","123.77","123.77","123.77","1 through 10","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.00","290.25","WELLPOINT [1015]","HB CH WELLPOINT","301.51","77.91","","483.51","229.32","1316.08","96","172.02","387","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","229.49","59.3","","439.50","225.34","1872.27","197","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3X20MM LAG CANNULATED","SUP-ITM-10019553","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.00","290.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.60","78.45","","385.32","55.36","1815.62","58","193.5","303.6","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","AETNA [1001]","HB CH AETNA HMO / PPO","594.90","58.3","","554.95","91.85","1421.75","94","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","744.91","73","","2490.03","2490.03","2490.03","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","594.90","58.3","","750.00","750.00","750.00","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","540.82","53","","1192.50","120.84","4149.90","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","867.36","85","","750.00","75.00","750.00","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1020.42","100","","657.00","121.50","1971.00","14","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1020.42","100","","75.00","75.00","75.00","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1020.42","100","","366.00","144.00","1971.00","45","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","744.91","73","","667.50","667.50","667.50","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.58","44.45","","123.77","123.77","123.77","1 through 10","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.42","765.31","WELLPOINT [1015]","HB CH WELLPOINT","795.01","77.91","","483.51","229.32","1316.08","96","453.58","1020.42","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","605.11","59.3","","439.50","225.34","1872.27","197","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X26MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10043011","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.42","765.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","800.52","78.45","","385.32","55.36","1815.62","58","510.21","800.52","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","AETNA [1001]","HB CH AETNA HMO / PPO","364.91","58.3","","554.95","91.85","1421.75","94","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","456.92","73","","2490.03","2490.03","2490.03","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","364.91","58.3","","750.00","750.00","750.00","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","331.74","53","","1192.50","120.84","4149.90","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","532.03","85","","750.00","75.00","750.00","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","625.92","100","","657.00","121.50","1971.00","14","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","625.92","100","","75.00","75.00","75.00","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","625.92","100","","366.00","144.00","1971.00","45","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","456.92","73","","667.50","667.50","667.50","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.22","44.45","","123.77","123.77","123.77","1 through 10","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","both","","","625.92","469.44","WELLPOINT [1015]","HB CH WELLPOINT","487.65","77.91","","483.51","229.32","1316.08","96","278.22","625.92","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","625.92","469.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.17","59.3","","439.50","225.34","1872.27","197","312.96","491.03","percent of total billed charges",""
"SCREW BONE 3X27MM CANNULATED SS COMPRESSION SHORT THREAD HEADLESS T8 STARDRIVE RECESS","SUP-ITM-10019150","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","625.92","469.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","491.03","78.45","","385.32","55.36","1815.62","58","312.96","491.03","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","AETNA [1001]","HB CH AETNA HMO / PPO","819.44","58.3","","554.95","91.85","1421.75","94","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","2490.03","2490.03","2490.03","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","819.44","58.3","","750.00","750.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.95","53","","1192.50","120.84","4149.90","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1194.73","85","","750.00","75.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1405.56","100","","657.00","121.50","1971.00","14","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1405.56","100","","75.00","75.00","75.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1405.56","100","","366.00","144.00","1971.00","45","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","667.50","667.50","667.50","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","123.77","123.77","123.77","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","WELLPOINT [1015]","HB CH WELLPOINT","1095.07","77.91","","483.51","229.32","1316.08","96","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","833.50","59.3","","439.50","225.34","1872.27","197","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 3X28MM MINI HEADLESS CANNULATED","SUP-ITM-10232412","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","385.32","55.36","1815.62","58","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","AETNA [1001]","HB CH AETNA HMO / PPO","472.23","58.3","","554.95","91.85","1421.75","94","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","591.30","73","","2490.03","2490.03","2490.03","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","472.23","58.3","","750.00","750.00","750.00","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","429.30","53","","1192.50","120.84","4149.90","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","688.50","85","","750.00","75.00","750.00","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","810.00","100","","657.00","121.50","1971.00","14","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","810.00","100","","75.00","75.00","75.00","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","810.00","100","","366.00","144.00","1971.00","45","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","591.30","73","","667.50","667.50","667.50","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","360.05","44.45","","123.77","123.77","123.77","1 through 10","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","both","","","810.00","607.50","WELLPOINT [1015]","HB CH WELLPOINT","631.07","77.91","","483.51","229.32","1316.08","96","360.05","810","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.00","607.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","480.33","59.3","","439.50","225.34","1872.27","197","405","635.45","percent of total billed charges",""
"SCREW BONE 3X50MM POLYAXIAL LOCKING CANNULATED COCR","SUP-ITM-10295785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","810.00","607.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","635.45","78.45","","385.32","55.36","1815.62","58","405","635.45","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","554.95","91.85","1421.75","94","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","2490.03","2490.03","2490.03","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","750.00","750.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","1192.50","120.84","4149.90","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","382.50","85","","750.00","75.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.00","100","","657.00","121.50","1971.00","14","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","450.00","100","","75.00","75.00","75.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","366.00","144.00","1971.00","45","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","667.50","667.50","667.50","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","123.77","123.77","123.77","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","483.51","229.32","1316.08","96","200.03","450","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","439.50","225.34","1872.27","197","225","353.03","percent of total billed charges",""
"SCREW BONE 3X50MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10153983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","385.32","55.36","1815.62","58","225","353.03","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","AETNA [1001]","HB CH AETNA HMO / PPO","2256.21","58.3","","554.95","91.85","1421.75","94","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2825.10","73","","2490.03","2490.03","2490.03","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2256.21","58.3","","750.00","750.00","750.00","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2051.10","53","","1192.50","120.84","4149.90","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3289.50","85","","750.00","75.00","750.00","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3870.00","100","","657.00","121.50","1971.00","14","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3870.00","100","","75.00","75.00","75.00","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3870.00","100","","366.00","144.00","1971.00","45","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2825.10","73","","667.50","667.50","667.50","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1720.22","44.45","","123.77","123.77","123.77","1 through 10","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","both","","","3870.00","2902.50","WELLPOINT [1015]","HB CH WELLPOINT","3015.12","77.91","","483.51","229.32","1316.08","96","1720.22","3870","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2294.91","59.3","","439.50","225.34","1872.27","197","1935","3036.02","percent of total billed charges",""
"SCREW BONE 3X80MM CLAVICLE DUAL TRAK SS NONLOCKING THREADED 40-0136","SUP-ITM-10124425","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3870.00","2902.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3036.02","78.45","","385.32","55.36","1815.62","58","1935","3036.02","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","554.95","91.85","1421.75","94","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","2490.03","2490.03","2490.03","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","750.00","750.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","1192.50","120.84","4149.90","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","280.50","85","","750.00","75.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","330.00","100","","657.00","121.50","1971.00","14","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","330.00","100","","75.00","75.00","75.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","330.00","100","","366.00","144.00","1971.00","45","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","667.50","667.50","667.50","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","123.77","123.77","123.77","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","483.51","229.32","1316.08","96","146.69","330","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","439.50","225.34","1872.27","197","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X16MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING MAGENTA","SUP-ITM-10115706","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","385.32","55.36","1815.62","58","165","258.89","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","AETNA [1001]","HB CH AETNA HMO / PPO","198.16","58.3","","554.95","91.85","1421.75","94","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","248.13","73","","2490.03","2490.03","2490.03","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.16","58.3","","750.00","750.00","750.00","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.15","53","","1192.50","120.84","4149.90","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","288.92","85","","750.00","75.00","750.00","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","339.90","100","","657.00","121.50","1971.00","14","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","339.90","100","","75.00","75.00","75.00","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","339.90","100","","366.00","144.00","1971.00","45","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.13","73","","667.50","667.50","667.50","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.09","44.45","","123.77","123.77","123.77","1 through 10","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","both","","","339.90","254.92","WELLPOINT [1015]","HB CH WELLPOINT","264.82","77.91","","483.51","229.32","1316.08","96","151.09","339.9","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.56","59.3","","439.50","225.34","1872.27","197","169.95","266.65","percent of total billed charges",""
"SCREW BONE 4.0X36MM TITANIUM CANCELLOUS LOCKING SELF TAPPING","SUP-ITM-10045379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","339.90","254.92","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","266.65","78.45","","385.32","55.36","1815.62","58","169.95","266.65","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","AETNA [1001]","HB CH AETNA HMO / PPO","268.42","58.3","","554.95","91.85","1421.75","94","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","336.10","73","","2490.03","2490.03","2490.03","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","268.42","58.3","","750.00","750.00","750.00","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","244.02","53","","1192.50","120.84","4149.90","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","391.35","85","","750.00","75.00","750.00","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","460.41","100","","657.00","121.50","1971.00","14","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","460.41","100","","75.00","75.00","75.00","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","460.41","100","","366.00","144.00","1971.00","45","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","336.10","73","","667.50","667.50","667.50","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.65","44.45","","123.77","123.77","123.77","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","WELLPOINT [1015]","HB CH WELLPOINT","358.71","77.91","","483.51","229.32","1316.08","96","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","273.02","59.3","","439.50","225.34","1872.27","197","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X40MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10017873","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.19","78.45","","385.32","55.36","1815.62","58","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","AETNA [1001]","HB CH AETNA HMO / PPO","268.42","58.3","","554.95","91.85","1421.75","94","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","336.10","73","","2490.03","2490.03","2490.03","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","268.42","58.3","","750.00","750.00","750.00","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","244.02","53","","1192.50","120.84","4149.90","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","391.35","85","","750.00","75.00","750.00","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","460.41","100","","657.00","121.50","1971.00","14","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","460.41","100","","75.00","75.00","75.00","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","460.41","100","","366.00","144.00","1971.00","45","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","336.10","73","","667.50","667.50","667.50","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.65","44.45","","123.77","123.77","123.77","1 through 10","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","both","","","460.41","345.31","WELLPOINT [1015]","HB CH WELLPOINT","358.71","77.91","","483.51","229.32","1316.08","96","204.65","460.41","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","CIGNA [1006]","HB CH CIGNA HMO / PPO","273.02","59.3","","439.50","225.34","1872.27","197","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM CANNULATED PARTIAL THREAD","SUP-ITM-10021692","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","460.41","345.31","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.19","78.45","","385.32","55.36","1815.62","58","230.21","361.19","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","AETNA [1001]","HB CH AETNA HMO / PPO","61.25","58.3","","554.95","91.85","1421.75","94","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.69","73","","2490.03","2490.03","2490.03","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.25","58.3","","750.00","750.00","750.00","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.68","53","","1192.50","120.84","4149.90","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.30","85","","750.00","75.00","750.00","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.06","100","","657.00","121.50","1971.00","14","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.06","100","","75.00","75.00","75.00","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.06","100","","366.00","144.00","1971.00","45","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.69","73","","667.50","667.50","667.50","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.70","44.45","","123.77","123.77","123.77","1 through 10","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.06","78.79","WELLPOINT [1015]","HB CH WELLPOINT","81.85","77.91","","483.51","229.32","1316.08","96","46.7","105.06","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.30","59.3","","439.50","225.34","1872.27","197","52.53","82.42","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS A.L.P.S. TITANIUM NONLOCKING PARTIAL THREAD","SUP-ITM-10017512","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.06","78.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.42","78.45","","385.32","55.36","1815.62","58","52.53","82.42","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","554.95","91.85","1421.75","94","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","2490.03","2490.03","2490.03","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","750.00","750.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","1192.50","120.84","4149.90","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.25","85","","750.00","75.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.00","100","","657.00","121.50","1971.00","14","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.00","100","","75.00","75.00","75.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.00","100","","366.00","144.00","1971.00","45","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","667.50","667.50","667.50","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","123.77","123.77","123.77","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","483.51","229.32","1316.08","96","46.67","105","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","439.50","225.34","1872.27","197","52.5","82.37","percent of total billed charges",""
"SCREW BONE 4.0X50MM CANCELLOUS SS NONLOCKING LOW PROFILE","SUP-ITM-10130663","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","385.32","55.36","1815.62","58","52.5","82.37","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","AETNA [1001]","HB CH AETNA HMO / PPO","726.46","58.3","","554.95","91.85","1421.75","94","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","909.64","73","","2490.03","2490.03","2490.03","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","726.46","58.3","","750.00","750.00","750.00","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","660.42","53","","1192.50","120.84","4149.90","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1059.17","85","","750.00","75.00","750.00","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1246.08","100","","657.00","121.50","1971.00","14","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1246.08","100","","75.00","75.00","75.00","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1246.08","100","","366.00","144.00","1971.00","45","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","909.64","73","","667.50","667.50","667.50","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","553.88","44.45","","123.77","123.77","123.77","1 through 10","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","both","","","1246.08","934.56","WELLPOINT [1015]","HB CH WELLPOINT","970.82","77.91","","483.51","229.32","1316.08","96","553.88","1246.08","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1246.08","934.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","738.93","59.3","","439.50","225.34","1872.27","197","623.04","977.55","percent of total billed charges",""
"SCREW BONE 4.3X34MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING","SUP-ITM-10080012","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1246.08","934.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","977.55","78.45","","385.32","55.36","1815.62","58","623.04","977.55","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","AETNA [1001]","HB CH AETNA HMO / PPO","844.07","58.3","","554.95","91.85","1421.75","94","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1056.89","73","","2490.03","2490.03","2490.03","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","844.07","58.3","","750.00","750.00","750.00","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","767.33","53","","1192.50","120.84","4149.90","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1230.63","85","","750.00","75.00","750.00","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1447.80","100","","657.00","121.50","1971.00","14","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1447.80","100","","75.00","75.00","75.00","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1447.80","100","","366.00","144.00","1971.00","45","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1056.89","73","","667.50","667.50","667.50","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","643.55","44.45","","123.77","123.77","123.77","1 through 10","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","both","","","1447.80","1085.85","WELLPOINT [1015]","HB CH WELLPOINT","1127.98","77.91","","483.51","229.32","1316.08","96","643.55","1447.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1447.80","1085.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","858.55","59.3","","439.50","225.34","1872.27","197","723.9","1135.8","percent of total billed charges",""
"SCREW BONE 4.3X45MM CANNULATED COMPR FIX SELF TAP S/S QWIX STRL","SUP-ITM-10080369","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1447.80","1085.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1135.80","78.45","","385.32","55.36","1815.62","58","723.9","1135.8","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","AETNA [1001]","HB CH AETNA HMO / PPO","72.86","58.3","","554.95","91.85","1421.75","94","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","91.24","73","","2490.03","2490.03","2490.03","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","72.86","58.3","","750.00","750.00","750.00","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","66.24","53","","1192.50","120.84","4149.90","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","106.23","85","","750.00","75.00","750.00","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","124.98","100","","657.00","121.50","1971.00","14","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","124.98","100","","75.00","75.00","75.00","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","124.98","100","","366.00","144.00","1971.00","45","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.24","73","","667.50","667.50","667.50","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.55","44.45","","123.77","123.77","123.77","1 through 10","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","WELLPOINT [1015]","HB CH WELLPOINT","97.37","77.91","","483.51","229.32","1316.08","96","55.55","124.98","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.11","59.3","","439.50","225.34","1872.27","197","62.49","98.05","percent of total billed charges",""
"SCREW BONE 4.5MM 50MM CORTICAL SELF-TAP LARGE HEX","SUP-ITM-10237565","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.05","78.45","","385.32","55.36","1815.62","58","62.49","98.05","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","AETNA [1001]","HB CH AETNA HMO / PPO","286.75","58.3","","554.95","91.85","1421.75","94","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","359.05","73","","2490.03","2490.03","2490.03","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","286.75","58.3","","750.00","750.00","750.00","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","260.68","53","","1192.50","120.84","4149.90","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","418.07","85","","750.00","75.00","750.00","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","491.85","100","","657.00","121.50","1971.00","14","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","491.85","100","","75.00","75.00","75.00","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","491.85","100","","366.00","144.00","1971.00","45","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","359.05","73","","667.50","667.50","667.50","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","218.63","44.45","","123.77","123.77","123.77","1 through 10","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","both","","","491.85","368.89","WELLPOINT [1015]","HB CH WELLPOINT","383.20","77.91","","483.51","229.32","1316.08","96","218.63","491.85","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","491.85","368.89","CIGNA [1006]","HB CH CIGNA HMO / PPO","291.67","59.3","","439.50","225.34","1872.27","197","245.93","385.86","percent of total billed charges",""
"SCREW BONE 4.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","491.85","368.89","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","385.86","78.45","","385.32","55.36","1815.62","58","245.93","385.86","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","AETNA [1001]","HB CH AETNA HMO / PPO","312.86","58.3","","554.95","91.85","1421.75","94","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","391.75","73","","2490.03","2490.03","2490.03","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","312.86","58.3","","750.00","750.00","750.00","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","284.42","53","","1192.50","120.84","4149.90","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","456.14","85","","750.00","75.00","750.00","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","536.64","100","","657.00","121.50","1971.00","14","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","536.64","100","","75.00","75.00","75.00","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","536.64","100","","366.00","144.00","1971.00","45","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","391.75","73","","667.50","667.50","667.50","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.54","44.45","","123.77","123.77","123.77","1 through 10","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","WELLPOINT [1015]","HB CH WELLPOINT","418.10","77.91","","483.51","229.32","1316.08","96","238.54","536.64","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","318.23","59.3","","439.50","225.34","1872.27","197","268.32","420.99","percent of total billed charges",""
"SCREW BONE 4.5MM STARDRIVE SS 2 PART RECESS","SUP-ITM-10074531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","420.99","78.45","","385.32","55.36","1815.62","58","268.32","420.99","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","AETNA [1001]","HB CH AETNA HMO / PPO","884.99","58.3","","554.95","91.85","1421.75","94","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1108.14","73","","2490.03","2490.03","2490.03","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","884.99","58.3","","750.00","750.00","750.00","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","804.54","53","","1192.50","120.84","4149.90","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1290.30","85","","750.00","75.00","750.00","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1518.00","100","","657.00","121.50","1971.00","14","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1518.00","100","","75.00","75.00","75.00","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1518.00","100","","366.00","144.00","1971.00","45","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1108.14","73","","667.50","667.50","667.50","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","674.75","44.45","","123.77","123.77","123.77","1 through 10","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","both","","","1518.00","1138.50","WELLPOINT [1015]","HB CH WELLPOINT","1182.67","77.91","","483.51","229.32","1316.08","96","674.75","1518","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","900.17","59.3","","439.50","225.34","1872.27","197","759","1190.87","percent of total billed charges",""
"SCREW BONE 4.5MMX26MM ARTHROSOPIC NON LOCKING CORTICAL FULLY THREADED CANNULATED SELF TAPPING DRILLING HEADLESS HEX DRIVE","SUP-ITM-10019030","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1518.00","1138.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1190.87","78.45","","385.32","55.36","1815.62","58","759","1190.87","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","AETNA [1001]","HB CH AETNA HMO / PPO","306.08","58.3","","554.95","91.85","1421.75","94","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","383.25","73","","2490.03","2490.03","2490.03","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","306.08","58.3","","750.00","750.00","750.00","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","278.25","53","","1192.50","120.84","4149.90","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","446.25","85","","750.00","75.00","750.00","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","525.00","100","","657.00","121.50","1971.00","14","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","525.00","100","","75.00","75.00","75.00","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","525.00","100","","366.00","144.00","1971.00","45","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","383.25","73","","667.50","667.50","667.50","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.36","44.45","","123.77","123.77","123.77","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB CH WELLPOINT","409.03","77.91","","483.51","229.32","1316.08","96","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","311.33","59.3","","439.50","225.34","1872.27","197","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5MMX36 CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING PARTIAL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10073104","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","411.86","78.45","","385.32","55.36","1815.62","58","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","554.95","91.85","1421.75","94","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","2490.03","2490.03","2490.03","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","271.10","58.3","","750.00","750.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.45","53","","1192.50","120.84","4149.90","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","395.25","85","","750.00","75.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","465.00","100","","657.00","121.50","1971.00","14","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","465.00","100","","75.00","75.00","75.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","465.00","100","","366.00","144.00","1971.00","45","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","667.50","667.50","667.50","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","123.77","123.77","123.77","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","483.51","229.32","1316.08","96","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","439.50","225.34","1872.27","197","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5MMX42MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079354","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","385.32","55.36","1815.62","58","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","554.95","91.85","1421.75","94","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","2490.03","2490.03","2490.03","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","271.10","58.3","","750.00","750.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.45","53","","1192.50","120.84","4149.90","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","395.25","85","","750.00","75.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","465.00","100","","657.00","121.50","1971.00","14","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","465.00","100","","75.00","75.00","75.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","465.00","100","","366.00","144.00","1971.00","45","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","667.50","667.50","667.50","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","123.77","123.77","123.77","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","483.51","229.32","1316.08","96","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","439.50","225.34","1872.27","197","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5MMX54MM CORTICAL TITANIUM DEPUY MITEK","SUP-ITM-10079360","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","385.32","55.36","1815.62","58","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","554.95","91.85","1421.75","94","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2490.03","2490.03","2490.03","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","750.00","750.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","1192.50","120.84","4149.90","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","750.00","75.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","657.00","121.50","1971.00","14","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","75.00","75.00","75.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","366.00","144.00","1971.00","45","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","667.50","667.50","667.50","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","123.77","123.77","123.77","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","483.51","229.32","1316.08","96","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","439.50","225.34","1872.27","197","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X10MM SPINE MOUNTAINEER FAVORED ANGLE TITANIUM OCCIPITAL","SUP-ITM-10017656","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","385.32","55.36","1815.62","58","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X11MM SPINE MOUNTAINEER FAVORED ANGLE TI OCCIPITAL","SUP-ITM-10046418","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","1830.28","315.58","1830.28","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X11MM SPINE MOUNTAINEER FAVORED ANGLE TI OCCIPITAL","SUP-ITM-10046418","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","4170.85","4170.85","4170.85","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X11MM SPINE MOUNTAINEER FAVORED ANGLE TI OCCIPITAL","SUP-ITM-10046418","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","649.55","649.55","649.55","1 through 10","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X11MM SPINE MOUNTAINEER FAVORED ANGLE TI OCCIPITAL","SUP-ITM-10046418","CDM","C1889","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","8998.38","2542.37","8998.38","20","133.35","300","percent of total billed charges",""
"SCREW BONE 4.5X11MM SPINE MOUNTAINEER FAVORED ANGLE TI OCCIPITAL","SUP-ITM-10046418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","1891.61","1609.14","3664.18","25","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X11MM SPINE MOUNTAINEER FAVORED ANGLE TI OCCIPITAL","SUP-ITM-10046418","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","1470.68","1310.06","2481.69","19","150","235.35","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","AETNA [1001]","HB CH AETNA HMO / PPO","91.79","58.3","","554.95","91.85","1421.75","94","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","114.93","73","","2490.03","2490.03","2490.03","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.79","58.3","","750.00","750.00","750.00","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","83.44","53","","1192.50","120.84","4149.90","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","133.82","85","","750.00","75.00","750.00","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","157.44","100","","657.00","121.50","1971.00","14","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","157.44","100","","75.00","75.00","75.00","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","157.44","100","","366.00","144.00","1971.00","45","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.93","73","","667.50","667.50","667.50","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.98","44.45","","123.77","123.77","123.77","1 through 10","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.44","118.08","WELLPOINT [1015]","HB CH WELLPOINT","122.66","77.91","","483.51","229.32","1316.08","96","69.98","157.44","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.44","118.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.36","59.3","","439.50","225.34","1872.27","197","78.72","123.51","percent of total billed charges",""
"SCREW BONE 4.5X150MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004530","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.44","118.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.51","78.45","","385.32","55.36","1815.62","58","78.72","123.51","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","AETNA [1001]","HB CH AETNA HMO / PPO","113.69","58.3","","554.95","91.85","1421.75","94","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","142.35","73","","2490.03","2490.03","2490.03","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","113.69","58.3","","750.00","750.00","750.00","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","103.35","53","","1192.50","120.84","4149.90","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","165.75","85","","750.00","75.00","750.00","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","195.00","100","","657.00","121.50","1971.00","14","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","195.00","100","","75.00","75.00","75.00","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","195.00","100","","366.00","144.00","1971.00","45","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","142.35","73","","667.50","667.50","667.50","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.68","44.45","","123.77","123.77","123.77","1 through 10","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","both","","","195.00","146.25","WELLPOINT [1015]","HB CH WELLPOINT","151.92","77.91","","483.51","229.32","1316.08","96","86.68","195","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","115.64","59.3","","439.50","225.34","1872.27","197","97.5","152.98","percent of total billed charges",""
"SCREW BONE 4.5X16MM SHOULDER GLENOID HUMERAL COMPONENT REUNION RSA PERIPHERAL REVERSE","SUP-ITM-10138621","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","195.00","146.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","152.98","78.45","","385.32","55.36","1815.62","58","97.5","152.98","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","AETNA [1001]","HB CH AETNA HMO / PPO","108.02","58.3","","554.95","91.85","1421.75","94","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","135.25","73","","2490.03","2490.03","2490.03","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.02","58.3","","750.00","750.00","750.00","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.20","53","","1192.50","120.84","4149.90","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","157.49","85","","750.00","75.00","750.00","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","185.28","100","","657.00","121.50","1971.00","14","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","185.28","100","","75.00","75.00","75.00","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","185.28","100","","366.00","144.00","1971.00","45","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.25","73","","667.50","667.50","667.50","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.36","44.45","","123.77","123.77","123.77","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","WELLPOINT [1015]","HB CH WELLPOINT","144.35","77.91","","483.51","229.32","1316.08","96","82.36","185.28","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.87","59.3","","439.50","225.34","1872.27","197","92.64","145.35","percent of total billed charges",""
"SCREW BONE 4.5X175MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004531","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.35","78.45","","385.32","55.36","1815.62","58","92.64","145.35","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","AETNA [1001]","HB CH AETNA HMO / PPO","224.99","58.3","","554.95","91.85","1421.75","94","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","281.72","73","","2490.03","2490.03","2490.03","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","224.99","58.3","","750.00","750.00","750.00","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","204.54","53","","1192.50","120.84","4149.90","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","328.03","85","","750.00","75.00","750.00","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","385.92","100","","657.00","121.50","1971.00","14","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","385.92","100","","75.00","75.00","75.00","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","385.92","100","","366.00","144.00","1971.00","45","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","281.72","73","","667.50","667.50","667.50","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.54","44.45","","123.77","123.77","123.77","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","WELLPOINT [1015]","HB CH WELLPOINT","300.67","77.91","","483.51","229.32","1316.08","96","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","228.85","59.3","","439.50","225.34","1872.27","197","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","302.75","78.45","","385.32","55.36","1815.62","58","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","AETNA [1001]","HB CH AETNA HMO / PPO","306.08","58.3","","554.95","91.85","1421.75","94","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","383.25","73","","2490.03","2490.03","2490.03","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","306.08","58.3","","750.00","750.00","750.00","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","278.25","53","","1192.50","120.84","4149.90","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","446.25","85","","750.00","75.00","750.00","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","525.00","100","","657.00","121.50","1971.00","14","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","525.00","100","","75.00","75.00","75.00","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","525.00","100","","366.00","144.00","1971.00","45","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","383.25","73","","667.50","667.50","667.50","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","233.36","44.45","","123.77","123.77","123.77","1 through 10","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","both","","","525.00","393.75","WELLPOINT [1015]","HB CH WELLPOINT","409.03","77.91","","483.51","229.32","1316.08","96","233.36","525","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","311.33","59.3","","439.50","225.34","1872.27","197","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5X20MM CANNULATED LPS FIXATION HEXAGONAL TITANIUM SELF DRILLING FULL THREAD PROXIMALIMAL SOCKET","SUP-ITM-10092366","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","525.00","393.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","411.86","78.45","","385.32","55.36","1815.62","58","262.5","411.86","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","AETNA [1001]","HB CH AETNA HMO / PPO","537.40","58.3","","554.95","91.85","1421.75","94","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","672.90","73","","2490.03","2490.03","2490.03","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","537.40","58.3","","750.00","750.00","750.00","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","488.54","53","","1192.50","120.84","4149.90","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","783.51","85","","750.00","75.00","750.00","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","921.78","100","","657.00","121.50","1971.00","14","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","921.78","100","","75.00","75.00","75.00","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","921.78","100","","366.00","144.00","1971.00","45","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","672.90","73","","667.50","667.50","667.50","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","409.73","44.45","","123.77","123.77","123.77","1 through 10","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","both","","","921.78","691.33","WELLPOINT [1015]","HB CH WELLPOINT","718.16","77.91","","483.51","229.32","1316.08","96","409.73","921.78","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.78","691.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","546.62","59.3","","439.50","225.34","1872.27","197","460.89","723.14","percent of total billed charges",""
"SCREW BONE 4.5X22MM HIP SET GAMMA 3 TI SELF TAPPING PARTIAL THREADED","SUP-ITM-10028308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","921.78","691.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","723.14","78.45","","385.32","55.36","1815.62","58","460.89","723.14","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","554.95","91.85","1421.75","94","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","2490.03","2490.03","2490.03","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","750.00","750.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","1192.50","120.84","4149.90","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","193.80","85","","750.00","75.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","228.00","100","","657.00","121.50","1971.00","14","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","228.00","100","","75.00","75.00","75.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","228.00","100","","366.00","144.00","1971.00","45","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","667.50","667.50","667.50","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","123.77","123.77","123.77","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","483.51","229.32","1316.08","96","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","439.50","225.34","1872.27","197","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X22MM SHOULDER KIT COMPRESSION EQUINOXE SS LOCKING CAP REVERSE BLACK","SUP-ITM-10170065","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","385.32","55.36","1815.62","58","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","554.95","91.85","1421.75","94","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","2490.03","2490.03","2490.03","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","750.00","750.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","1192.50","120.84","4149.90","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","227.59","85","","750.00","75.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","267.75","100","","657.00","121.50","1971.00","14","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","267.75","100","","75.00","75.00","75.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","267.75","100","","366.00","144.00","1971.00","45","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","667.50","667.50","667.50","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","123.77","123.77","123.77","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","483.51","229.32","1316.08","96","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","439.50","225.34","1872.27","197","133.88","210.05","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018263","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","385.32","55.36","1815.62","58","133.88","210.05","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","554.95","91.85","1421.75","94","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","2490.03","2490.03","2490.03","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","750.00","750.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","1192.50","120.84","4149.90","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","193.80","85","","750.00","75.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","228.00","100","","657.00","121.50","1971.00","14","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","228.00","100","","75.00","75.00","75.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","228.00","100","","366.00","144.00","1971.00","45","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","667.50","667.50","667.50","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","123.77","123.77","123.77","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","483.51","229.32","1316.08","96","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","439.50","225.34","1872.27","197","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM SHOULDER LOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10022556","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","385.32","55.36","1815.62","58","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","AETNA [1001]","HB CH AETNA HMO / PPO","341.06","58.3","","554.95","91.85","1421.75","94","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","427.05","73","","2490.03","2490.03","2490.03","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","341.06","58.3","","750.00","750.00","750.00","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","310.05","53","","1192.50","120.84","4149.90","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","497.25","85","","750.00","75.00","750.00","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","585.00","100","","657.00","121.50","1971.00","14","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","585.00","100","","75.00","75.00","75.00","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","585.00","100","","366.00","144.00","1971.00","45","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","427.05","73","","667.50","667.50","667.50","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","260.03","44.45","","123.77","123.77","123.77","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","WELLPOINT [1015]","HB CH WELLPOINT","455.77","77.91","","483.51","229.32","1316.08","96","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.91","59.3","","439.50","225.34","1872.27","197","292.5","458.93","percent of total billed charges",""
"SCREW BONE 4.5X24MM TITANIUM LOCKING LOW PROFILE","SUP-ITM-10148122","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.93","78.45","","385.32","55.36","1815.62","58","292.5","458.93","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","554.95","91.85","1421.75","94","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","2490.03","2490.03","2490.03","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","750.00","750.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","1192.50","120.84","4149.90","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","280.50","85","","750.00","75.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","330.00","100","","657.00","121.50","1971.00","14","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","330.00","100","","75.00","75.00","75.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","330.00","100","","366.00","144.00","1971.00","45","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","667.50","667.50","667.50","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","123.77","123.77","123.77","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","483.51","229.32","1316.08","96","146.69","330","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","439.50","225.34","1872.27","197","165","258.89","percent of total billed charges",""
"SCREW BONE 4.5X28MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10072069","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","385.32","55.36","1815.62","58","165","258.89","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","AETNA [1001]","HB CH AETNA HMO / PPO","137.56","58.3","","554.95","91.85","1421.75","94","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","2490.03","2490.03","2490.03","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","137.56","58.3","","750.00","750.00","750.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.05","53","","1192.50","120.84","4149.90","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","200.56","85","","750.00","75.00","750.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","235.95","100","","657.00","121.50","1971.00","14","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","235.95","100","","75.00","75.00","75.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","235.95","100","","366.00","144.00","1971.00","45","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","667.50","667.50","667.50","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","123.77","123.77","123.77","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","WELLPOINT [1015]","HB CH WELLPOINT","183.83","77.91","","483.51","229.32","1316.08","96","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","139.92","59.3","","439.50","225.34","1872.27","197","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X28MM PERIPHERAL NONLOCKING","SUP-ITM-10233522","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","385.32","55.36","1815.62","58","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","AETNA [1001]","HB CH AETNA HMO / PPO","286.84","58.3","","554.95","91.85","1421.75","94","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","359.16","73","","2490.03","2490.03","2490.03","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","286.84","58.3","","750.00","750.00","750.00","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","260.76","53","","1192.50","120.84","4149.90","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","418.20","85","","750.00","75.00","750.00","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","492.00","100","","657.00","121.50","1971.00","14","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","492.00","100","","75.00","75.00","75.00","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","492.00","100","","366.00","144.00","1971.00","45","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","359.16","73","","667.50","667.50","667.50","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","218.69","44.45","","123.77","123.77","123.77","1 through 10","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","both","","","492.00","369.00","WELLPOINT [1015]","HB CH WELLPOINT","383.32","77.91","","483.51","229.32","1316.08","96","218.69","492","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","492.00","369.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","291.76","59.3","","439.50","225.34","1872.27","197","246","385.97","percent of total billed charges",""
"SCREW BONE 4.5X28MM TITANIUM CORTICAL","SUP-ITM-10030013","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","492.00","369.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","385.97","78.45","","385.32","55.36","1815.62","58","246","385.97","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","AETNA [1001]","HB CH AETNA HMO / PPO","137.56","58.3","","554.95","91.85","1421.75","94","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","2490.03","2490.03","2490.03","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","137.56","58.3","","750.00","750.00","750.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.05","53","","1192.50","120.84","4149.90","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","200.56","85","","750.00","75.00","750.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","235.95","100","","657.00","121.50","1971.00","14","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","235.95","100","","75.00","75.00","75.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","235.95","100","","366.00","144.00","1971.00","45","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","667.50","667.50","667.50","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","123.77","123.77","123.77","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","WELLPOINT [1015]","HB CH WELLPOINT","183.83","77.91","","483.51","229.32","1316.08","96","104.88","235.95","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","139.92","59.3","","439.50","225.34","1872.27","197","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM CANCELLOUS UNIVERSAL REVERSAL VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126757","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","385.32","55.36","1815.62","58","117.98","185.1","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","AETNA [1001]","HB CH AETNA HMO / PPO","87.36","58.3","","554.95","91.85","1421.75","94","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.39","73","","2490.03","2490.03","2490.03","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.36","58.3","","750.00","750.00","750.00","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.42","53","","1192.50","120.84","4149.90","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.37","85","","750.00","75.00","750.00","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","149.85","100","","657.00","121.50","1971.00","14","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","149.85","100","","75.00","75.00","75.00","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","149.85","100","","366.00","144.00","1971.00","45","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.39","73","","667.50","667.50","667.50","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.61","44.45","","123.77","123.77","123.77","1 through 10","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","both","","","149.85","112.39","WELLPOINT [1015]","HB CH WELLPOINT","116.75","77.91","","483.51","229.32","1316.08","96","66.61","149.85","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","149.85","112.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.86","59.3","","439.50","225.34","1872.27","197","74.93","117.56","percent of total billed charges",""
"SCREW BONE 4.5X30MM CORTEX SS STANDARD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004461","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","149.85","112.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.56","78.45","","385.32","55.36","1815.62","58","74.93","117.56","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","554.95","91.85","1421.75","94","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","2490.03","2490.03","2490.03","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","750.00","750.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","1192.50","120.84","4149.90","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","193.80","85","","750.00","75.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","228.00","100","","657.00","121.50","1971.00","14","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","228.00","100","","75.00","75.00","75.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","228.00","100","","366.00","144.00","1971.00","45","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","667.50","667.50","667.50","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","123.77","123.77","123.77","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","483.51","229.32","1316.08","96","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","439.50","225.34","1872.27","197","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER LOCKING METAGLENE DELTA REVERSE 08","SUP-ITM-10022557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","385.32","55.36","1815.62","58","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","554.95","91.85","1421.75","94","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","2490.03","2490.03","2490.03","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","132.92","58.3","","750.00","750.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","120.84","53","","1192.50","120.84","4149.90","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","193.80","85","","750.00","75.00","750.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","228.00","100","","657.00","121.50","1971.00","14","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","228.00","100","","75.00","75.00","75.00","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","228.00","100","","366.00","144.00","1971.00","45","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","166.44","73","","667.50","667.50","667.50","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","101.35","44.45","","123.77","123.77","123.77","1 through 10","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","both","","","228.00","171.00","WELLPOINT [1015]","HB CH WELLPOINT","177.63","77.91","","483.51","229.32","1316.08","96","101.35","228","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","439.50","225.34","1872.27","197","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X30MM SHOULDER NONLOCKING METAGLENE DELTA EXTENDED REVERSE 08","SUP-ITM-10025100","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","385.32","55.36","1815.62","58","114","178.87","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","AETNA [1001]","HB CH AETNA HMO / PPO","224.99","58.3","","554.95","91.85","1421.75","94","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","281.72","73","","2490.03","2490.03","2490.03","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","224.99","58.3","","750.00","750.00","750.00","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","204.54","53","","1192.50","120.84","4149.90","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","328.03","85","","750.00","75.00","750.00","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","385.92","100","","657.00","121.50","1971.00","14","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","385.92","100","","75.00","75.00","75.00","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","385.92","100","","366.00","144.00","1971.00","45","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","281.72","73","","667.50","667.50","667.50","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","171.54","44.45","","123.77","123.77","123.77","1 through 10","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","both","","","385.92","289.44","WELLPOINT [1015]","HB CH WELLPOINT","300.67","77.91","","483.51","229.32","1316.08","96","171.54","385.92","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","228.85","59.3","","439.50","225.34","1872.27","197","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANCELLOUS SS CANNULATED SELF DRILLING TAPPING 1/3 THREAD LG HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10002087","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","385.92","289.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","302.75","78.45","","385.32","55.36","1815.62","58","192.96","302.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","AETNA [1001]","HB CH AETNA HMO / PPO","231.15","58.3","","554.95","91.85","1421.75","94","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","289.43","73","","2490.03","2490.03","2490.03","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","231.15","58.3","","750.00","750.00","750.00","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","210.13","53","","1192.50","120.84","4149.90","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","337.01","85","","750.00","75.00","750.00","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","396.48","100","","657.00","121.50","1971.00","14","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","396.48","100","","75.00","75.00","75.00","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","396.48","100","","366.00","144.00","1971.00","45","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","289.43","73","","667.50","667.50","667.50","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","176.24","44.45","","123.77","123.77","123.77","1 through 10","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","both","","","396.48","297.36","WELLPOINT [1015]","HB CH WELLPOINT","308.90","77.91","","483.51","229.32","1316.08","96","176.24","396.48","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","235.11","59.3","","439.50","225.34","1872.27","197","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X32MM CANNULATED SS SELF DRILLING TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10002134","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","396.48","297.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","311.04","78.45","","385.32","55.36","1815.62","58","198.24","311.04","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","AETNA [1001]","HB CH AETNA HMO / PPO","324.00","58.3","","554.95","91.85","1421.75","94","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","405.70","73","","2490.03","2490.03","2490.03","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","324.00","58.3","","750.00","750.00","750.00","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","294.55","53","","1192.50","120.84","4149.90","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","472.39","85","","750.00","75.00","750.00","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","555.75","100","","657.00","121.50","1971.00","14","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","555.75","100","","75.00","75.00","75.00","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","555.75","100","","366.00","144.00","1971.00","45","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","405.70","73","","667.50","667.50","667.50","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","247.03","44.45","","123.77","123.77","123.77","1 through 10","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.75","416.81","WELLPOINT [1015]","HB CH WELLPOINT","432.98","77.91","","483.51","229.32","1316.08","96","247.03","555.75","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.75","416.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.56","59.3","","439.50","225.34","1872.27","197","277.88","435.99","percent of total billed charges",""
"SCREW BONE 4.5X32MM SILVERBACK NONLOCKING PLATE","SUP-ITM-10238138","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.75","416.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","435.99","78.45","","385.32","55.36","1815.62","58","277.88","435.99","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE XIA 3 TITANIUM POLYAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086488","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1830.28","315.58","1830.28","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE XIA 3 TITANIUM POLYAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086488","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","4170.85","4170.85","4170.85","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE XIA 3 TITANIUM POLYAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086488","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","649.55","649.55","649.55","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE XIA 3 TITANIUM POLYAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086488","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","8998.38","2542.37","8998.38","20","533.4","1200","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE XIA 3 TITANIUM POLYAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1891.61","1609.14","3664.18","25","600","941.4","percent of total billed charges",""
"SCREW BONE 4.5X35MM SPINE XIA 3 TITANIUM POLYAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086488","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1470.68","1310.06","2481.69","19","600","941.4","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","AETNA [1001]","HB CH AETNA HMO / PPO","106.72","58.3","","554.95","91.85","1421.75","94","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","133.63","73","","2490.03","2490.03","2490.03","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","106.72","58.3","","750.00","750.00","750.00","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.02","53","","1192.50","120.84","4149.90","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","155.60","85","","750.00","75.00","750.00","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","183.06","100","","657.00","121.50","1971.00","14","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","183.06","100","","75.00","75.00","75.00","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","183.06","100","","366.00","144.00","1971.00","45","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.63","73","","667.50","667.50","667.50","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.37","44.45","","123.77","123.77","123.77","1 through 10","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","WELLPOINT [1015]","HB CH WELLPOINT","142.62","77.91","","483.51","229.32","1316.08","96","81.37","183.06","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.55","59.3","","439.50","225.34","1872.27","197","91.53","143.61","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTEX AXSOS LOCKING TITANIUM","SUP-ITM-10145002","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.61","78.45","","385.32","55.36","1815.62","58","91.53","143.61","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","AETNA [1001]","HB CH AETNA HMO / PPO","270.05","58.3","","554.95","91.85","1421.75","94","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","338.14","73","","2490.03","2490.03","2490.03","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","270.05","58.3","","750.00","750.00","750.00","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.50","53","","1192.50","120.84","4149.90","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","393.72","85","","750.00","75.00","750.00","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","463.20","100","","657.00","121.50","1971.00","14","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","463.20","100","","75.00","75.00","75.00","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","463.20","100","","366.00","144.00","1971.00","45","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.14","73","","667.50","667.50","667.50","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.89","44.45","","123.77","123.77","123.77","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","WELLPOINT [1015]","HB CH WELLPOINT","360.88","77.91","","483.51","229.32","1316.08","96","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.20","347.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.68","59.3","","439.50","225.34","1872.27","197","231.6","363.38","percent of total billed charges",""
"SCREW BONE 4.5X36MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.20","347.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","363.38","78.45","","385.32","55.36","1815.62","58","231.6","363.38","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","AETNA [1001]","HB CH AETNA HMO / PPO","1617.83","58.3","","554.95","91.85","1421.75","94","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","2490.03","2490.03","2490.03","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1617.83","58.3","","750.00","750.00","750.00","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1470.75","53","","1192.50","120.84","4149.90","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2358.75","85","","750.00","75.00","750.00","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2775.00","100","","657.00","121.50","1971.00","14","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2775.00","100","","75.00","75.00","75.00","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2775.00","100","","366.00","144.00","1971.00","45","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2025.75","73","","667.50","667.50","667.50","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1233.49","44.45","","123.77","123.77","123.77","1 through 10","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","both","","","2775.00","2081.25","WELLPOINT [1015]","HB CH WELLPOINT","2162.00","77.91","","483.51","229.32","1316.08","96","1233.49","2775","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1645.58","59.3","","439.50","225.34","1872.27","197","1387.5","2176.99","percent of total billed charges",""
"SCREW BONE 4.5X36MM FOOT CHARLOTTE LISFRANC TITANIUM","SUP-ITM-10056896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2775.00","2081.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2176.99","78.45","","385.32","55.36","1815.62","58","1387.5","2176.99","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","AETNA [1001]","HB CH AETNA HMO / PPO","341.06","58.3","","554.95","91.85","1421.75","94","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","427.05","73","","2490.03","2490.03","2490.03","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","341.06","58.3","","750.00","750.00","750.00","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","310.05","53","","1192.50","120.84","4149.90","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","497.25","85","","750.00","75.00","750.00","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","585.00","100","","657.00","121.50","1971.00","14","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","585.00","100","","75.00","75.00","75.00","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","585.00","100","","366.00","144.00","1971.00","45","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","427.05","73","","667.50","667.50","667.50","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","260.03","44.45","","123.77","123.77","123.77","1 through 10","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.00","438.75","WELLPOINT [1015]","HB CH WELLPOINT","455.77","77.91","","483.51","229.32","1316.08","96","260.03","585","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.91","59.3","","439.50","225.34","1872.27","197","292.5","458.93","percent of total billed charges",""
"SCREW BONE 4.5X36MM TITANIUM LOW PROFILE LOCKING AR-8545L-36","SUP-ITM-10149077","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.00","438.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.93","78.45","","385.32","55.36","1815.62","58","292.5","458.93","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","554.95","91.85","1421.75","94","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","2490.03","2490.03","2490.03","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","271.10","58.3","","750.00","750.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.45","53","","1192.50","120.84","4149.90","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","395.25","85","","750.00","75.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","465.00","100","","657.00","121.50","1971.00","14","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","465.00","100","","75.00","75.00","75.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","465.00","100","","366.00","144.00","1971.00","45","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","667.50","667.50","667.50","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","123.77","123.77","123.77","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","483.51","229.32","1316.08","96","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","439.50","225.34","1872.27","197","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX FIXATION TITANIUM","SUP-ITM-10079353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","385.32","55.36","1815.62","58","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","AETNA [1001]","HB CH AETNA HMO / PPO","97.37","58.3","","554.95","91.85","1421.75","94","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","121.92","73","","2490.03","2490.03","2490.03","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","97.37","58.3","","750.00","750.00","750.00","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","88.52","53","","1192.50","120.84","4149.90","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","141.96","85","","750.00","75.00","750.00","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","167.01","100","","657.00","121.50","1971.00","14","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","167.01","100","","75.00","75.00","75.00","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","167.01","100","","366.00","144.00","1971.00","45","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","121.92","73","","667.50","667.50","667.50","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","74.24","44.45","","123.77","123.77","123.77","1 through 10","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","both","","","167.01","125.26","WELLPOINT [1015]","HB CH WELLPOINT","130.12","77.91","","483.51","229.32","1316.08","96","74.24","167.01","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","99.04","59.3","","439.50","225.34","1872.27","197","83.51","131.02","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTEX OMEGA 3 SS SELF TAPPING FULL THREAD","SUP-ITM-10016891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","167.01","125.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.02","78.45","","385.32","55.36","1815.62","58","83.51","131.02","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","AETNA [1001]","HB CH AETNA HMO / PPO","87.90","58.3","","554.95","91.85","1421.75","94","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","110.07","73","","2490.03","2490.03","2490.03","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.90","58.3","","750.00","750.00","750.00","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.91","53","","1192.50","120.84","4149.90","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","128.16","85","","750.00","75.00","750.00","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.78","100","","657.00","121.50","1971.00","14","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.78","100","","75.00","75.00","75.00","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.78","100","","366.00","144.00","1971.00","45","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.07","73","","667.50","667.50","667.50","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.02","44.45","","123.77","123.77","123.77","1 through 10","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.78","113.08","WELLPOINT [1015]","HB CH WELLPOINT","117.47","77.91","","483.51","229.32","1316.08","96","67.02","150.78","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.78","113.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.41","59.3","","439.50","225.34","1872.27","197","75.39","118.29","percent of total billed charges",""
"SCREW BONE 4.5X40MM CORTICAL TITANIUM NONLOCKING FULL THREAD","SUP-ITM-10056504","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.78","113.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.29","78.45","","385.32","55.36","1815.62","58","75.39","118.29","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","AETNA [1001]","HB CH AETNA HMO / PPO","51.77","58.3","","554.95","91.85","1421.75","94","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","64.82","73","","2490.03","2490.03","2490.03","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","51.77","58.3","","750.00","750.00","750.00","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","47.06","53","","1192.50","120.84","4149.90","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","75.48","85","","750.00","75.00","750.00","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","88.80","100","","657.00","121.50","1971.00","14","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","88.80","100","","75.00","75.00","75.00","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","88.80","100","","366.00","144.00","1971.00","45","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","64.82","73","","667.50","667.50","667.50","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","39.47","44.45","","123.77","123.77","123.77","1 through 10","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","both","","","88.80","66.60","WELLPOINT [1015]","HB CH WELLPOINT","69.18","77.91","","483.51","229.32","1316.08","96","39.47","88.8","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.80","66.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","52.66","59.3","","439.50","225.34","1872.27","197","44.4","69.66","percent of total billed charges",""
"SCREW BONE 4.5X42MM CORTEX TITANIUM SELF TAPPING LG HEXAGONAL SOCKET","SUP-ITM-10040241","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","88.80","66.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","69.66","78.45","","385.32","55.36","1815.62","58","44.4","69.66","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","554.95","91.85","1421.75","94","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","2490.03","2490.03","2490.03","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","750.00","750.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","1192.50","120.84","4149.90","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","227.59","85","","750.00","75.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","267.75","100","","657.00","121.50","1971.00","14","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","267.75","100","","75.00","75.00","75.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","267.75","100","","366.00","144.00","1971.00","45","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","667.50","667.50","667.50","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","123.77","123.77","123.77","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","483.51","229.32","1316.08","96","119.01","267.75","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","439.50","225.34","1872.27","197","133.88","210.05","percent of total billed charges",""
"SCREW BONE 4.5X42MM SHOULDER CANCELLOUS INVERSE REVERSE 08","SUP-ITM-10018186","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","385.32","55.36","1815.62","58","133.88","210.05","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","AETNA [1001]","HB CH AETNA HMO / PPO","270.05","58.3","","554.95","91.85","1421.75","94","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","338.14","73","","2490.03","2490.03","2490.03","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","270.05","58.3","","750.00","750.00","750.00","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.50","53","","1192.50","120.84","4149.90","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","393.72","85","","750.00","75.00","750.00","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","463.20","100","","657.00","121.50","1971.00","14","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","463.20","100","","75.00","75.00","75.00","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","463.20","100","","366.00","144.00","1971.00","45","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.14","73","","667.50","667.50","667.50","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","205.89","44.45","","123.77","123.77","123.77","1 through 10","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.20","347.40","WELLPOINT [1015]","HB CH WELLPOINT","360.88","77.91","","483.51","229.32","1316.08","96","205.89","463.2","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.20","347.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.68","59.3","","439.50","225.34","1872.27","197","231.6","363.38","percent of total billed charges",""
"SCREW BONE 4.5X45MM CORTICAL TITANIUM LOCKING SELF TAPPING FULL THREAD","SUP-ITM-10023300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.20","347.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","363.38","78.45","","385.32","55.36","1815.62","58","231.6","363.38","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","AETNA [1001]","HB CH AETNA HMO / PPO","47.24","58.3","","554.95","91.85","1421.75","94","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","59.15","73","","2490.03","2490.03","2490.03","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","47.24","58.3","","750.00","750.00","750.00","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.95","53","","1192.50","120.84","4149.90","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","68.88","85","","750.00","75.00","750.00","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","81.03","100","","657.00","121.50","1971.00","14","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","81.03","100","","75.00","75.00","75.00","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","81.03","100","","366.00","144.00","1971.00","45","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","59.15","73","","667.50","667.50","667.50","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.02","44.45","","123.77","123.77","123.77","1 through 10","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","both","","","81.03","60.77","WELLPOINT [1015]","HB CH WELLPOINT","63.13","77.91","","483.51","229.32","1316.08","96","36.02","81.03","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.03","60.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.05","59.3","","439.50","225.34","1872.27","197","40.52","63.57","percent of total billed charges",""
"SCREW BONE 4.5X46MM CORTEX SS SELF TAPPING FULL THREAD LG HEXAGONAL SOCKET","SUP-ITM-10001507","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","81.03","60.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.57","78.45","","385.32","55.36","1815.62","58","40.52","63.57","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","554.95","91.85","1421.75","94","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","2490.03","2490.03","2490.03","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","271.10","58.3","","750.00","750.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.45","53","","1192.50","120.84","4149.90","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","395.25","85","","750.00","75.00","750.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","465.00","100","","657.00","121.50","1971.00","14","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","465.00","100","","75.00","75.00","75.00","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","465.00","100","","366.00","144.00","1971.00","45","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","339.45","73","","667.50","667.50","667.50","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.69","44.45","","123.77","123.77","123.77","1 through 10","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","483.51","229.32","1316.08","96","206.69","465","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","439.50","225.34","1872.27","197","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5X46MM TITANIUM CORTICAL","SUP-ITM-10079356","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","385.32","55.36","1815.62","58","232.5","364.79","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","AETNA [1001]","HB CH AETNA HMO / PPO","45.47","58.3","","554.95","91.85","1421.75","94","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","2490.03","2490.03","2490.03","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","45.47","58.3","","750.00","750.00","750.00","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","41.34","53","","1192.50","120.84","4149.90","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","66.30","85","","750.00","75.00","750.00","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","78.00","100","","657.00","121.50","1971.00","14","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","78.00","100","","75.00","75.00","75.00","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","78.00","100","","366.00","144.00","1971.00","45","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","56.94","73","","667.50","667.50","667.50","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","34.67","44.45","","123.77","123.77","123.77","1 through 10","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","both","","","78.00","58.50","WELLPOINT [1015]","HB CH WELLPOINT","60.77","77.91","","483.51","229.32","1316.08","96","34.67","78","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","46.25","59.3","","439.50","225.34","1872.27","197","39","61.19","percent of total billed charges",""
"SCREW BONE 4.5X48MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10017859","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","78.00","58.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","61.19","78.45","","385.32","55.36","1815.62","58","39","61.19","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","AETNA [1001]","HB CH AETNA HMO / PPO","46.84","58.3","","554.95","91.85","1421.75","94","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","2490.03","2490.03","2490.03","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","46.84","58.3","","750.00","750.00","750.00","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","42.58","53","","1192.50","120.84","4149.90","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","68.29","85","","750.00","75.00","750.00","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","80.34","100","","657.00","121.50","1971.00","14","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","80.34","100","","75.00","75.00","75.00","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","80.34","100","","366.00","144.00","1971.00","45","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","58.65","73","","667.50","667.50","667.50","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","35.71","44.45","","123.77","123.77","123.77","1 through 10","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","both","","","80.34","60.25","WELLPOINT [1015]","HB CH WELLPOINT","62.59","77.91","","483.51","229.32","1316.08","96","35.71","80.34","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","47.64","59.3","","439.50","225.34","1872.27","197","40.17","63.03","percent of total billed charges",""
"SCREW BONE 4.5X50MM CORTICAL TK2 TITANIUM SOLID SELF TAPPING FULLY THREADED","SUP-ITM-10016951","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","80.34","60.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","63.03","78.45","","385.32","55.36","1815.62","58","40.17","63.03","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","AETNA [1001]","HB CH AETNA HMO / PPO","323.57","58.3","","554.95","91.85","1421.75","94","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","405.15","73","","2490.03","2490.03","2490.03","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","323.57","58.3","","750.00","750.00","750.00","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","294.15","53","","1192.50","120.84","4149.90","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","471.75","85","","750.00","75.00","750.00","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","555.00","100","","657.00","121.50","1971.00","14","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","555.00","100","","75.00","75.00","75.00","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","555.00","100","","366.00","144.00","1971.00","45","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","405.15","73","","667.50","667.50","667.50","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","246.70","44.45","","123.77","123.77","123.77","1 through 10","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","both","","","555.00","416.25","WELLPOINT [1015]","HB CH WELLPOINT","432.40","77.91","","483.51","229.32","1316.08","96","246.7","555","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","329.12","59.3","","439.50","225.34","1872.27","197","277.5","435.4","percent of total billed charges",""
"SCREW BONE 4.5X50MM TITANIUM SELF CUTTING FULL THREAD BLUNT TIP MULTILOC SUTURE HOLE COUNTERSINK HEAD GOLD","SUP-ITM-10095896","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","555.00","416.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","435.40","78.45","","385.32","55.36","1815.62","58","277.5","435.4","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","554.95","91.85","1421.75","94","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","2490.03","2490.03","2490.03","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","750.00","750.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","1192.50","120.84","4149.90","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2065.50","85","","750.00","75.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2430.00","100","","657.00","121.50","1971.00","14","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2430.00","100","","75.00","75.00","75.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2430.00","100","","366.00","144.00","1971.00","45","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","667.50","667.50","667.50","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","123.77","123.77","123.77","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","483.51","229.32","1316.08","96","1080.14","2430","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","439.50","225.34","1872.27","197","1215","1906.34","percent of total billed charges",""
"SCREW BONE 4.5X65MM FOOT JONES LOW PROFILE SS","SUP-ITM-10046547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","385.32","55.36","1815.62","58","1215","1906.34","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","554.95","91.85","1421.75","94","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","2490.03","2490.03","2490.03","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.67","58.3","","750.00","750.00","750.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","1192.50","120.84","4149.90","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","216.75","85","","750.00","75.00","750.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","255.00","100","","657.00","121.50","1971.00","14","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","255.00","100","","75.00","75.00","75.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","255.00","100","","366.00","144.00","1971.00","45","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","667.50","667.50","667.50","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","123.77","123.77","123.77","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","483.51","229.32","1316.08","96","113.35","255","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","439.50","225.34","1872.27","197","127.5","200.05","percent of total billed charges",""
"SCREW BONE 40.0X4.5MM TIBIAL CORTICAL HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042407","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","385.32","55.36","1815.62","58","127.5","200.05","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","554.95","91.85","1421.75","94","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","2490.03","2490.03","2490.03","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","750.00","750.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","1192.50","120.84","4149.90","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","382.50","85","","750.00","75.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.00","100","","657.00","121.50","1971.00","14","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","450.00","100","","75.00","75.00","75.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","366.00","144.00","1971.00","45","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","667.50","667.50","667.50","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","123.77","123.77","123.77","1 through 10","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","483.51","229.32","1316.08","96","200.03","450","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","439.50","225.34","1872.27","197","225","353.03","percent of total billed charges",""
"SCREW BONE 40X3MM QUICKFIX CANNULATED FIXATION TI PARTIAL THREAD LOW PROFILE","SUP-ITM-10115966","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","385.32","55.36","1815.62","58","225","353.03","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","AETNA [1001]","HB CH AETNA HMO / PPO","1390.46","58.3","","554.95","91.85","1421.75","94","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","2490.03","2490.03","2490.03","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.46","58.3","","750.00","750.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1264.05","53","","1192.50","120.84","4149.90","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2027.25","85","","750.00","75.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2385.00","100","","657.00","121.50","1971.00","14","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2385.00","100","","75.00","75.00","75.00","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2385.00","100","","366.00","144.00","1971.00","45","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","667.50","667.50","667.50","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","123.77","123.77","123.77","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","WELLPOINT [1015]","HB CH WELLPOINT","1858.15","77.91","","483.51","229.32","1316.08","96","1060.13","2385","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.31","59.3","","439.50","225.34","1872.27","197","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 40X4.5MM METATARSAL FIXED ANGLE TITANIUM LOW PROFILE PARTIAL THREAD HEAD","SUP-ITM-10136388","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","385.32","55.36","1815.62","58","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","554.95","91.85","1421.75","94","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","2490.03","2490.03","2490.03","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","750.00","750.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","1192.50","120.84","4149.90","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.90","85","","750.00","75.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","114.00","100","","657.00","121.50","1971.00","14","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","114.00","100","","75.00","75.00","75.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","114.00","100","","366.00","144.00","1971.00","45","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","667.50","667.50","667.50","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","123.77","123.77","123.77","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","483.51","229.32","1316.08","96","50.67","114","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","439.50","225.34","1872.27","197","57","89.43","percent of total billed charges",""
"SCREW BONE 40X6.5MM CANCELLOUS PLATE RESTORATION GAP S/S HIP 16A","SUP-ITM-10006597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","385.32","55.36","1815.62","58","57","89.43","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","554.95","91.85","1421.75","94","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","2490.03","2490.03","2490.03","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.67","58.3","","750.00","750.00","750.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","1192.50","120.84","4149.90","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","216.75","85","","750.00","75.00","750.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","255.00","100","","657.00","121.50","1971.00","14","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","255.00","100","","75.00","75.00","75.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","255.00","100","","366.00","144.00","1971.00","45","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","667.50","667.50","667.50","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","123.77","123.77","123.77","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","483.51","229.32","1316.08","96","113.35","255","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","439.50","225.34","1872.27","197","127.5","200.05","percent of total billed charges",""
"SCREW BONE 40X6.5MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10056516","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","385.32","55.36","1815.62","58","127.5","200.05","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","554.95","91.85","1421.75","94","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2490.03","2490.03","2490.03","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","750.00","750.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","1192.50","120.84","4149.90","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","750.00","75.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","657.00","121.50","1971.00","14","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","75.00","75.00","75.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","366.00","144.00","1971.00","45","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","667.50","667.50","667.50","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","123.77","123.77","123.77","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","483.51","229.32","1316.08","96","533.4","1200","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","439.50","225.34","1872.27","197","600","941.4","percent of total billed charges",""
"SCREW BONE 40X6MM SPINE PEDICLE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10018107","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","385.32","55.36","1815.62","58","600","941.4","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","AETNA [1001]","HB CH AETNA HMO / PPO","137.56","58.3","","554.95","91.85","1421.75","94","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","2490.03","2490.03","2490.03","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","137.56","58.3","","750.00","750.00","750.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.05","53","","1192.50","120.84","4149.90","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","200.56","85","","750.00","75.00","750.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","235.95","100","","657.00","121.50","1971.00","14","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","235.95","100","","75.00","75.00","75.00","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","235.95","100","","366.00","144.00","1971.00","45","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","172.24","73","","667.50","667.50","667.50","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","104.88","44.45","","123.77","123.77","123.77","1 through 10","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","both","","","235.95","176.96","WELLPOINT [1015]","HB CH WELLPOINT","183.83","77.91","","483.51","229.32","1316.08","96","104.88","235.95","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","139.92","59.3","","439.50","225.34","1872.27","197","117.98","185.1","percent of total billed charges",""
"SCREW BONE 42MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING PERIPHERAL","SUP-ITM-10126756","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","235.95","176.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.10","78.45","","385.32","55.36","1815.62","58","117.98","185.1","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","AETNA [1001]","HB CH AETNA HMO / PPO","351.55","58.3","","554.95","91.85","1421.75","94","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","440.19","73","","2490.03","2490.03","2490.03","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","351.55","58.3","","750.00","750.00","750.00","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","319.59","53","","1192.50","120.84","4149.90","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","512.55","85","","750.00","75.00","750.00","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","603.00","100","","657.00","121.50","1971.00","14","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","603.00","100","","75.00","75.00","75.00","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","603.00","100","","366.00","144.00","1971.00","45","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","440.19","73","","667.50","667.50","667.50","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","268.03","44.45","","123.77","123.77","123.77","1 through 10","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","both","","","603.00","452.25","WELLPOINT [1015]","HB CH WELLPOINT","469.80","77.91","","483.51","229.32","1316.08","96","268.03","603","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.00","452.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","357.58","59.3","","439.50","225.34","1872.27","197","301.5","473.05","percent of total billed charges",""
"SCREW BONE 44X3.5MM ORTHOLOC TITANIUM LOCK PLATING SYSTEM","SUP-ITM-10132049","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","603.00","452.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","473.05","78.45","","385.32","55.36","1815.62","58","301.5","473.05","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","554.95","91.85","1421.75","94","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","2490.03","2490.03","2490.03","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","750.00","750.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","1192.50","120.84","4149.90","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.25","85","","750.00","75.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.00","100","","657.00","121.50","1971.00","14","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.00","100","","75.00","75.00","75.00","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.00","100","","366.00","144.00","1971.00","45","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","667.50","667.50","667.50","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","123.77","123.77","123.77","1 through 10","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","483.51","229.32","1316.08","96","46.67","105","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","439.50","225.34","1872.27","197","52.5","82.37","percent of total billed charges",""
"SCREW BONE 45.0X3.5MM CORTICAL SS NONLOCKING LOW PROFILE","SUP-ITM-10076886","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","385.32","55.36","1815.62","58","52.5","82.37","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","AETNA [1001]","HB CH AETNA HMO / PPO","99.17","58.3","","554.95","91.85","1421.75","94","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","124.17","73","","2490.03","2490.03","2490.03","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","99.17","58.3","","750.00","750.00","750.00","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","90.15","53","","1192.50","120.84","4149.90","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","144.59","85","","750.00","75.00","750.00","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","170.10","100","","657.00","121.50","1971.00","14","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","170.10","100","","75.00","75.00","75.00","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","170.10","100","","366.00","144.00","1971.00","45","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","124.17","73","","667.50","667.50","667.50","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.61","44.45","","123.77","123.77","123.77","1 through 10","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","both","","","170.10","127.57","WELLPOINT [1015]","HB CH WELLPOINT","132.52","77.91","","483.51","229.32","1316.08","96","75.61","170.1","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.87","59.3","","439.50","225.34","1872.27","197","85.05","133.44","percent of total billed charges",""
"SCREW BONE 48MM KNEE TITANIUM FIXATION HEX HEADED","SUP-ITM-10021361","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","170.10","127.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","133.44","78.45","","385.32","55.36","1815.62","58","85.05","133.44","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","AETNA [1001]","HB CH AETNA HMO / PPO","365.63","58.3","","554.95","91.85","1421.75","94","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","457.82","73","","2490.03","2490.03","2490.03","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","365.63","58.3","","750.00","750.00","750.00","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","332.39","53","","1192.50","120.84","4149.90","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","533.08","85","","750.00","75.00","750.00","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","627.15","100","","657.00","121.50","1971.00","14","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","627.15","100","","75.00","75.00","75.00","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","627.15","100","","366.00","144.00","1971.00","45","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","457.82","73","","667.50","667.50","667.50","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","278.77","44.45","","123.77","123.77","123.77","1 through 10","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","both","","","627.15","470.36","WELLPOINT [1015]","HB CH WELLPOINT","488.61","77.91","","483.51","229.32","1316.08","96","278.77","627.15","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.15","470.36","CIGNA [1006]","HB CH CIGNA HMO / PPO","371.90","59.3","","439.50","225.34","1872.27","197","313.58","492","percent of total billed charges",""
"SCREW BONE 4X150MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 40MM THREAD","SUP-ITM-10038637","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","627.15","470.36","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","492.00","78.45","","385.32","55.36","1815.62","58","313.58","492","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","554.95","91.85","1421.75","94","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","2490.03","2490.03","2490.03","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","750.00","750.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","1192.50","120.84","4149.90","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","280.50","85","","750.00","75.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","330.00","100","","657.00","121.50","1971.00","14","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","330.00","100","","75.00","75.00","75.00","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","330.00","100","","366.00","144.00","1971.00","45","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","667.50","667.50","667.50","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","123.77","123.77","123.77","1 through 10","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","483.51","229.32","1316.08","96","146.69","330","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","439.50","225.34","1872.27","197","165","258.89","percent of total billed charges",""
"SCREW BONE 4X18MM SPINE SKYLINE TITANIUM VARIABLE ANGLE SELF TAPPING","SUP-ITM-10126272","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","385.32","55.36","1815.62","58","165","258.89","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","AETNA [1001]","HB CH AETNA HMO / PPO","213.80","58.3","","554.95","91.85","1421.75","94","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","267.71","73","","2490.03","2490.03","2490.03","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","213.80","58.3","","750.00","750.00","750.00","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","194.36","53","","1192.50","120.84","4149.90","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","311.71","85","","750.00","75.00","750.00","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","366.72","100","","657.00","121.50","1971.00","14","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","366.72","100","","75.00","75.00","75.00","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","366.72","100","","366.00","144.00","1971.00","45","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","267.71","73","","667.50","667.50","667.50","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","163.01","44.45","","123.77","123.77","123.77","1 through 10","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","both","","","366.72","275.04","WELLPOINT [1015]","HB CH WELLPOINT","285.71","77.91","","483.51","229.32","1316.08","96","163.01","366.72","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.72","275.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","217.46","59.3","","439.50","225.34","1872.27","197","183.36","287.69","percent of total billed charges",""
"SCREW BONE 4X20MM CANNULATED SS SELF DRILLING TAPPING SHORT THREAD HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10003852","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","366.72","275.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","287.69","78.45","","385.32","55.36","1815.62","58","183.36","287.69","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","AETNA [1001]","HB CH AETNA HMO / PPO","235.07","58.3","","554.95","91.85","1421.75","94","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","294.34","73","","2490.03","2490.03","2490.03","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","235.07","58.3","","750.00","750.00","750.00","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","213.70","53","","1192.50","120.84","4149.90","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","342.72","85","","750.00","75.00","750.00","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","403.20","100","","657.00","121.50","1971.00","14","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","403.20","100","","75.00","75.00","75.00","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","403.20","100","","366.00","144.00","1971.00","45","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","294.34","73","","667.50","667.50","667.50","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","179.22","44.45","","123.77","123.77","123.77","1 through 10","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","both","","","403.20","302.40","WELLPOINT [1015]","HB CH WELLPOINT","314.13","77.91","","483.51","229.32","1316.08","96","179.22","403.2","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.20","302.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","239.10","59.3","","439.50","225.34","1872.27","197","201.6","316.31","percent of total billed charges",""
"SCREW BONE 4X24MM CANCELLOUS TITANIUM CANNULATED SHORT THREAD","SUP-ITM-10039858","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","403.20","302.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","316.31","78.45","","385.32","55.36","1815.62","58","201.6","316.31","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","AETNA [1001]","HB CH AETNA HMO / PPO","791.63","58.3","","554.95","91.85","1421.75","94","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","991.24","73","","2490.03","2490.03","2490.03","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","791.63","58.3","","750.00","750.00","750.00","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","719.67","53","","1192.50","120.84","4149.90","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1154.18","85","","750.00","75.00","750.00","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1357.86","100","","657.00","121.50","1971.00","14","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1357.86","100","","75.00","75.00","75.00","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1357.86","100","","366.00","144.00","1971.00","45","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","991.24","73","","667.50","667.50","667.50","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","603.57","44.45","","123.77","123.77","123.77","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","WELLPOINT [1015]","HB CH WELLPOINT","1057.91","77.91","","483.51","229.32","1316.08","96","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1357.86","1018.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","805.21","59.3","","439.50","225.34","1872.27","197","678.93","1065.24","percent of total billed charges",""
"SCREW BONE 4X24MM FIXOS TITANIUM COMPRESSION HEADLESS","SUP-ITM-10144823","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1357.86","1018.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1065.24","78.45","","385.32","55.36","1815.62","58","678.93","1065.24","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","AETNA [1001]","HB CH AETNA HMO / PPO","195.43","58.3","","554.95","91.85","1421.75","94","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","244.71","73","","2490.03","2490.03","2490.03","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","195.43","58.3","","750.00","750.00","750.00","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","177.67","53","","1192.50","120.84","4149.90","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","284.94","85","","750.00","75.00","750.00","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","335.22","100","","657.00","121.50","1971.00","14","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","335.22","100","","75.00","75.00","75.00","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","335.22","100","","366.00","144.00","1971.00","45","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","244.71","73","","667.50","667.50","667.50","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.01","44.45","","123.77","123.77","123.77","1 through 10","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","both","","","335.22","251.41","WELLPOINT [1015]","HB CH WELLPOINT","261.17","77.91","","483.51","229.32","1316.08","96","149.01","335.22","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","335.22","251.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.79","59.3","","439.50","225.34","1872.27","197","167.61","262.98","percent of total billed charges",""
"SCREW BONE 4X26MM FIXATION SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS","SUP-ITM-10020175","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","335.22","251.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.98","78.45","","385.32","55.36","1815.62","58","167.61","262.98","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","AETNA [1001]","HB CH AETNA HMO / PPO","792.65","58.3","","554.95","91.85","1421.75","94","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","992.51","73","","2490.03","2490.03","2490.03","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","792.65","58.3","","750.00","750.00","750.00","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","720.59","53","","1192.50","120.84","4149.90","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1155.66","85","","750.00","75.00","750.00","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1359.60","100","","657.00","121.50","1971.00","14","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1359.60","100","","75.00","75.00","75.00","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1359.60","100","","366.00","144.00","1971.00","45","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","992.51","73","","667.50","667.50","667.50","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","604.34","44.45","","123.77","123.77","123.77","1 through 10","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","both","","","1359.60","1019.70","WELLPOINT [1015]","HB CH WELLPOINT","1059.26","77.91","","483.51","229.32","1316.08","96","604.34","1359.6","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1359.60","1019.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","806.24","59.3","","439.50","225.34","1872.27","197","679.8","1066.61","percent of total billed charges",""
"SCREW BONE 4X26MM MAX VPC VARIABLE PITCH COMPRESSION","SUP-ITM-10175116","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1359.60","1019.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1066.61","78.45","","385.32","55.36","1815.62","58","679.8","1066.61","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","554.95","91.85","1421.75","94","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","2490.03","2490.03","2490.03","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","288.59","58.3","","750.00","750.00","750.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","1192.50","120.84","4149.90","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","420.75","85","","750.00","75.00","750.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","495.00","100","","657.00","121.50","1971.00","14","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","495.00","100","","75.00","75.00","75.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","495.00","100","","366.00","144.00","1971.00","45","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","667.50","667.50","667.50","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","123.77","123.77","123.77","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","483.51","229.32","1316.08","96","220.03","495","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","439.50","225.34","1872.27","197","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X26MM QUICKFIX CANNULATED TI PARTIAL SHORT THREAD","SUP-ITM-10154033","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","385.32","55.36","1815.62","58","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","AETNA [1001]","HB CH AETNA HMO / PPO","195.89","58.3","","554.95","91.85","1421.75","94","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","245.28","73","","2490.03","2490.03","2490.03","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","195.89","58.3","","750.00","750.00","750.00","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","178.08","53","","1192.50","120.84","4149.90","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","285.60","85","","750.00","75.00","750.00","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","336.00","100","","657.00","121.50","1971.00","14","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","336.00","100","","75.00","75.00","75.00","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","336.00","100","","366.00","144.00","1971.00","45","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","245.28","73","","667.50","667.50","667.50","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.35","44.45","","123.77","123.77","123.77","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","WELLPOINT [1015]","HB CH WELLPOINT","261.78","77.91","","483.51","229.32","1316.08","96","149.35","336","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","199.25","59.3","","439.50","225.34","1872.27","197","168","263.59","percent of total billed charges",""
"SCREW BONE 4X30MM TITANIUM CANCELLOUS LOCKING","SUP-ITM-10130380","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","263.59","78.45","","385.32","55.36","1815.62","58","168","263.59","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","AETNA [1001]","HB CH AETNA HMO / PPO","791.63","58.3","","554.95","91.85","1421.75","94","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","991.24","73","","2490.03","2490.03","2490.03","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","791.63","58.3","","750.00","750.00","750.00","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","719.67","53","","1192.50","120.84","4149.90","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1154.18","85","","750.00","75.00","750.00","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1357.86","100","","657.00","121.50","1971.00","14","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1357.86","100","","75.00","75.00","75.00","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1357.86","100","","366.00","144.00","1971.00","45","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","991.24","73","","667.50","667.50","667.50","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","603.57","44.45","","123.77","123.77","123.77","1 through 10","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","both","","","1357.86","1018.39","WELLPOINT [1015]","HB CH WELLPOINT","1057.91","77.91","","483.51","229.32","1316.08","96","603.57","1357.86","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1357.86","1018.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","805.21","59.3","","439.50","225.34","1872.27","197","678.93","1065.24","percent of total billed charges",""
"SCREW BONE 4X32MM CANNULATED COMPRESSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1357.86","1018.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1065.24","78.45","","385.32","55.36","1815.62","58","678.93","1065.24","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","AETNA [1001]","HB CH AETNA HMO / PPO","559.87","58.3","","554.95","91.85","1421.75","94","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","701.04","73","","2490.03","2490.03","2490.03","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","559.87","58.3","","750.00","750.00","750.00","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","508.97","53","","1192.50","120.84","4149.90","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","816.28","85","","750.00","75.00","750.00","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","960.33","100","","657.00","121.50","1971.00","14","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","960.33","100","","75.00","75.00","75.00","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","960.33","100","","366.00","144.00","1971.00","45","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","701.04","73","","667.50","667.50","667.50","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.87","44.45","","123.77","123.77","123.77","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","WELLPOINT [1015]","HB CH WELLPOINT","748.19","77.91","","483.51","229.32","1316.08","96","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","569.48","59.3","","439.50","225.34","1872.27","197","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X32MM MINI HEADED CANNULATED","SUP-ITM-10232447","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","753.38","78.45","","385.32","55.36","1815.62","58","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","AETNA [1001]","HB CH AETNA HMO / PPO","505.57","58.3","","554.95","91.85","1421.75","94","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","633.04","73","","2490.03","2490.03","2490.03","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","505.57","58.3","","750.00","750.00","750.00","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","459.61","53","","1192.50","120.84","4149.90","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","737.10","85","","750.00","75.00","750.00","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","867.18","100","","657.00","121.50","1971.00","14","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","867.18","100","","75.00","75.00","75.00","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","867.18","100","","366.00","144.00","1971.00","45","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","633.04","73","","667.50","667.50","667.50","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.46","44.45","","123.77","123.77","123.77","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","WELLPOINT [1015]","HB CH WELLPOINT","675.62","77.91","","483.51","229.32","1316.08","96","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","514.24","59.3","","439.50","225.34","1872.27","197","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X38MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10100552","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","680.30","78.45","","385.32","55.36","1815.62","58","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","AETNA [1001]","HB CH AETNA HMO / PPO","819.44","58.3","","554.95","91.85","1421.75","94","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","2490.03","2490.03","2490.03","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","819.44","58.3","","750.00","750.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.95","53","","1192.50","120.84","4149.90","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1194.73","85","","750.00","75.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1405.56","100","","657.00","121.50","1971.00","14","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1405.56","100","","75.00","75.00","75.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1405.56","100","","366.00","144.00","1971.00","45","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","667.50","667.50","667.50","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","123.77","123.77","123.77","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","WELLPOINT [1015]","HB CH WELLPOINT","1095.07","77.91","","483.51","229.32","1316.08","96","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","833.50","59.3","","439.50","225.34","1872.27","197","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 4X38MM MINI HEADLESS CANNULATED","SUP-ITM-10232392","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","385.32","55.36","1815.62","58","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","AETNA [1001]","HB CH AETNA HMO / PPO","54.36","58.3","","554.95","91.85","1421.75","94","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","68.07","73","","2490.03","2490.03","2490.03","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","54.36","58.3","","750.00","750.00","750.00","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","49.42","53","","1192.50","120.84","4149.90","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","79.25","85","","750.00","75.00","750.00","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","93.24","100","","657.00","121.50","1971.00","14","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","93.24","100","","75.00","75.00","75.00","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","93.24","100","","366.00","144.00","1971.00","45","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","68.07","73","","667.50","667.50","667.50","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","41.45","44.45","","123.77","123.77","123.77","1 through 10","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","both","","","93.24","69.93","WELLPOINT [1015]","HB CH WELLPOINT","72.64","77.91","","483.51","229.32","1316.08","96","41.45","93.24","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.24","69.93","CIGNA [1006]","HB CH CIGNA HMO / PPO","55.29","59.3","","439.50","225.34","1872.27","197","46.62","73.15","percent of total billed charges",""
"SCREW BONE 4X40MM CANCELLOUS TITANIUM FULL THREAD SM HEXAGONAL SOCKET","SUP-ITM-10002219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","93.24","69.93","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","73.15","78.45","","385.32","55.36","1815.62","58","46.62","73.15","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","AETNA [1001]","HB CH AETNA HMO / PPO","407.52","58.3","","554.95","91.85","1421.75","94","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","2490.03","2490.03","2490.03","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","407.52","58.3","","750.00","750.00","750.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","370.47","53","","1192.50","120.84","4149.90","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","594.15","85","","750.00","75.00","750.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","699.00","100","","657.00","121.50","1971.00","14","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","699.00","100","","75.00","75.00","75.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","699.00","100","","366.00","144.00","1971.00","45","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","667.50","667.50","667.50","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.71","44.45","","123.77","123.77","123.77","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","WELLPOINT [1015]","HB CH WELLPOINT","544.59","77.91","","483.51","229.32","1316.08","96","310.71","699","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","414.51","59.3","","439.50","225.34","1872.27","197","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X40MM DARCO TI COMPRESSION FULL","SUP-ITM-10133629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","548.37","78.45","","385.32","55.36","1815.62","58","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","AETNA [1001]","HB CH AETNA HMO / PPO","313.07","58.3","","554.95","91.85","1421.75","94","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","392.01","73","","2490.03","2490.03","2490.03","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","313.07","58.3","","750.00","750.00","750.00","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","284.61","53","","1192.50","120.84","4149.90","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","456.45","85","","750.00","75.00","750.00","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","537.00","100","","657.00","121.50","1971.00","14","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","537.00","100","","75.00","75.00","75.00","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","537.00","100","","366.00","144.00","1971.00","45","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","392.01","73","","667.50","667.50","667.50","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.70","44.45","","123.77","123.77","123.77","1 through 10","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","both","","","537.00","402.75","WELLPOINT [1015]","HB CH WELLPOINT","418.38","77.91","","483.51","229.32","1316.08","96","238.7","537","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.00","402.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","318.44","59.3","","439.50","225.34","1872.27","197","268.5","421.28","percent of total billed charges",""
"SCREW BONE 4X40MM MAXTORQUE CANNULATED TI SELF DRILLING TAPPING LONG THREAD","SUP-ITM-10083162","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","537.00","402.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","421.28","78.45","","385.32","55.36","1815.62","58","268.5","421.28","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","AETNA [1001]","HB CH AETNA HMO / PPO","379.97","58.3","","554.95","91.85","1421.75","94","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","475.78","73","","2490.03","2490.03","2490.03","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","379.97","58.3","","750.00","750.00","750.00","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.43","53","","1192.50","120.84","4149.90","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","553.99","85","","750.00","75.00","750.00","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.75","100","","657.00","121.50","1971.00","14","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","651.75","100","","75.00","75.00","75.00","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.75","100","","366.00","144.00","1971.00","45","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.78","73","","667.50","667.50","667.50","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.70","44.45","","123.77","123.77","123.77","1 through 10","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.75","488.81","WELLPOINT [1015]","HB CH WELLPOINT","507.78","77.91","","483.51","229.32","1316.08","96","289.7","651.75","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.49","59.3","","439.50","225.34","1872.27","197","325.88","511.3","percent of total billed charges",""
"SCREW BONE 4X40MM MINI MONSTER CANNULATED SHORT THREAD STRAIGHT","SUP-ITM-10236278","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.75","488.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","511.30","78.45","","385.32","55.36","1815.62","58","325.88","511.3","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","AETNA [1001]","HB CH AETNA HMO / PPO","407.52","58.3","","554.95","91.85","1421.75","94","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","2490.03","2490.03","2490.03","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","407.52","58.3","","750.00","750.00","750.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","370.47","53","","1192.50","120.84","4149.90","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","594.15","85","","750.00","75.00","750.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","699.00","100","","657.00","121.50","1971.00","14","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","699.00","100","","75.00","75.00","75.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","699.00","100","","366.00","144.00","1971.00","45","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","667.50","667.50","667.50","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.71","44.45","","123.77","123.77","123.77","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","WELLPOINT [1015]","HB CH WELLPOINT","544.59","77.91","","483.51","229.32","1316.08","96","310.71","699","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","414.51","59.3","","439.50","225.34","1872.27","197","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X44MM DARCO TI COMPRESSION LONG","SUP-ITM-10133636","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","548.37","78.45","","385.32","55.36","1815.62","58","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","AETNA [1001]","HB CH AETNA HMO / PPO","288.59","58.3","","554.95","91.85","1421.75","94","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","2490.03","2490.03","2490.03","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","288.59","58.3","","750.00","750.00","750.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","262.35","53","","1192.50","120.84","4149.90","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","420.75","85","","750.00","75.00","750.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","495.00","100","","657.00","121.50","1971.00","14","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","495.00","100","","75.00","75.00","75.00","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","495.00","100","","366.00","144.00","1971.00","45","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","361.35","73","","667.50","667.50","667.50","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","220.03","44.45","","123.77","123.77","123.77","1 through 10","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","both","","","495.00","371.25","WELLPOINT [1015]","HB CH WELLPOINT","385.65","77.91","","483.51","229.32","1316.08","96","220.03","495","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","293.54","59.3","","439.50","225.34","1872.27","197","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X44MM QUICKFIX CANNULATED TITANIUM PARTIAL SHORT THREAD","SUP-ITM-10135921","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","495.00","371.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","388.33","78.45","","385.32","55.36","1815.62","58","247.5","388.33","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","AETNA [1001]","HB CH AETNA HMO / PPO","47.89","58.3","","554.95","91.85","1421.75","94","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","59.96","73","","2490.03","2490.03","2490.03","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","47.89","58.3","","750.00","750.00","750.00","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","43.53","53","","1192.50","120.84","4149.90","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","69.82","85","","750.00","75.00","750.00","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","82.14","100","","657.00","121.50","1971.00","14","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","82.14","100","","75.00","75.00","75.00","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","82.14","100","","366.00","144.00","1971.00","45","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","59.96","73","","667.50","667.50","667.50","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","36.51","44.45","","123.77","123.77","123.77","1 through 10","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","both","","","82.14","61.60","WELLPOINT [1015]","HB CH WELLPOINT","64.00","77.91","","483.51","229.32","1316.08","96","36.51","82.14","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.14","61.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","48.71","59.3","","439.50","225.34","1872.27","197","41.07","64.44","percent of total billed charges",""
"SCREW BONE 4X45MM CANCELLOUS SS FULLY THREADED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10001579","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","82.14","61.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","64.44","78.45","","385.32","55.36","1815.62","58","41.07","64.44","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","AETNA [1001]","HB CH AETNA HMO / PPO","407.52","58.3","","554.95","91.85","1421.75","94","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","2490.03","2490.03","2490.03","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","407.52","58.3","","750.00","750.00","750.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","370.47","53","","1192.50","120.84","4149.90","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","594.15","85","","750.00","75.00","750.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","699.00","100","","657.00","121.50","1971.00","14","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","699.00","100","","75.00","75.00","75.00","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","699.00","100","","366.00","144.00","1971.00","45","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","510.27","73","","667.50","667.50","667.50","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.71","44.45","","123.77","123.77","123.77","1 through 10","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","both","","","699.00","524.25","WELLPOINT [1015]","HB CH WELLPOINT","544.59","77.91","","483.51","229.32","1316.08","96","310.71","699","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","414.51","59.3","","439.50","225.34","1872.27","197","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X50MM DARCO TI COMPRESSION FULL","SUP-ITM-10133644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","699.00","524.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","548.37","78.45","","385.32","55.36","1815.62","58","349.5","548.37","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","AETNA [1001]","HB CH AETNA HMO / PPO","559.87","58.3","","554.95","91.85","1421.75","94","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","701.04","73","","2490.03","2490.03","2490.03","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","559.87","58.3","","750.00","750.00","750.00","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","508.97","53","","1192.50","120.84","4149.90","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","816.28","85","","750.00","75.00","750.00","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","960.33","100","","657.00","121.50","1971.00","14","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","960.33","100","","75.00","75.00","75.00","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","960.33","100","","366.00","144.00","1971.00","45","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","701.04","73","","667.50","667.50","667.50","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","426.87","44.45","","123.77","123.77","123.77","1 through 10","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","both","","","960.33","720.25","WELLPOINT [1015]","HB CH WELLPOINT","748.19","77.91","","483.51","229.32","1316.08","96","426.87","960.33","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","569.48","59.3","","439.50","225.34","1872.27","197","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADED CANNULATED","SUP-ITM-10232438","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","960.33","720.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","753.38","78.45","","385.32","55.36","1815.62","58","480.17","753.38","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","AETNA [1001]","HB CH AETNA HMO / PPO","819.44","58.3","","554.95","91.85","1421.75","94","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","2490.03","2490.03","2490.03","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","819.44","58.3","","750.00","750.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.95","53","","1192.50","120.84","4149.90","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1194.73","85","","750.00","75.00","750.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1405.56","100","","657.00","121.50","1971.00","14","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1405.56","100","","75.00","75.00","75.00","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1405.56","100","","366.00","144.00","1971.00","45","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1026.06","73","","667.50","667.50","667.50","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.77","44.45","","123.77","123.77","123.77","1 through 10","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","both","","","1405.56","1054.17","WELLPOINT [1015]","HB CH WELLPOINT","1095.07","77.91","","483.51","229.32","1316.08","96","624.77","1405.56","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","833.50","59.3","","439.50","225.34","1872.27","197","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 4X50MM MINI HEADLESS CANNULATED","SUP-ITM-10232386","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1405.56","1054.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1102.66","78.45","","385.32","55.36","1815.62","58","702.78","1102.66","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","AETNA [1001]","HB CH AETNA HMO / PPO","48.53","58.3","","554.95","91.85","1421.75","94","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","60.77","73","","2490.03","2490.03","2490.03","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","48.53","58.3","","750.00","750.00","750.00","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","44.12","53","","1192.50","120.84","4149.90","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","70.76","85","","750.00","75.00","750.00","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","83.25","100","","657.00","121.50","1971.00","14","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","83.25","100","","75.00","75.00","75.00","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","83.25","100","","366.00","144.00","1971.00","45","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","60.77","73","","667.50","667.50","667.50","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","37.00","44.45","","123.77","123.77","123.77","1 through 10","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","both","","","83.25","62.44","WELLPOINT [1015]","HB CH WELLPOINT","64.86","77.91","","483.51","229.32","1316.08","96","37","83.25","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","83.25","62.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.37","59.3","","439.50","225.34","1872.27","197","41.63","65.31","percent of total billed charges",""
"SCREW BONE 4X54MM CORTEX SS SELF TAPPING","SUP-ITM-10037221","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","83.25","62.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.31","78.45","","385.32","55.36","1815.62","58","41.63","65.31","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","AETNA [1001]","HB CH AETNA HMO / PPO","505.57","58.3","","554.95","91.85","1421.75","94","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","633.04","73","","2490.03","2490.03","2490.03","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","505.57","58.3","","750.00","750.00","750.00","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","459.61","53","","1192.50","120.84","4149.90","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","737.10","85","","750.00","75.00","750.00","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","867.18","100","","657.00","121.50","1971.00","14","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","867.18","100","","75.00","75.00","75.00","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","867.18","100","","366.00","144.00","1971.00","45","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","633.04","73","","667.50","667.50","667.50","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","385.46","44.45","","123.77","123.77","123.77","1 through 10","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","both","","","867.18","650.38","WELLPOINT [1015]","HB CH WELLPOINT","675.62","77.91","","483.51","229.32","1316.08","96","385.46","867.18","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","514.24","59.3","","439.50","225.34","1872.27","197","433.59","680.3","percent of total billed charges",""
"SCREW BONE 4X55MM ASNIS III CANNULATED TI PARTIAL THREAD","SUP-ITM-10144223","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","867.18","650.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","680.30","78.45","","385.32","55.36","1815.62","58","433.59","680.3","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","AETNA [1001]","HB CH AETNA HMO / PPO","479.91","58.3","","554.95","91.85","1421.75","94","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","600.91","73","","2490.03","2490.03","2490.03","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","479.91","58.3","","750.00","750.00","750.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","436.28","53","","1192.50","120.84","4149.90","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","699.69","85","","750.00","75.00","750.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","823.17","100","","657.00","121.50","1971.00","14","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","823.17","100","","75.00","75.00","75.00","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","823.17","100","","366.00","144.00","1971.00","45","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","600.91","73","","667.50","667.50","667.50","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","365.90","44.45","","123.77","123.77","123.77","1 through 10","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","both","","","823.17","617.38","WELLPOINT [1015]","HB CH WELLPOINT","641.33","77.91","","483.51","229.32","1316.08","96","365.9","823.17","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","823.17","617.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","488.14","59.3","","439.50","225.34","1872.27","197","411.59","645.78","percent of total billed charges",""
"SCREW BONE 5.0X34MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD","SUP-ITM-10030059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","823.17","617.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","645.78","78.45","","385.32","55.36","1815.62","58","411.59","645.78","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","AETNA [1001]","HB CH AETNA HMO / PPO","407.13","58.3","","554.95","91.85","1421.75","94","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","509.79","73","","2490.03","2490.03","2490.03","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","407.13","58.3","","750.00","750.00","750.00","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","370.12","53","","1192.50","120.84","4149.90","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","593.59","85","","750.00","75.00","750.00","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","698.34","100","","657.00","121.50","1971.00","14","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","698.34","100","","75.00","75.00","75.00","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","698.34","100","","366.00","144.00","1971.00","45","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","509.79","73","","667.50","667.50","667.50","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","310.41","44.45","","123.77","123.77","123.77","1 through 10","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","both","","","698.34","523.75","WELLPOINT [1015]","HB CH WELLPOINT","544.08","77.91","","483.51","229.32","1316.08","96","310.41","698.34","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.34","523.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","414.12","59.3","","439.50","225.34","1872.27","197","349.17","547.85","percent of total billed charges",""
"SCREW BONE 5.0X46MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10134780","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","698.34","523.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","547.85","78.45","","385.32","55.36","1815.62","58","349.17","547.85","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","AETNA [1001]","HB CH AETNA HMO / PPO","513.05","58.3","","554.95","91.85","1421.75","94","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","642.41","73","","2490.03","2490.03","2490.03","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","513.05","58.3","","750.00","750.00","750.00","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","466.41","53","","1192.50","120.84","4149.90","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","748.02","85","","750.00","75.00","750.00","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","880.02","100","","657.00","121.50","1971.00","14","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","880.02","100","","75.00","75.00","75.00","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","880.02","100","","366.00","144.00","1971.00","45","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","642.41","73","","667.50","667.50","667.50","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.17","44.45","","123.77","123.77","123.77","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","WELLPOINT [1015]","HB CH WELLPOINT","685.62","77.91","","483.51","229.32","1316.08","96","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","521.85","59.3","","439.50","225.34","1872.27","197","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5.0X75MM T2 TITANIUM LOCKING FULL THREAD","SUP-ITM-10028329","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","690.38","78.45","","385.32","55.36","1815.62","58","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","AETNA [1001]","HB CH AETNA HMO / PPO","414.95","58.3","","554.95","91.85","1421.75","94","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","519.58","73","","2490.03","2490.03","2490.03","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","414.95","58.3","","750.00","750.00","750.00","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","377.23","53","","1192.50","120.84","4149.90","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","604.99","85","","750.00","75.00","750.00","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","711.75","100","","657.00","121.50","1971.00","14","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","711.75","100","","75.00","75.00","75.00","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","711.75","100","","366.00","144.00","1971.00","45","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","519.58","73","","667.50","667.50","667.50","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.37","44.45","","123.77","123.77","123.77","1 through 10","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.75","533.81","WELLPOINT [1015]","HB CH WELLPOINT","554.52","77.91","","483.51","229.32","1316.08","96","316.37","711.75","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.75","533.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","422.07","59.3","","439.50","225.34","1872.27","197","355.88","558.37","percent of total billed charges",""
"SCREW BONE 5.2X40MM SILVERBACK LOCKING PLATE","SUP-ITM-10238155","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.75","533.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","558.37","78.45","","385.32","55.36","1815.62","58","355.88","558.37","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","AETNA [1001]","HB CH AETNA HMO / PPO","585.92","58.3","","554.95","91.85","1421.75","94","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","2490.03","2490.03","2490.03","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","585.92","58.3","","750.00","750.00","750.00","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","532.65","53","","1192.50","120.84","4149.90","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","854.25","85","","750.00","75.00","750.00","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1005.00","100","","657.00","121.50","1971.00","14","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1005.00","100","","75.00","75.00","75.00","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1005.00","100","","366.00","144.00","1971.00","45","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","733.65","73","","667.50","667.50","667.50","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","446.72","44.45","","123.77","123.77","123.77","1 through 10","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","both","","","1005.00","753.75","WELLPOINT [1015]","HB CH WELLPOINT","783.00","77.91","","483.51","229.32","1316.08","96","446.72","1005","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","595.97","59.3","","439.50","225.34","1872.27","197","502.5","788.42","percent of total billed charges",""
"SCREW BONE 5.5 TO 6.25MM SPINE LUMBAR MP TULIP POSTERIOR INTERBODY FUSION","SUP-ITM-10117063","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1005.00","753.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","788.42","78.45","","385.32","55.36","1815.62","58","502.5","788.42","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","AETNA [1001]","HB CH AETNA HMO / PPO","245.00","58.3","","554.95","91.85","1421.75","94","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","2490.03","2490.03","2490.03","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","245.00","58.3","","750.00","750.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","222.73","53","","1192.50","120.84","4149.90","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","357.20","85","","750.00","75.00","750.00","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","420.24","100","","657.00","121.50","1971.00","14","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","420.24","100","","75.00","75.00","75.00","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.24","100","","366.00","144.00","1971.00","45","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","306.78","73","","667.50","667.50","667.50","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","186.80","44.45","","123.77","123.77","123.77","1 through 10","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","both","","","420.24","315.18","WELLPOINT [1015]","HB CH WELLPOINT","327.41","77.91","","483.51","229.32","1316.08","96","186.8","420.24","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.20","59.3","","439.50","225.34","1872.27","197","210.12","329.68","percent of total billed charges",""
"SCREW BONE 5.5X35MM CORTICAL SOLID FULL THREAD PROXIMALIMAL ACE","SUP-ITM-10017851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","420.24","315.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.68","78.45","","385.32","55.36","1815.62","58","210.12","329.68","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","1830.28","315.58","1830.28","1 through 10","520.07","1170","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","4170.85","4170.85","4170.85","1 through 10","520.07","1170","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","649.55","649.55","649.55","1 through 10","520.07","1170","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","8998.38","2542.37","8998.38","20","520.07","1170","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","1891.61","1609.14","3664.18","25","585","917.87","percent of total billed charges",""
"SCREW BONE 5.5X35MM SPINE LUMBAR MP SHANK POSTERIOR INTERBODY FUSION","SUP-ITM-10117074","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","1470.68","1310.06","2481.69","19","585","917.87","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","AETNA [1001]","HB CH AETNA HMO / PPO","765.07","58.3","","554.95","91.85","1421.75","94","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","957.97","73","","2490.03","2490.03","2490.03","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","765.07","58.3","","750.00","750.00","750.00","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","695.51","53","","1192.50","120.84","4149.90","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1115.45","85","","750.00","75.00","750.00","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1312.29","100","","657.00","121.50","1971.00","14","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1312.29","100","","75.00","75.00","75.00","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1312.29","100","","366.00","144.00","1971.00","45","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","957.97","73","","667.50","667.50","667.50","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","583.31","44.45","","123.77","123.77","123.77","1 through 10","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","both","","","1312.29","984.22","WELLPOINT [1015]","HB CH WELLPOINT","1022.41","77.91","","483.51","229.32","1316.08","96","583.31","1312.29","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.29","984.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","778.19","59.3","","439.50","225.34","1872.27","197","656.15","1029.49","percent of total billed charges",""
"SCREW BONE 5.5X40MM QWIX TITANIUM FIXATION CANNULATED SELF TAPPING DRILLING","SUP-ITM-10073322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1312.29","984.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1029.49","78.45","","385.32","55.36","1815.62","58","656.15","1029.49","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","AETNA [1001]","HB CH AETNA HMO / PPO","1390.46","58.3","","554.95","91.85","1421.75","94","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","2490.03","2490.03","2490.03","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.46","58.3","","750.00","750.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1264.05","53","","1192.50","120.84","4149.90","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2027.25","85","","750.00","75.00","750.00","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2385.00","100","","657.00","121.50","1971.00","14","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2385.00","100","","75.00","75.00","75.00","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2385.00","100","","366.00","144.00","1971.00","45","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1741.05","73","","667.50","667.50","667.50","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1060.13","44.45","","123.77","123.77","123.77","1 through 10","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","both","","","2385.00","1788.75","WELLPOINT [1015]","HB CH WELLPOINT","1858.15","77.91","","483.51","229.32","1316.08","96","1060.13","2385","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.31","59.3","","439.50","225.34","1872.27","197","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 5.5X40MM TITANIUM PARTIAL THREAD LOW PROFILE","SUP-ITM-10134869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2385.00","1788.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1871.03","78.45","","385.32","55.36","1815.62","58","1192.5","1871.03","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","AETNA [1001]","HB CH AETNA HMO / PPO","599.91","58.3","","554.95","91.85","1421.75","94","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","751.17","73","","2490.03","2490.03","2490.03","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","599.91","58.3","","750.00","750.00","750.00","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","545.37","53","","1192.50","120.84","4149.90","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","874.65","85","","750.00","75.00","750.00","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1029.00","100","","657.00","121.50","1971.00","14","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1029.00","100","","75.00","75.00","75.00","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1029.00","100","","366.00","144.00","1971.00","45","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","751.17","73","","667.50","667.50","667.50","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","457.39","44.45","","123.77","123.77","123.77","1 through 10","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","both","","","1029.00","771.75","WELLPOINT [1015]","HB CH WELLPOINT","801.69","77.91","","483.51","229.32","1316.08","96","457.39","1029","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","610.20","59.3","","439.50","225.34","1872.27","197","514.5","807.25","percent of total billed charges",""
"SCREW BONE 5.5X44MM COMPRESSION SS LOCKING SELF TAPPING FULL THREAD T15 STARDRIVE RECESS","SUP-ITM-10030996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1029.00","771.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","807.25","78.45","","385.32","55.36","1815.62","58","514.5","807.25","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","1830.28","315.58","1830.28","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","4170.85","4170.85","4170.85","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","649.55","649.55","649.55","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","8998.38","2542.37","8998.38","20","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","1891.61","1609.14","3664.18","25","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X5.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10125926","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","1470.68","1310.06","2481.69","19","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","AETNA [1001]","HB CH AETNA HMO / PPO","261.21","58.3","","554.95","91.85","1421.75","94","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","327.08","73","","2490.03","2490.03","2490.03","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","261.21","58.3","","750.00","750.00","750.00","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","237.47","53","","1192.50","120.84","4149.90","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","380.84","85","","750.00","75.00","750.00","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","448.05","100","","657.00","121.50","1971.00","14","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","448.05","100","","75.00","75.00","75.00","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","448.05","100","","366.00","144.00","1971.00","45","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","327.08","73","","667.50","667.50","667.50","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.16","44.45","","123.77","123.77","123.77","1 through 10","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.05","336.04","WELLPOINT [1015]","HB CH WELLPOINT","349.08","77.91","","483.51","229.32","1316.08","96","199.16","448.05","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.05","336.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","265.69","59.3","","439.50","225.34","1872.27","197","224.03","351.5","percent of total billed charges",""
"SCREW BONE 5.5X50MM CORTICAL VERSANAIL TITANIUM FULL THREAD","SUP-ITM-10016947","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.05","336.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.50","78.45","","385.32","55.36","1815.62","58","224.03","351.5","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","554.95","91.85","1421.75","94","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","2490.03","2490.03","2490.03","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","131.18","58.3","","750.00","750.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","1192.50","120.84","4149.90","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","191.25","85","","750.00","75.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.00","100","","657.00","121.50","1971.00","14","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","225.00","100","","75.00","75.00","75.00","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.00","100","","366.00","144.00","1971.00","45","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","667.50","667.50","667.50","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","123.77","123.77","123.77","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","483.51","229.32","1316.08","96","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","439.50","225.34","1872.27","197","112.5","176.51","percent of total billed charges",""
"SCREW BONE 5.5X50MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10148128","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","385.32","55.36","1815.62","58","112.5","176.51","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","AETNA [1001]","HB CH AETNA HMO / PPO","1335.80","58.3","","554.95","91.85","1421.75","94","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1672.61","73","","2490.03","2490.03","2490.03","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1335.80","58.3","","750.00","750.00","750.00","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1214.36","53","","1192.50","120.84","4149.90","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1947.56","85","","750.00","75.00","750.00","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2291.25","100","","657.00","121.50","1971.00","14","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2291.25","100","","75.00","75.00","75.00","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2291.25","100","","366.00","144.00","1971.00","45","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1672.61","73","","667.50","667.50","667.50","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1018.46","44.45","","123.77","123.77","123.77","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","WELLPOINT [1015]","HB CH WELLPOINT","1785.11","77.91","","483.51","229.32","1316.08","96","1018.46","2291.25","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2291.25","1718.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1358.71","59.3","","439.50","225.34","1872.27","197","1145.63","1797.49","percent of total billed charges",""
"SCREW BONE 5.5X50MM MONSTER JONES SOLID SHORT THREAD BLUNT TIP","SUP-ITM-10242213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2291.25","1718.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1797.49","78.45","","385.32","55.36","1815.62","58","1145.63","1797.49","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","554.95","91.85","1421.75","94","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","2490.03","2490.03","2490.03","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","750.00","750.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","1192.50","120.84","4149.90","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2065.50","85","","750.00","75.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2430.00","100","","657.00","121.50","1971.00","14","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2430.00","100","","75.00","75.00","75.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2430.00","100","","366.00","144.00","1971.00","45","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","667.50","667.50","667.50","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","123.77","123.77","123.77","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","483.51","229.32","1316.08","96","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","439.50","225.34","1872.27","197","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X6.0X40.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115482","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","385.32","55.36","1815.62","58","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","AETNA [1001]","HB CH AETNA HMO / PPO","131.18","58.3","","554.95","91.85","1421.75","94","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","2490.03","2490.03","2490.03","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","131.18","58.3","","750.00","750.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","119.25","53","","1192.50","120.84","4149.90","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","191.25","85","","750.00","75.00","750.00","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","225.00","100","","657.00","121.50","1971.00","14","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","225.00","100","","75.00","75.00","75.00","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","225.00","100","","366.00","144.00","1971.00","45","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","164.25","73","","667.50","667.50","667.50","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","100.01","44.45","","123.77","123.77","123.77","1 through 10","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","both","","","225.00","168.75","WELLPOINT [1015]","HB CH WELLPOINT","175.30","77.91","","483.51","229.32","1316.08","96","100.01","225","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","133.43","59.3","","439.50","225.34","1872.27","197","112.5","176.51","percent of total billed charges",""
"SCREW BONE 5.5X60MM LOW PROFILE CANCELLOUS NONLOCKING","SUP-ITM-10149080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","225.00","168.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","176.51","78.45","","385.32","55.36","1815.62","58","112.5","176.51","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","1830.28","315.58","1830.28","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","4170.85","4170.85","4170.85","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","649.55","649.55","649.55","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","8998.38","2542.37","8998.38","20","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","1891.61","1609.14","3664.18","25","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X45.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115642","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","1470.68","1310.06","2481.69","19","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","1830.28","315.58","1830.28","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","4170.85","4170.85","4170.85","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","649.55","649.55","649.55","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","8998.38","2542.37","8998.38","20","1080.14","2430","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","1891.61","1609.14","3664.18","25","1215","1906.34","percent of total billed charges",""
"SCREW BONE 5.5X7.0X50.0MM SPINE PEDICLE CORTICAL EXPEDIUM POLYAXIAL TITANIUM","SUP-ITM-10115484","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","1470.68","1310.06","2481.69","19","1215","1906.34","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","AETNA [1001]","HB CH AETNA HMO / PPO","891.99","58.3","","554.95","91.85","1421.75","94","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1116.90","73","","2490.03","2490.03","2490.03","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","891.99","58.3","","750.00","750.00","750.00","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","810.90","53","","1192.50","120.84","4149.90","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1300.50","85","","750.00","75.00","750.00","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1530.00","100","","657.00","121.50","1971.00","14","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1530.00","100","","75.00","75.00","75.00","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1530.00","100","","366.00","144.00","1971.00","45","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1116.90","73","","667.50","667.50","667.50","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","680.09","44.45","","123.77","123.77","123.77","1 through 10","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","both","","","1530.00","1147.50","WELLPOINT [1015]","HB CH WELLPOINT","1192.02","77.91","","483.51","229.32","1316.08","96","680.09","1530","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.00","1147.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","907.29","59.3","","439.50","225.34","1872.27","197","765","1200.29","percent of total billed charges",""
"SCREW BONE 50X19MM UNION METAPHYSIS LF TITANIUM ADAPTER","SUP-ITM-10194822","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1530.00","1147.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1200.29","78.45","","385.32","55.36","1815.62","58","765","1200.29","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","AETNA [1001]","HB CH AETNA HMO / PPO","88.01","58.3","","554.95","91.85","1421.75","94","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","110.20","73","","2490.03","2490.03","2490.03","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","88.01","58.3","","750.00","750.00","750.00","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","80.01","53","","1192.50","120.84","4149.90","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","128.32","85","","750.00","75.00","750.00","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.96","100","","657.00","121.50","1971.00","14","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.96","100","","75.00","75.00","75.00","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.96","100","","366.00","144.00","1971.00","45","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.20","73","","667.50","667.50","667.50","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","67.10","44.45","","123.77","123.77","123.77","1 through 10","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.96","113.22","WELLPOINT [1015]","HB CH WELLPOINT","117.61","77.91","","483.51","229.32","1316.08","96","67.1","150.96","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.52","59.3","","439.50","225.34","1872.27","197","75.48","118.43","percent of total billed charges",""
"SCREW BONE 50X3.5MM CORTEX DUPONT TITANIUM SELF TAPPING FULL THREAD","SUP-ITM-10077571","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.96","113.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.43","78.45","","385.32","55.36","1815.62","58","75.48","118.43","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","AETNA [1001]","HB CH AETNA HMO / PPO","270.50","58.3","","554.95","91.85","1421.75","94","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","338.71","73","","2490.03","2490.03","2490.03","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","270.50","58.3","","750.00","750.00","750.00","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","245.91","53","","1192.50","120.84","4149.90","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","394.38","85","","750.00","75.00","750.00","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","463.98","100","","657.00","121.50","1971.00","14","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","463.98","100","","75.00","75.00","75.00","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","463.98","100","","366.00","144.00","1971.00","45","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","338.71","73","","667.50","667.50","667.50","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","206.24","44.45","","123.77","123.77","123.77","1 through 10","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","both","","","463.98","347.98","WELLPOINT [1015]","HB CH WELLPOINT","361.49","77.91","","483.51","229.32","1316.08","96","206.24","463.98","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.98","347.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.14","59.3","","439.50","225.34","1872.27","197","231.99","363.99","percent of total billed charges",""
"SCREW BONE 5X10MM LOCKING PERIPROSTHETIC SS SELF TAPPING FULL THREAD T2 STARDRIVE RECESS","SUP-ITM-10019468","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","463.98","347.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","363.99","78.45","","385.32","55.36","1815.62","58","231.99","363.99","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","AETNA [1001]","HB CH AETNA HMO / PPO","176.67","58.3","","554.95","91.85","1421.75","94","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","221.21","73","","2490.03","2490.03","2490.03","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","176.67","58.3","","750.00","750.00","750.00","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","160.61","53","","1192.50","120.84","4149.90","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","257.58","85","","750.00","75.00","750.00","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","303.03","100","","657.00","121.50","1971.00","14","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","303.03","100","","75.00","75.00","75.00","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","303.03","100","","366.00","144.00","1971.00","45","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","221.21","73","","667.50","667.50","667.50","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","134.70","44.45","","123.77","123.77","123.77","1 through 10","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","both","","","303.03","227.27","WELLPOINT [1015]","HB CH WELLPOINT","236.09","77.91","","483.51","229.32","1316.08","96","134.7","303.03","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","303.03","227.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","179.70","59.3","","439.50","225.34","1872.27","197","151.52","237.73","percent of total billed charges",""
"SCREW BONE 5X14MM SS LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS FLAT HEAD","SUP-ITM-10016983","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","303.03","227.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","237.73","78.45","","385.32","55.36","1815.62","58","151.52","237.73","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","AETNA [1001]","HB CH AETNA HMO / PPO","267.91","58.3","","554.95","91.85","1421.75","94","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","335.46","73","","2490.03","2490.03","2490.03","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","267.91","58.3","","750.00","750.00","750.00","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","243.56","53","","1192.50","120.84","4149.90","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","390.61","85","","750.00","75.00","750.00","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","459.54","100","","657.00","121.50","1971.00","14","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","459.54","100","","75.00","75.00","75.00","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","459.54","100","","366.00","144.00","1971.00","45","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","335.46","73","","667.50","667.50","667.50","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","204.27","44.45","","123.77","123.77","123.77","1 through 10","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","both","","","459.54","344.65","WELLPOINT [1015]","HB CH WELLPOINT","358.03","77.91","","483.51","229.32","1316.08","96","204.27","459.54","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","459.54","344.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","272.51","59.3","","439.50","225.34","1872.27","197","229.77","360.51","percent of total billed charges",""
"SCREW BONE 5X170MM FIXATION EXTERNAL SCHANZ SS BLUNT TROCAR POINT","SUP-ITM-10038615","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","459.54","344.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","360.51","78.45","","385.32","55.36","1815.62","58","229.77","360.51","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","AETNA [1001]","HB CH AETNA HMO / PPO","119.77","58.3","","554.95","91.85","1421.75","94","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","149.97","73","","2490.03","2490.03","2490.03","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","119.77","58.3","","750.00","750.00","750.00","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","108.88","53","","1192.50","120.84","4149.90","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","174.62","85","","750.00","75.00","750.00","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","205.44","100","","657.00","121.50","1971.00","14","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","205.44","100","","75.00","75.00","75.00","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","205.44","100","","366.00","144.00","1971.00","45","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","149.97","73","","667.50","667.50","667.50","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","91.32","44.45","","123.77","123.77","123.77","1 through 10","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","both","","","205.44","154.08","WELLPOINT [1015]","HB CH WELLPOINT","160.06","77.91","","483.51","229.32","1316.08","96","91.32","205.44","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.44","154.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","121.83","59.3","","439.50","225.34","1872.27","197","102.72","161.17","percent of total billed charges",""
"SCREW BONE 5X170MM SCHANZ EXTERNAL FIXATION BLUNT TROCAR POINT SS","SUP-ITM-10004528","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","205.44","154.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","161.17","78.45","","385.32","55.36","1815.62","58","102.72","161.17","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","AETNA [1001]","HB CH AETNA HMO / PPO","421.54","58.3","","554.95","91.85","1421.75","94","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","527.83","73","","2490.03","2490.03","2490.03","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","421.54","58.3","","750.00","750.00","750.00","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","383.22","53","","1192.50","120.84","4149.90","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","614.60","85","","750.00","75.00","750.00","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","723.06","100","","657.00","121.50","1971.00","14","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","723.06","100","","75.00","75.00","75.00","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","723.06","100","","366.00","144.00","1971.00","45","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","527.83","73","","667.50","667.50","667.50","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","321.40","44.45","","123.77","123.77","123.77","1 through 10","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","both","","","723.06","542.29","WELLPOINT [1015]","HB CH WELLPOINT","563.34","77.91","","483.51","229.32","1316.08","96","321.4","723.06","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","723.06","542.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","428.77","59.3","","439.50","225.34","1872.27","197","361.53","567.24","percent of total billed charges",""
"SCREW BONE 5X20MM CORTICAL PHOENIX TITANIUM SELF TAPPING DOUBLE LEAD THREAD INTERIOR THREADED HEAD LIGHT GREEN","SUP-ITM-10072687","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","723.06","542.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","567.24","78.45","","385.32","55.36","1815.62","58","361.53","567.24","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","AETNA [1001]","HB CH AETNA HMO / PPO","318.86","58.3","","554.95","91.85","1421.75","94","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","399.26","73","","2490.03","2490.03","2490.03","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","318.86","58.3","","750.00","750.00","750.00","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","289.87","53","","1192.50","120.84","4149.90","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","464.89","85","","750.00","75.00","750.00","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","546.93","100","","657.00","121.50","1971.00","14","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","546.93","100","","75.00","75.00","75.00","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","546.93","100","","366.00","144.00","1971.00","45","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","399.26","73","","667.50","667.50","667.50","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","243.11","44.45","","123.77","123.77","123.77","1 through 10","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","both","","","546.93","410.20","WELLPOINT [1015]","HB CH WELLPOINT","426.11","77.91","","483.51","229.32","1316.08","96","243.11","546.93","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.93","410.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","324.33","59.3","","439.50","225.34","1872.27","197","273.47","429.07","percent of total billed charges",""
"SCREW BONE 5X24MM CORTICAL PHOENIX TITANIUM DOUBLE LEAD THREAD GREEN","SUP-ITM-10072689","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","546.93","410.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","429.07","78.45","","385.32","55.36","1815.62","58","273.47","429.07","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","AETNA [1001]","HB CH AETNA HMO / PPO","471.86","58.3","","554.95","91.85","1421.75","94","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","590.84","73","","2490.03","2490.03","2490.03","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","471.86","58.3","","750.00","750.00","750.00","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.97","53","","1192.50","120.84","4149.90","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","687.96","85","","750.00","75.00","750.00","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","809.37","100","","657.00","121.50","1971.00","14","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","809.37","100","","75.00","75.00","75.00","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","809.37","100","","366.00","144.00","1971.00","45","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","590.84","73","","667.50","667.50","667.50","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.76","44.45","","123.77","123.77","123.77","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","WELLPOINT [1015]","HB CH WELLPOINT","630.58","77.91","","483.51","229.32","1316.08","96","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.96","59.3","","439.50","225.34","1872.27","197","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X26MM AXSOS TITANIUM LOCKING","SUP-ITM-10144942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.95","78.45","","385.32","55.36","1815.62","58","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","AETNA [1001]","HB CH AETNA HMO / PPO","261.44","58.3","","554.95","91.85","1421.75","94","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","327.36","73","","2490.03","2490.03","2490.03","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","261.44","58.3","","750.00","750.00","750.00","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","237.67","53","","1192.50","120.84","4149.90","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","381.17","85","","750.00","75.00","750.00","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","448.44","100","","657.00","121.50","1971.00","14","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","448.44","100","","75.00","75.00","75.00","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","448.44","100","","366.00","144.00","1971.00","45","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","327.36","73","","667.50","667.50","667.50","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","199.33","44.45","","123.77","123.77","123.77","1 through 10","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","both","","","448.44","336.33","WELLPOINT [1015]","HB CH WELLPOINT","349.38","77.91","","483.51","229.32","1316.08","96","199.33","448.44","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","265.92","59.3","","439.50","225.34","1872.27","197","224.22","351.8","percent of total billed charges",""
"SCREW BONE 5X26MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007372","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","448.44","336.33","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","351.80","78.45","","385.32","55.36","1815.62","58","224.22","351.8","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","AETNA [1001]","HB CH AETNA HMO / PPO","286.03","58.3","","554.95","91.85","1421.75","94","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","358.15","73","","2490.03","2490.03","2490.03","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","286.03","58.3","","750.00","750.00","750.00","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","260.03","53","","1192.50","120.84","4149.90","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","417.03","85","","750.00","75.00","750.00","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","490.62","100","","657.00","121.50","1971.00","14","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","490.62","100","","75.00","75.00","75.00","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","490.62","100","","366.00","144.00","1971.00","45","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","358.15","73","","667.50","667.50","667.50","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","218.08","44.45","","123.77","123.77","123.77","1 through 10","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","both","","","490.62","367.96","WELLPOINT [1015]","HB CH WELLPOINT","382.24","77.91","","483.51","229.32","1316.08","96","218.08","490.62","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.62","367.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","290.94","59.3","","439.50","225.34","1872.27","197","245.31","384.89","percent of total billed charges",""
"SCREW BONE 5X26MM LOCKING SELF DRILLING PARTIAL THREAD TITANIUM","SUP-ITM-10017868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","490.62","367.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","384.89","78.45","","385.32","55.36","1815.62","58","245.31","384.89","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","AETNA [1001]","HB CH AETNA HMO / PPO","471.86","58.3","","554.95","91.85","1421.75","94","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","590.84","73","","2490.03","2490.03","2490.03","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","471.86","58.3","","750.00","750.00","750.00","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","428.97","53","","1192.50","120.84","4149.90","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","687.96","85","","750.00","75.00","750.00","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","809.37","100","","657.00","121.50","1971.00","14","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","809.37","100","","75.00","75.00","75.00","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","809.37","100","","366.00","144.00","1971.00","45","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","590.84","73","","667.50","667.50","667.50","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.76","44.45","","123.77","123.77","123.77","1 through 10","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","both","","","809.37","607.03","WELLPOINT [1015]","HB CH WELLPOINT","630.58","77.91","","483.51","229.32","1316.08","96","359.76","809.37","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.96","59.3","","439.50","225.34","1872.27","197","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X28MM AXSOS TITANIUM LOCKING","SUP-ITM-10144943","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","809.37","607.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.95","78.45","","385.32","55.36","1815.62","58","404.69","634.95","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","554.95","91.85","1421.75","94","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","2490.03","2490.03","2490.03","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","750.00","750.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","1192.50","120.84","4149.90","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.25","85","","750.00","75.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.00","100","","657.00","121.50","1971.00","14","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.00","100","","75.00","75.00","75.00","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.00","100","","366.00","144.00","1971.00","45","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","667.50","667.50","667.50","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","123.77","123.77","123.77","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","483.51","229.32","1316.08","96","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","439.50","225.34","1872.27","197","712.5","1117.91","percent of total billed charges",""
"SCREW BONE 5X30MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10319733","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","385.32","55.36","1815.62","58","712.5","1117.91","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","AETNA [1001]","HB CH AETNA HMO / PPO","220.02","58.3","","554.95","91.85","1421.75","94","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","275.50","73","","2490.03","2490.03","2490.03","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","220.02","58.3","","750.00","750.00","750.00","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","200.02","53","","1192.50","120.84","4149.90","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","320.79","85","","750.00","75.00","750.00","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","377.40","100","","657.00","121.50","1971.00","14","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","377.40","100","","75.00","75.00","75.00","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","377.40","100","","366.00","144.00","1971.00","45","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","275.50","73","","667.50","667.50","667.50","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","167.75","44.45","","123.77","123.77","123.77","1 through 10","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","both","","","377.40","283.05","WELLPOINT [1015]","HB CH WELLPOINT","294.03","77.91","","483.51","229.32","1316.08","96","167.75","377.4","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","377.40","283.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","223.80","59.3","","439.50","225.34","1872.27","197","188.7","296.07","percent of total billed charges",""
"SCREW BONE 5X36MM LOCKING T25 STARDRIVE RECESS FOR IM NAIL TITANIUM","SUP-ITM-10018421","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","377.40","283.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","296.07","78.45","","385.32","55.36","1815.62","58","188.7","296.07","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","AETNA [1001]","HB CH AETNA HMO / PPO","284.74","58.3","","554.95","91.85","1421.75","94","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","356.53","73","","2490.03","2490.03","2490.03","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.74","58.3","","750.00","750.00","750.00","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.85","53","","1192.50","120.84","4149.90","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","415.14","85","","750.00","75.00","750.00","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","488.40","100","","657.00","121.50","1971.00","14","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","488.40","100","","75.00","75.00","75.00","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","488.40","100","","366.00","144.00","1971.00","45","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","356.53","73","","667.50","667.50","667.50","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.09","44.45","","123.77","123.77","123.77","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","WELLPOINT [1015]","HB CH WELLPOINT","380.51","77.91","","483.51","229.32","1316.08","96","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.62","59.3","","439.50","225.34","1872.27","197","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X36MM TITANIUM LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10036831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","383.15","78.45","","385.32","55.36","1815.62","58","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","AETNA [1001]","HB CH AETNA HMO / PPO","567.36","58.3","","554.95","91.85","1421.75","94","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","710.41","73","","2490.03","2490.03","2490.03","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","567.36","58.3","","750.00","750.00","750.00","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","515.78","53","","1192.50","120.84","4149.90","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","827.19","85","","750.00","75.00","750.00","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","973.17","100","","657.00","121.50","1971.00","14","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","973.17","100","","75.00","75.00","75.00","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","973.17","100","","366.00","144.00","1971.00","45","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","710.41","73","","667.50","667.50","667.50","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","432.57","44.45","","123.77","123.77","123.77","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","WELLPOINT [1015]","HB CH WELLPOINT","758.20","77.91","","483.51","229.32","1316.08","96","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.17","729.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","577.09","59.3","","439.50","225.34","1872.27","197","486.59","763.45","percent of total billed charges",""
"SCREW BONE 5X37.5MM LOCKING","SUP-ITM-10232829","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.17","729.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","763.45","78.45","","385.32","55.36","1815.62","58","486.59","763.45","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","554.95","91.85","1421.75","94","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2490.03","2490.03","2490.03","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","750.00","750.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","1192.50","120.84","4149.90","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","750.00","75.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","657.00","121.50","1971.00","14","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","75.00","75.00","75.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","366.00","144.00","1971.00","45","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","667.50","667.50","667.50","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","123.77","123.77","123.77","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","483.51","229.32","1316.08","96","72.01","162","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","439.50","225.34","1872.27","197","81","127.09","percent of total billed charges",""
"SCREW BONE 5X40MM HIP CORTICAL TITANIUM TAPERED HEAD PERIPHERAL","SUP-ITM-10025179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","385.32","55.36","1815.62","58","81","127.09","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","AETNA [1001]","HB CH AETNA HMO / PPO","225.85","58.3","","554.95","91.85","1421.75","94","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","282.79","73","","2490.03","2490.03","2490.03","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","225.85","58.3","","750.00","750.00","750.00","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","205.32","53","","1192.50","120.84","4149.90","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","329.28","85","","750.00","75.00","750.00","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","387.39","100","","657.00","121.50","1971.00","14","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","387.39","100","","75.00","75.00","75.00","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","387.39","100","","366.00","144.00","1971.00","45","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","282.79","73","","667.50","667.50","667.50","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","172.19","44.45","","123.77","123.77","123.77","1 through 10","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","both","","","387.39","290.54","WELLPOINT [1015]","HB CH WELLPOINT","301.82","77.91","","483.51","229.32","1316.08","96","172.19","387.39","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.39","290.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","229.72","59.3","","439.50","225.34","1872.27","197","193.7","303.91","percent of total billed charges",""
"SCREW BONE 5X40MM LOCKING FOR INTRAMEDULLARY NAIL GREEN TITANIUM","SUP-ITM-10009824","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","387.39","290.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","303.91","78.45","","385.32","55.36","1815.62","58","193.7","303.91","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","AETNA [1001]","HB CH AETNA HMO / PPO","513.05","58.3","","554.95","91.85","1421.75","94","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","642.41","73","","2490.03","2490.03","2490.03","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","513.05","58.3","","750.00","750.00","750.00","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","466.41","53","","1192.50","120.84","4149.90","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","748.02","85","","750.00","75.00","750.00","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","880.02","100","","657.00","121.50","1971.00","14","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","880.02","100","","75.00","75.00","75.00","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","880.02","100","","366.00","144.00","1971.00","45","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","642.41","73","","667.50","667.50","667.50","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","391.17","44.45","","123.77","123.77","123.77","1 through 10","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","both","","","880.02","660.01","WELLPOINT [1015]","HB CH WELLPOINT","685.62","77.91","","483.51","229.32","1316.08","96","391.17","880.02","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","521.85","59.3","","439.50","225.34","1872.27","197","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5X40MM T2 LOCKING FULLY THREADED","SUP-ITM-10016990","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","880.02","660.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","690.38","78.45","","385.32","55.36","1815.62","58","440.01","690.38","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","AETNA [1001]","HB CH AETNA HMO / PPO","284.74","58.3","","554.95","91.85","1421.75","94","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","356.53","73","","2490.03","2490.03","2490.03","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","284.74","58.3","","750.00","750.00","750.00","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","258.85","53","","1192.50","120.84","4149.90","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","415.14","85","","750.00","75.00","750.00","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","488.40","100","","657.00","121.50","1971.00","14","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","488.40","100","","75.00","75.00","75.00","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","488.40","100","","366.00","144.00","1971.00","45","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","356.53","73","","667.50","667.50","667.50","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","217.09","44.45","","123.77","123.77","123.77","1 through 10","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","both","","","488.40","366.30","WELLPOINT [1015]","HB CH WELLPOINT","380.51","77.91","","483.51","229.32","1316.08","96","217.09","488.4","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","CIGNA [1006]","HB CH CIGNA HMO / PPO","289.62","59.3","","439.50","225.34","1872.27","197","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X40MM TI LOCKING SELF TAPPING FULL THREAD T25 STARDRIVE RECESS AQUA","SUP-ITM-10030477","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","488.40","366.30","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","383.15","78.45","","385.32","55.36","1815.62","58","244.2","383.15","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","AETNA [1001]","HB CH AETNA HMO / PPO","567.36","58.3","","554.95","91.85","1421.75","94","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","710.41","73","","2490.03","2490.03","2490.03","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","567.36","58.3","","750.00","750.00","750.00","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","515.78","53","","1192.50","120.84","4149.90","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","827.19","85","","750.00","75.00","750.00","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","973.17","100","","657.00","121.50","1971.00","14","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","973.17","100","","75.00","75.00","75.00","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","973.17","100","","366.00","144.00","1971.00","45","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","710.41","73","","667.50","667.50","667.50","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","432.57","44.45","","123.77","123.77","123.77","1 through 10","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","both","","","973.17","729.88","WELLPOINT [1015]","HB CH WELLPOINT","758.20","77.91","","483.51","229.32","1316.08","96","432.57","973.17","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.17","729.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","577.09","59.3","","439.50","225.34","1872.27","197","486.59","763.45","percent of total billed charges",""
"SCREW BONE 5X42.5MM LOCKING","SUP-ITM-10232827","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","973.17","729.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","763.45","78.45","","385.32","55.36","1815.62","58","486.59","763.45","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","AETNA [1001]","HB CH AETNA HMO / PPO","355.73","58.3","","554.95","91.85","1421.75","94","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","445.42","73","","2490.03","2490.03","2490.03","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","355.73","58.3","","750.00","750.00","750.00","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","323.39","53","","1192.50","120.84","4149.90","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","518.64","85","","750.00","75.00","750.00","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","610.17","100","","657.00","121.50","1971.00","14","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","610.17","100","","75.00","75.00","75.00","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","610.17","100","","366.00","144.00","1971.00","45","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","445.42","73","","667.50","667.50","667.50","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","271.22","44.45","","123.77","123.77","123.77","1 through 10","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","both","","","610.17","457.63","WELLPOINT [1015]","HB CH WELLPOINT","475.38","77.91","","483.51","229.32","1316.08","96","271.22","610.17","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","610.17","457.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","361.83","59.3","","439.50","225.34","1872.27","197","305.09","478.68","percent of total billed charges",""
"SCREW BONE 5X50MM CONDYLAR VA LCP SS CANNULATED VARIABLE ANGLE LOCKING SELF DRILLING HEXAGONAL SOCKET","SUP-ITM-10095442","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","610.17","457.63","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","478.68","78.45","","385.32","55.36","1815.62","58","305.09","478.68","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","AETNA [1001]","HB CH AETNA HMO / PPO","258.85","58.3","","554.95","91.85","1421.75","94","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","324.12","73","","2490.03","2490.03","2490.03","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","258.85","58.3","","750.00","750.00","750.00","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","235.32","53","","1192.50","120.84","4149.90","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","377.40","85","","750.00","75.00","750.00","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","444.00","100","","657.00","121.50","1971.00","14","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","444.00","100","","75.00","75.00","75.00","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","444.00","100","","366.00","144.00","1971.00","45","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","324.12","73","","667.50","667.50","667.50","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.36","44.45","","123.77","123.77","123.77","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","WELLPOINT [1015]","HB CH WELLPOINT","345.92","77.91","","483.51","229.32","1316.08","96","197.36","444","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","263.29","59.3","","439.50","225.34","1872.27","197","222","348.32","percent of total billed charges",""
"SCREW BONE 5X50MM TITANIUM LOCKING SELF TAPPING FULL THREAD HEXAGONAL DRIVE","SUP-ITM-10017869","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","348.32","78.45","","385.32","55.36","1815.62","58","222","348.32","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","554.95","91.85","1421.75","94","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","2490.03","2490.03","2490.03","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","750.00","750.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","1192.50","120.84","4149.90","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.25","85","","750.00","75.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.00","100","","657.00","121.50","1971.00","14","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.00","100","","75.00","75.00","75.00","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.00","100","","366.00","144.00","1971.00","45","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","667.50","667.50","667.50","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","123.77","123.77","123.77","1 through 10","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","483.51","229.32","1316.08","96","633.41","1425","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","439.50","225.34","1872.27","197","712.5","1117.91","percent of total billed charges",""
"SCREW BONE 5X55MM COMPRESSION FULL THREAD HEADLESS","SUP-ITM-10317799","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","385.32","55.36","1815.62","58","712.5","1117.91","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","AETNA [1001]","HB CH AETNA HMO / PPO","258.85","58.3","","554.95","91.85","1421.75","94","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","324.12","73","","2490.03","2490.03","2490.03","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","258.85","58.3","","750.00","750.00","750.00","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","235.32","53","","1192.50","120.84","4149.90","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","377.40","85","","750.00","75.00","750.00","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","444.00","100","","657.00","121.50","1971.00","14","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","444.00","100","","75.00","75.00","75.00","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","444.00","100","","366.00","144.00","1971.00","45","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","324.12","73","","667.50","667.50","667.50","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","197.36","44.45","","123.77","123.77","123.77","1 through 10","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","both","","","444.00","333.00","WELLPOINT [1015]","HB CH WELLPOINT","345.92","77.91","","483.51","229.32","1316.08","96","197.36","444","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","263.29","59.3","","439.50","225.34","1872.27","197","222","348.32","percent of total billed charges",""
"SCREW BONE 5X55MM SELF TAPPING LOCKING HEAD TITANIUM","SUP-ITM-10017870","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","444.00","333.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","348.32","78.45","","385.32","55.36","1815.62","58","222","348.32","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","AETNA [1001]","HB CH AETNA HMO / PPO","389.12","58.3","","554.95","91.85","1421.75","94","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","487.23","73","","2490.03","2490.03","2490.03","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","389.12","58.3","","750.00","750.00","750.00","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","353.74","53","","1192.50","120.84","4149.90","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","567.32","85","","750.00","75.00","750.00","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","667.44","100","","657.00","121.50","1971.00","14","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","667.44","100","","75.00","75.00","75.00","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","667.44","100","","366.00","144.00","1971.00","45","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","487.23","73","","667.50","667.50","667.50","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.68","44.45","","123.77","123.77","123.77","1 through 10","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","both","","","667.44","500.58","WELLPOINT [1015]","HB CH WELLPOINT","520.00","77.91","","483.51","229.32","1316.08","96","296.68","667.44","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.44","500.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","395.79","59.3","","439.50","225.34","1872.27","197","333.72","523.61","percent of total billed charges",""
"SCREW BONE 5X65MM CANNULATED PARTIAL THREAD 110007662","SUP-ITM-10230529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","667.44","500.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","523.61","78.45","","385.32","55.36","1815.62","58","333.72","523.61","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","AETNA [1001]","HB CH AETNA HMO / PPO","265.32","58.3","","554.95","91.85","1421.75","94","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","332.22","73","","2490.03","2490.03","2490.03","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","265.32","58.3","","750.00","750.00","750.00","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","241.20","53","","1192.50","120.84","4149.90","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","386.84","85","","750.00","75.00","750.00","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","455.10","100","","657.00","121.50","1971.00","14","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","455.10","100","","75.00","75.00","75.00","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","455.10","100","","366.00","144.00","1971.00","45","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","332.22","73","","667.50","667.50","667.50","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","202.29","44.45","","123.77","123.77","123.77","1 through 10","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","both","","","455.10","341.32","WELLPOINT [1015]","HB CH WELLPOINT","354.57","77.91","","483.51","229.32","1316.08","96","202.29","455.1","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.10","341.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","269.87","59.3","","439.50","225.34","1872.27","197","227.55","357.03","percent of total billed charges",""
"SCREW BONE 5X65MM CONICAL TITANIUM CANNULATED LOCKING SELF DRILLING HEAD HEXAGONAL STARDRIVE RECESS","SUP-ITM-10007374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","455.10","341.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","357.03","78.45","","385.32","55.36","1815.62","58","227.55","357.03","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","AETNA [1001]","HB CH AETNA HMO / PPO","690.86","58.3","","554.95","91.85","1421.75","94","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","865.05","73","","2490.03","2490.03","2490.03","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","690.86","58.3","","750.00","750.00","750.00","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","628.05","53","","1192.50","120.84","4149.90","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1007.25","85","","750.00","75.00","750.00","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1185.00","100","","657.00","121.50","1971.00","14","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1185.00","100","","75.00","75.00","75.00","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1185.00","100","","366.00","144.00","1971.00","45","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","865.05","73","","667.50","667.50","667.50","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","526.73","44.45","","123.77","123.77","123.77","1 through 10","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","both","","","1185.00","888.75","WELLPOINT [1015]","HB CH WELLPOINT","923.23","77.91","","483.51","229.32","1316.08","96","526.73","1185","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","702.71","59.3","","439.50","225.34","1872.27","197","592.5","929.63","percent of total billed charges",""
"SCREW BONE 5X75MM DYNANAIL HEADLESS PA","SUP-ITM-10276981","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1185.00","888.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","929.63","78.45","","385.32","55.36","1815.62","58","592.5","929.63","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","AETNA [1001]","HB CH AETNA HMO / PPO","84.30","58.3","","554.95","91.85","1421.75","94","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","105.56","73","","2490.03","2490.03","2490.03","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","84.30","58.3","","750.00","750.00","750.00","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.64","53","","1192.50","120.84","4149.90","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","122.91","85","","750.00","75.00","750.00","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","144.60","100","","657.00","121.50","1971.00","14","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","144.60","100","","75.00","75.00","75.00","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","144.60","100","","366.00","144.00","1971.00","45","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.56","73","","667.50","667.50","667.50","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.27","44.45","","123.77","123.77","123.77","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","WELLPOINT [1015]","HB CH WELLPOINT","112.66","77.91","","483.51","229.32","1316.08","96","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.60","108.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.75","59.3","","439.50","225.34","1872.27","197","72.3","113.44","percent of total billed charges",""
"SCREW BONE 6.5MM 85MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.60","108.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.44","78.45","","385.32","55.36","1815.62","58","72.3","113.44","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","AETNA [1001]","HB CH AETNA HMO / PPO","84.30","58.3","","554.95","91.85","1421.75","94","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","105.56","73","","2490.03","2490.03","2490.03","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","84.30","58.3","","750.00","750.00","750.00","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","76.64","53","","1192.50","120.84","4149.90","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","122.91","85","","750.00","75.00","750.00","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","144.60","100","","657.00","121.50","1971.00","14","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","144.60","100","","75.00","75.00","75.00","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","144.60","100","","366.00","144.00","1971.00","45","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","105.56","73","","667.50","667.50","667.50","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","64.27","44.45","","123.77","123.77","123.77","1 through 10","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","both","","","144.60","108.45","WELLPOINT [1015]","HB CH WELLPOINT","112.66","77.91","","483.51","229.32","1316.08","96","64.27","144.6","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.60","108.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","85.75","59.3","","439.50","225.34","1872.27","197","72.3","113.44","percent of total billed charges",""
"SCREW BONE 6.5MM 90MM 32MM THREAD CANCELLOUS LG HEX","SUP-ITM-10237570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","144.60","108.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","113.44","78.45","","385.32","55.36","1815.62","58","72.3","113.44","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","AETNA [1001]","HB CH AETNA HMO / PPO","303.43","58.3","","554.95","91.85","1421.75","94","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","379.94","73","","2490.03","2490.03","2490.03","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","303.43","58.3","","750.00","750.00","750.00","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","275.85","53","","1192.50","120.84","4149.90","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","442.40","85","","750.00","75.00","750.00","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","520.47","100","","657.00","121.50","1971.00","14","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","520.47","100","","75.00","75.00","75.00","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","520.47","100","","366.00","144.00","1971.00","45","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","379.94","73","","667.50","667.50","667.50","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.35","44.45","","123.77","123.77","123.77","1 through 10","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","both","","","520.47","390.35","WELLPOINT [1015]","HB CH WELLPOINT","405.50","77.91","","483.51","229.32","1316.08","96","231.35","520.47","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.47","390.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","308.64","59.3","","439.50","225.34","1872.27","197","260.24","408.31","percent of total billed charges",""
"SCREW BONE 6.5MM LOCKING REPLACEMENT HINDFOOT SURFIX SS","SUP-ITM-10091891","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","520.47","390.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","408.31","78.45","","385.32","55.36","1815.62","58","260.24","408.31","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","AETNA [1001]","HB CH AETNA HMO / PPO","145.76","58.3","","554.95","91.85","1421.75","94","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","182.51","73","","2490.03","2490.03","2490.03","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","145.76","58.3","","750.00","750.00","750.00","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","132.51","53","","1192.50","120.84","4149.90","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","212.52","85","","750.00","75.00","750.00","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","250.02","100","","657.00","121.50","1971.00","14","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","250.02","100","","75.00","75.00","75.00","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","250.02","100","","366.00","144.00","1971.00","45","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","182.51","73","","667.50","667.50","667.50","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","111.13","44.45","","123.77","123.77","123.77","1 through 10","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","both","","","250.02","187.51","WELLPOINT [1015]","HB CH WELLPOINT","194.79","77.91","","483.51","229.32","1316.08","96","111.13","250.02","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","250.02","187.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","148.26","59.3","","439.50","225.34","1872.27","197","125.01","196.14","percent of total billed charges",""
"SCREW BONE 6.5X100MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","250.02","187.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","196.14","78.45","","385.32","55.36","1815.62","58","125.01","196.14","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","AETNA [1001]","HB CH AETNA HMO / PPO","208.90","58.3","","554.95","91.85","1421.75","94","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","261.57","73","","2490.03","2490.03","2490.03","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","208.90","58.3","","750.00","750.00","750.00","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","189.91","53","","1192.50","120.84","4149.90","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","304.57","85","","750.00","75.00","750.00","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","358.32","100","","657.00","121.50","1971.00","14","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","358.32","100","","75.00","75.00","75.00","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","358.32","100","","366.00","144.00","1971.00","45","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","261.57","73","","667.50","667.50","667.50","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","159.27","44.45","","123.77","123.77","123.77","1 through 10","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","both","","","358.32","268.74","WELLPOINT [1015]","HB CH WELLPOINT","279.17","77.91","","483.51","229.32","1316.08","96","159.27","358.32","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","358.32","268.74","CIGNA [1006]","HB CH CIGNA HMO / PPO","212.48","59.3","","439.50","225.34","1872.27","197","179.16","281.1","percent of total billed charges",""
"SCREW BONE 6.5X105MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072182","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","358.32","268.74","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","281.10","78.45","","385.32","55.36","1815.62","58","179.16","281.1","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X12MM HIP CANCELLOUS OSTEOLOCK TITANIUM ACETABULAR","SUP-ITM-10011770","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","AETNA [1001]","HB CH AETNA HMO / PPO","595.20","58.3","","554.95","91.85","1421.75","94","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","745.28","73","","2490.03","2490.03","2490.03","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","595.20","58.3","","750.00","750.00","750.00","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","541.09","53","","1192.50","120.84","4149.90","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","867.79","85","","750.00","75.00","750.00","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1020.93","100","","657.00","121.50","1971.00","14","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1020.93","100","","75.00","75.00","75.00","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1020.93","100","","366.00","144.00","1971.00","45","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","745.28","73","","667.50","667.50","667.50","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","453.80","44.45","","123.77","123.77","123.77","1 through 10","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","both","","","1020.93","765.70","WELLPOINT [1015]","HB CH WELLPOINT","795.41","77.91","","483.51","229.32","1316.08","96","453.8","1020.93","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.93","765.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","605.41","59.3","","439.50","225.34","1872.27","197","510.47","800.92","percent of total billed charges",""
"SCREW BONE 6.5X16X40MM CANNULATED TIMAX","SUP-ITM-10230557","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1020.93","765.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","800.92","78.45","","385.32","55.36","1815.62","58","510.47","800.92","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","AETNA [1001]","HB CH AETNA HMO / PPO","194.87","58.3","","554.95","91.85","1421.75","94","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","244.01","73","","2490.03","2490.03","2490.03","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","194.87","58.3","","750.00","750.00","750.00","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","177.16","53","","1192.50","120.84","4149.90","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","284.12","85","","750.00","75.00","750.00","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","334.26","100","","657.00","121.50","1971.00","14","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","334.26","100","","75.00","75.00","75.00","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","334.26","100","","366.00","144.00","1971.00","45","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","244.01","73","","667.50","667.50","667.50","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.58","44.45","","123.77","123.77","123.77","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","WELLPOINT [1015]","HB CH WELLPOINT","260.42","77.91","","483.51","229.32","1316.08","96","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.22","59.3","","439.50","225.34","1872.27","197","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X20MM CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10126755","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.23","78.45","","385.32","55.36","1815.62","58","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB CH AETNA HMO / PPO","570.17","58.3","","554.95","91.85","1421.75","94","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","2490.03","2490.03","2490.03","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","570.17","58.3","","750.00","750.00","750.00","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.34","53","","1192.50","120.84","4149.90","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","831.30","85","","750.00","75.00","750.00","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","978.00","100","","657.00","121.50","1971.00","14","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","978.00","100","","75.00","75.00","75.00","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","978.00","100","","366.00","144.00","1971.00","45","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","667.50","667.50","667.50","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.72","44.45","","123.77","123.77","123.77","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","WELLPOINT [1015]","HB CH WELLPOINT","761.96","77.91","","483.51","229.32","1316.08","96","434.72","978","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.95","59.3","","439.50","225.34","1872.27","197","489","767.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM CENTRAL NON STERILE","SUP-ITM-10215303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.24","78.45","","385.32","55.36","1815.62","58","489","767.24","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","AETNA [1001]","HB CH AETNA HMO / PPO","194.87","58.3","","554.95","91.85","1421.75","94","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","244.01","73","","2490.03","2490.03","2490.03","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","194.87","58.3","","750.00","750.00","750.00","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","177.16","53","","1192.50","120.84","4149.90","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","284.12","85","","750.00","75.00","750.00","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","334.26","100","","657.00","121.50","1971.00","14","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","334.26","100","","75.00","75.00","75.00","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","334.26","100","","366.00","144.00","1971.00","45","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","244.01","73","","667.50","667.50","667.50","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","148.58","44.45","","123.77","123.77","123.77","1 through 10","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","both","","","334.26","250.69","WELLPOINT [1015]","HB CH WELLPOINT","260.42","77.91","","483.51","229.32","1316.08","96","148.58","334.26","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.22","59.3","","439.50","225.34","1872.27","197","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X25MM GLENOID CANCELLOUS UNIVERS REVERS VARIABLE ANGLE TITANIUM LOCKING CENTRAL","SUP-ITM-10132817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","334.26","250.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","262.23","78.45","","385.32","55.36","1815.62","58","167.13","262.23","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","AETNA [1001]","HB CH AETNA HMO / PPO","69.79","58.3","","554.95","91.85","1421.75","94","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","2490.03","2490.03","2490.03","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.79","58.3","","750.00","750.00","750.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.44","53","","1192.50","120.84","4149.90","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","101.75","85","","750.00","75.00","750.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","119.70","100","","657.00","121.50","1971.00","14","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","119.70","100","","75.00","75.00","75.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","119.70","100","","366.00","144.00","1971.00","45","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","667.50","667.50","667.50","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","123.77","123.77","123.77","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","WELLPOINT [1015]","HB CH WELLPOINT","93.26","77.91","","483.51","229.32","1316.08","96","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.98","59.3","","439.50","225.34","1872.27","197","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP ACETABULAR DOME G7 LOW PROFILE","SUP-ITM-10132545","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","385.32","55.36","1815.62","58","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","554.95","91.85","1421.75","94","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","2490.03","2490.03","2490.03","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","750.00","750.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","1192.50","120.84","4149.90","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.90","85","","750.00","75.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","114.00","100","","657.00","121.50","1971.00","14","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","114.00","100","","75.00","75.00","75.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","114.00","100","","366.00","144.00","1971.00","45","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","667.50","667.50","667.50","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","123.77","123.77","123.77","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","483.51","229.32","1316.08","96","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","439.50","225.34","1872.27","197","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X25MM HIP CANCELLOUS SPHERICAL HD FOR REFLECTION SYSTEM 16A","SUP-ITM-10015410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","385.32","55.36","1815.62","58","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","AETNA [1001]","HB CH AETNA HMO / PPO","195.89","58.3","","554.95","91.85","1421.75","94","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","245.28","73","","2490.03","2490.03","2490.03","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","195.89","58.3","","750.00","750.00","750.00","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","178.08","53","","1192.50","120.84","4149.90","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","285.60","85","","750.00","75.00","750.00","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","336.00","100","","657.00","121.50","1971.00","14","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","336.00","100","","75.00","75.00","75.00","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","336.00","100","","366.00","144.00","1971.00","45","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","245.28","73","","667.50","667.50","667.50","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","149.35","44.45","","123.77","123.77","123.77","1 through 10","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","both","","","336.00","252.00","WELLPOINT [1015]","HB CH WELLPOINT","261.78","77.91","","483.51","229.32","1316.08","96","149.35","336","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","199.25","59.3","","439.50","225.34","1872.27","197","168","263.59","percent of total billed charges",""
"SCREW BONE 6.5X30.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10025622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","336.00","252.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","263.59","78.45","","385.32","55.36","1815.62","58","168","263.59","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","AETNA [1001]","HB CH AETNA HMO / PPO","69.79","58.3","","554.95","91.85","1421.75","94","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","2490.03","2490.03","2490.03","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.79","58.3","","750.00","750.00","750.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.44","53","","1192.50","120.84","4149.90","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","101.75","85","","750.00","75.00","750.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","119.70","100","","657.00","121.50","1971.00","14","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","119.70","100","","75.00","75.00","75.00","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","119.70","100","","366.00","144.00","1971.00","45","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.38","73","","667.50","667.50","667.50","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.21","44.45","","123.77","123.77","123.77","1 through 10","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.70","89.77","WELLPOINT [1015]","HB CH WELLPOINT","93.26","77.91","","483.51","229.32","1316.08","96","53.21","119.7","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.98","59.3","","439.50","225.34","1872.27","197","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X30MM HIP DOME G7 ACETABULAR LOW PROFILE","SUP-ITM-10132544","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.70","89.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.90","78.45","","385.32","55.36","1815.62","58","59.85","93.9","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","AETNA [1001]","HB CH AETNA HMO / PPO","91.25","58.3","","554.95","91.85","1421.75","94","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","114.25","73","","2490.03","2490.03","2490.03","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.25","58.3","","750.00","750.00","750.00","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.95","53","","1192.50","120.84","4149.90","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","133.03","85","","750.00","75.00","750.00","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","156.51","100","","657.00","121.50","1971.00","14","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","156.51","100","","75.00","75.00","75.00","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","156.51","100","","366.00","144.00","1971.00","45","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","114.25","73","","667.50","667.50","667.50","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","69.57","44.45","","123.77","123.77","123.77","1 through 10","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","both","","","156.51","117.38","WELLPOINT [1015]","HB CH WELLPOINT","121.94","77.91","","483.51","229.32","1316.08","96","69.57","156.51","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","CIGNA [1006]","HB CH CIGNA HMO / PPO","92.81","59.3","","439.50","225.34","1872.27","197","78.26","122.78","percent of total billed charges",""
"SCREW BONE 6.5X35MM CANCELLOUS LG FRAGMENT FULL THREAD HEX SOCKET SS","SUP-ITM-10001510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","156.51","117.38","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","122.78","78.45","","385.32","55.36","1815.62","58","78.26","122.78","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","AETNA [1001]","HB CH AETNA HMO / PPO","206.38","58.3","","554.95","91.85","1421.75","94","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","258.42","73","","2490.03","2490.03","2490.03","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","206.38","58.3","","750.00","750.00","750.00","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","187.62","53","","1192.50","120.84","4149.90","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","300.90","85","","750.00","75.00","750.00","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","354.00","100","","657.00","121.50","1971.00","14","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","354.00","100","","75.00","75.00","75.00","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","354.00","100","","366.00","144.00","1971.00","45","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","258.42","73","","667.50","667.50","667.50","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","157.35","44.45","","123.77","123.77","123.77","1 through 10","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","both","","","354.00","265.50","WELLPOINT [1015]","HB CH WELLPOINT","275.80","77.91","","483.51","229.32","1316.08","96","157.35","354","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.00","265.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","209.92","59.3","","439.50","225.34","1872.27","197","177","277.71","percent of total billed charges",""
"SCREW BONE 6.5X45.0MM CANCELLOUS TITANIUM FULLY THREADED","SUP-ITM-10041749","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","354.00","265.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","277.71","78.45","","385.32","55.36","1815.62","58","177","277.71","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X45MM HIP CANCELLOUS SELF TAPPING PARTIAL THRD TRIDENT S/S 16A","SUP-ITM-10002041","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","1634.24","1004.95","1718.99","42","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2123.89","1900.92","2123.89","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","3729.00","1254.19","3729.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","939.37","939.37","5593.65","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","2323.25","1864.50","2882.25","16","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","2909.44","1772.40","10952.08","45","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","2323.25","2323.25","2323.25","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","2882.25","1772.40","10169.17","187","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","1659.41","1659.41","1659.41","1 through 10","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","2050.91","1468.48","2902.83","52","72.01","162","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","1548.60","1092.60","3613.79","82","81","127.09","percent of total billed charges",""
"SCREW BONE 6.5X50MM HIP S-ROM TITANIUM SELF TAPPING DOME HEAD LOW PROFILE","SUP-ITM-10002081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","2085.51","998.68","6202.11","56","81","127.09","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","AETNA [1001]","HB CH AETNA HMO / PPO","148.67","58.3","","554.95","91.85","1421.75","94","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","2490.03","2490.03","2490.03","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","148.67","58.3","","750.00","750.00","750.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","135.15","53","","1192.50","120.84","4149.90","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","216.75","85","","750.00","75.00","750.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","255.00","100","","657.00","121.50","1971.00","14","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","255.00","100","","75.00","75.00","75.00","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","255.00","100","","366.00","144.00","1971.00","45","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","186.15","73","","667.50","667.50","667.50","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","113.35","44.45","","123.77","123.77","123.77","1 through 10","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","both","","","255.00","191.25","WELLPOINT [1015]","HB CH WELLPOINT","198.67","77.91","","483.51","229.32","1316.08","96","113.35","255","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","151.22","59.3","","439.50","225.34","1872.27","197","127.5","200.05","percent of total billed charges",""
"SCREW BONE 6.5X50MM TIBIAL CANCELLOUS HIGH OSTEOTOMY PLATE TITANIUM","SUP-ITM-10042405","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","255.00","191.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","200.05","78.45","","385.32","55.36","1815.62","58","127.5","200.05","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","AETNA [1001]","HB CH AETNA HMO / PPO","66.46","58.3","","554.95","91.85","1421.75","94","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","2490.03","2490.03","2490.03","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","66.46","58.3","","750.00","750.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","60.42","53","","1192.50","120.84","4149.90","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","96.90","85","","750.00","75.00","750.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","114.00","100","","657.00","121.50","1971.00","14","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","114.00","100","","75.00","75.00","75.00","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","114.00","100","","366.00","144.00","1971.00","45","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","83.22","73","","667.50","667.50","667.50","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","50.67","44.45","","123.77","123.77","123.77","1 through 10","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","both","","","114.00","85.50","WELLPOINT [1015]","HB CH WELLPOINT","88.82","77.91","","483.51","229.32","1316.08","96","50.67","114","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","67.60","59.3","","439.50","225.34","1872.27","197","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X55MM HIP CANCELLOUS TI TORX HEAD","SUP-ITM-10006598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","114.00","85.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","89.43","78.45","","385.32","55.36","1815.62","58","57","89.43","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","AETNA [1001]","HB CH AETNA HMO / PPO","93.68","58.3","","554.95","91.85","1421.75","94","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","117.30","73","","2490.03","2490.03","2490.03","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","93.68","58.3","","750.00","750.00","750.00","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.16","53","","1192.50","120.84","4149.90","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","136.58","85","","750.00","75.00","750.00","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","160.68","100","","657.00","121.50","1971.00","14","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","160.68","100","","75.00","75.00","75.00","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","160.68","100","","366.00","144.00","1971.00","45","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","117.30","73","","667.50","667.50","667.50","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","71.42","44.45","","123.77","123.77","123.77","1 through 10","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","both","","","160.68","120.51","WELLPOINT [1015]","HB CH WELLPOINT","125.19","77.91","","483.51","229.32","1316.08","96","71.42","160.68","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.68","120.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","95.28","59.3","","439.50","225.34","1872.27","197","80.34","126.05","percent of total billed charges",""
"SCREW BONE 6.5X60MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072173","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","160.68","120.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","126.05","78.45","","385.32","55.36","1815.62","58","80.34","126.05","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","554.95","91.85","1421.75","94","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2490.03","2490.03","2490.03","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","750.00","750.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","1192.50","120.84","4149.90","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","750.00","75.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","657.00","121.50","1971.00","14","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","75.00","75.00","75.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","366.00","144.00","1971.00","45","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","667.50","667.50","667.50","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","123.77","123.77","123.77","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","483.51","229.32","1316.08","96","533.4","1200","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","439.50","225.34","1872.27","197","600","941.4","percent of total billed charges",""
"SCREW BONE 6.5X60MM SPINE MEDIAL BIASED ILIOS AND REVISION POLYAXIAL","SUP-ITM-10086570","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","385.32","55.36","1815.62","58","600","941.4","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","AETNA [1001]","HB CH AETNA HMO / PPO","283.76","58.3","","554.95","91.85","1421.75","94","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","355.31","73","","2490.03","2490.03","2490.03","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","283.76","58.3","","750.00","750.00","750.00","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","257.96","53","","1192.50","120.84","4149.90","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","413.71","85","","750.00","75.00","750.00","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","486.72","100","","657.00","121.50","1971.00","14","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","486.72","100","","75.00","75.00","75.00","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","486.72","100","","366.00","144.00","1971.00","45","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","355.31","73","","667.50","667.50","667.50","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","216.35","44.45","","123.77","123.77","123.77","1 through 10","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","both","","","486.72","365.04","WELLPOINT [1015]","HB CH WELLPOINT","379.20","77.91","","483.51","229.32","1316.08","96","216.35","486.72","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","288.62","59.3","","439.50","225.34","1872.27","197","243.36","381.83","percent of total billed charges",""
"SCREW BONE 6.5X70MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10019108","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","486.72","365.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","381.83","78.45","","385.32","55.36","1815.62","58","243.36","381.83","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","AETNA [1001]","HB CH AETNA HMO / PPO","925.05","58.3","","554.95","91.85","1421.75","94","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1158.29","73","","2490.03","2490.03","2490.03","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","925.05","58.3","","750.00","750.00","750.00","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","840.95","53","","1192.50","120.84","4149.90","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1348.70","85","","750.00","75.00","750.00","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1586.70","100","","657.00","121.50","1971.00","14","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1586.70","100","","75.00","75.00","75.00","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1586.70","100","","366.00","144.00","1971.00","45","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1158.29","73","","667.50","667.50","667.50","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","705.29","44.45","","123.77","123.77","123.77","1 through 10","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","both","","","1586.70","1190.02","WELLPOINT [1015]","HB CH WELLPOINT","1236.20","77.91","","483.51","229.32","1316.08","96","705.29","1586.7","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1586.70","1190.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","940.91","59.3","","439.50","225.34","1872.27","197","793.35","1244.77","percent of total billed charges",""
"SCREW BONE 6.5X70MM COMPRESSION TI CANNULATED HEADLESS SHORT THREAD","SUP-ITM-10276389","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1586.70","1190.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1244.77","78.45","","385.32","55.36","1815.62","58","793.35","1244.77","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","AETNA [1001]","HB CH AETNA HMO / PPO","311.74","58.3","","554.95","91.85","1421.75","94","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","390.35","73","","2490.03","2490.03","2490.03","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","311.74","58.3","","750.00","750.00","750.00","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","283.40","53","","1192.50","120.84","4149.90","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","454.51","85","","750.00","75.00","750.00","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","534.72","100","","657.00","121.50","1971.00","14","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","534.72","100","","75.00","75.00","75.00","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","534.72","100","","366.00","144.00","1971.00","45","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","390.35","73","","667.50","667.50","667.50","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.68","44.45","","123.77","123.77","123.77","1 through 10","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","both","","","534.72","401.04","WELLPOINT [1015]","HB CH WELLPOINT","416.60","77.91","","483.51","229.32","1316.08","96","237.68","534.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.72","401.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","317.09","59.3","","439.50","225.34","1872.27","197","267.36","419.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD CANNULATED TITANIUM HEXAGONAL SOCKET","SUP-ITM-10039932","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","534.72","401.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","419.49","78.45","","385.32","55.36","1815.62","58","267.36","419.49","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","AETNA [1001]","HB CH AETNA HMO / PPO","98.36","58.3","","554.95","91.85","1421.75","94","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","123.17","73","","2490.03","2490.03","2490.03","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","98.36","58.3","","750.00","750.00","750.00","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","89.42","53","","1192.50","120.84","4149.90","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","143.41","85","","750.00","75.00","750.00","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","168.72","100","","657.00","121.50","1971.00","14","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","168.72","100","","75.00","75.00","75.00","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","168.72","100","","366.00","144.00","1971.00","45","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","123.17","73","","667.50","667.50","667.50","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","75.00","44.45","","123.77","123.77","123.77","1 through 10","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","both","","","168.72","126.54","WELLPOINT [1015]","HB CH WELLPOINT","131.45","77.91","","483.51","229.32","1316.08","96","75","168.72","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.72","126.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","100.05","59.3","","439.50","225.34","1872.27","197","84.36","132.36","percent of total billed charges",""
"SCREW BONE 6.5X85MM 32MM THREAD LG CANCELLOUS SS HEXAGONAL SOCKET","SUP-ITM-10001630","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","168.72","126.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","132.36","78.45","","385.32","55.36","1815.62","58","84.36","132.36","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","AETNA [1001]","HB CH AETNA HMO / PPO","142.12","58.3","","554.95","91.85","1421.75","94","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","177.96","73","","2490.03","2490.03","2490.03","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","142.12","58.3","","750.00","750.00","750.00","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","129.20","53","","1192.50","120.84","4149.90","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","207.21","85","","750.00","75.00","750.00","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","243.78","100","","657.00","121.50","1971.00","14","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","243.78","100","","75.00","75.00","75.00","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","243.78","100","","366.00","144.00","1971.00","45","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","177.96","73","","667.50","667.50","667.50","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.36","44.45","","123.77","123.77","123.77","1 through 10","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","both","","","243.78","182.83","WELLPOINT [1015]","HB CH WELLPOINT","189.93","77.91","","483.51","229.32","1316.08","96","108.36","243.78","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.78","182.83","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.56","59.3","","439.50","225.34","1872.27","197","121.89","191.25","percent of total billed charges",""
"SCREW BONE 6.5X90MM CANCELLOUS 40 TITANIUM THREAD","SUP-ITM-10072179","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","243.78","182.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","191.25","78.45","","385.32","55.36","1815.62","58","121.89","191.25","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","554.95","91.85","1421.75","94","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2490.03","2490.03","2490.03","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","750.00","750.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","1192.50","120.84","4149.90","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","750.00","75.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","657.00","121.50","1971.00","14","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","75.00","75.00","75.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","366.00","144.00","1971.00","45","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","667.50","667.50","667.50","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","123.77","123.77","123.77","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","483.51","229.32","1316.08","96","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","439.50","225.34","1872.27","197","375","588.38","percent of total billed charges",""
"SCREW BONE 6.7MMX40 18 CANNULATED TITANIUM LOW PROFILE SYSTEM THREAD","SUP-ITM-10050599","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","385.32","55.36","1815.62","58","375","588.38","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","554.95","91.85","1421.75","94","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2490.03","2490.03","2490.03","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","750.00","750.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","1192.50","120.84","4149.90","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","750.00","75.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","657.00","121.50","1971.00","14","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","75.00","75.00","75.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","366.00","144.00","1971.00","45","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","667.50","667.50","667.50","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","123.77","123.77","123.77","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","483.51","229.32","1316.08","96","333.38","750","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","439.50","225.34","1872.27","197","375","588.38","percent of total billed charges",""
"SCREW BONE 6.7X80MM TITANIUM LAG LOW PROFILE","SUP-ITM-10090508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","385.32","55.36","1815.62","58","375","588.38","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","AETNA [1001]","HB CH AETNA HMO / PPO","108.02","58.3","","554.95","91.85","1421.75","94","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","135.25","73","","2490.03","2490.03","2490.03","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.02","58.3","","750.00","750.00","750.00","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.20","53","","1192.50","120.84","4149.90","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","157.49","85","","750.00","75.00","750.00","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","185.28","100","","657.00","121.50","1971.00","14","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","185.28","100","","75.00","75.00","75.00","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","185.28","100","","366.00","144.00","1971.00","45","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.25","73","","667.50","667.50","667.50","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.36","44.45","","123.77","123.77","123.77","1 through 10","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.28","138.96","WELLPOINT [1015]","HB CH WELLPOINT","144.35","77.91","","483.51","229.32","1316.08","96","82.36","185.28","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.87","59.3","","439.50","225.34","1872.27","197","92.64","145.35","percent of total billed charges",""
"SCREW BONE 6X190MM SCHANZ EXTERNAL FIXATION DIAMOND POINT SS","SUP-ITM-10004029","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.28","138.96","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.35","78.45","","385.32","55.36","1815.62","58","92.64","145.35","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","AETNA [1001]","HB CH AETNA HMO / PPO","69.68","58.3","","554.95","91.85","1421.75","94","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.25","73","","2490.03","2490.03","2490.03","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.68","58.3","","750.00","750.00","750.00","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.35","53","","1192.50","120.84","4149.90","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","101.59","85","","750.00","75.00","750.00","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","119.52","100","","657.00","121.50","1971.00","14","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","119.52","100","","75.00","75.00","75.00","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","119.52","100","","366.00","144.00","1971.00","45","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.25","73","","667.50","667.50","667.50","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.13","44.45","","123.77","123.77","123.77","1 through 10","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","both","","","119.52","89.64","WELLPOINT [1015]","HB CH WELLPOINT","93.12","77.91","","483.51","229.32","1316.08","96","53.13","119.52","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.52","89.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","70.88","59.3","","439.50","225.34","1872.27","197","59.76","93.76","percent of total billed charges",""
"SCREW BONE 6X2.1X6MM MATRIX TITANIUM EMERGENCY SELF TAPPING PITCH SINGLE .","SUP-ITM-10131206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","119.52","89.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","93.76","78.45","","385.32","55.36","1815.62","58","59.76","93.76","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","AETNA [1001]","HB CH AETNA HMO / PPO","427.11","58.3","","554.95","91.85","1421.75","94","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","534.80","73","","2490.03","2490.03","2490.03","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","427.11","58.3","","750.00","750.00","750.00","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","388.28","53","","1192.50","120.84","4149.90","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","622.71","85","","750.00","75.00","750.00","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","732.60","100","","657.00","121.50","1971.00","14","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","732.60","100","","75.00","75.00","75.00","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","732.60","100","","366.00","144.00","1971.00","45","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","534.80","73","","667.50","667.50","667.50","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","325.64","44.45","","123.77","123.77","123.77","1 through 10","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","both","","","732.60","549.45","WELLPOINT [1015]","HB CH WELLPOINT","570.77","77.91","","483.51","229.32","1316.08","96","325.64","732.6","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","732.60","549.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","434.43","59.3","","439.50","225.34","1872.27","197","366.3","574.72","percent of total billed charges",""
"SCREW BONE 6X200MM FIXATION EXTERNAL SCHANZ STAINLESS STEEL HYDROXYAPATITE COATING SELF DRILLING 80MM THREAD","SUP-ITM-10038649","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","732.60","549.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","574.72","78.45","","385.32","55.36","1815.62","58","366.3","574.72","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","554.95","91.85","1421.75","94","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","2490.03","2490.03","2490.03","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","750.00","750.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","1192.50","120.84","4149.90","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","510.00","85","","750.00","75.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","600.00","100","","657.00","121.50","1971.00","14","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","600.00","100","","75.00","75.00","75.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","600.00","100","","366.00","144.00","1971.00","45","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","667.50","667.50","667.50","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","123.77","123.77","123.77","1 through 10","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","483.51","229.32","1316.08","96","266.7","600","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","439.50","225.34","1872.27","197","300","470.7","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE HA POLYLACTIC ACID HYDROXYAPATITE CANNULATED ABSORBABLE","SUP-ITM-10049559","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","385.32","55.36","1815.62","58","300","470.7","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","463.49","58.3","","554.95","91.85","1421.75","94","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","2490.03","2490.03","2490.03","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","463.49","58.3","","750.00","750.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","421.35","53","","1192.50","120.84","4149.90","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","675.75","85","","750.00","75.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","795.00","100","","657.00","121.50","1971.00","14","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","795.00","100","","75.00","75.00","75.00","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","795.00","100","","366.00","144.00","1971.00","45","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","667.50","667.50","667.50","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","123.77","123.77","123.77","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","WELLPOINT [1015]","HB CH WELLPOINT","619.38","77.91","","483.51","229.32","1316.08","96","353.38","795","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","439.50","225.34","1872.27","197","397.5","623.68","percent of total billed charges",""
"SCREW BONE 6X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191587","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","385.32","55.36","1815.62","58","397.5","623.68","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","554.95","91.85","1421.75","94","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2490.03","2490.03","2490.03","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","750.00","750.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","1192.50","120.84","4149.90","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","750.00","75.00","750.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","657.00","121.50","1971.00","14","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","75.00","75.00","75.00","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","366.00","144.00","1971.00","45","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","667.50","667.50","667.50","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","123.77","123.77","123.77","1 through 10","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","483.51","229.32","1316.08","96","333.38","750","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","439.50","225.34","1872.27","197","375","588.38","percent of total billed charges",""
"SCREW BONE 6X25MM CENTRAL INHANCE SHOULDER SYSTEM","SUP-ITM-10311998","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","385.32","55.36","1815.62","58","375","588.38","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1830.28","315.58","1830.28","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","4170.85","4170.85","4170.85","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","649.55","649.55","649.55","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","8998.38","2542.37","8998.38","20","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1891.61","1609.14","3664.18","25","600","941.4","percent of total billed charges",""
"SCREW BONE 6X40MM SPINE REDUCTION EXPEDIUM TITANIUM UNIPLANAR SINGLE INNER EXTENDED TAB","SUP-ITM-10111674","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1470.68","1310.06","2481.69","19","600","941.4","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","AETNA [1001]","HB CH AETNA HMO / PPO","1635.32","58.3","","554.95","91.85","1421.75","94","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","2490.03","2490.03","2490.03","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1635.32","58.3","","750.00","750.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1486.65","53","","1192.50","120.84","4149.90","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2384.25","85","","750.00","75.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2805.00","100","","657.00","121.50","1971.00","14","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2805.00","100","","75.00","75.00","75.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2805.00","100","","366.00","144.00","1971.00","45","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","667.50","667.50","667.50","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.82","44.45","","123.77","123.77","123.77","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","WELLPOINT [1015]","HB CH WELLPOINT","2185.38","77.91","","483.51","229.32","1316.08","96","1246.82","2805","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1663.37","59.3","","439.50","225.34","1872.27","197","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 6X45MM SPINE CANNULATED EXTENDED TAB MINIMALLY INVASIVE VIPER TITANIUM","SUP-ITM-10046191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2200.52","78.45","","385.32","55.36","1815.62","58","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","554.95","91.85","1421.75","94","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","2490.03","2490.03","2490.03","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","750.00","750.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","1192.50","120.84","4149.90","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2065.50","85","","750.00","75.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2430.00","100","","657.00","121.50","1971.00","14","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2430.00","100","","75.00","75.00","75.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2430.00","100","","366.00","144.00","1971.00","45","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","667.50","667.50","667.50","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","123.77","123.77","123.77","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","483.51","229.32","1316.08","96","1080.14","2430","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","439.50","225.34","1872.27","197","1215","1906.34","percent of total billed charges",""
"SCREW BONE 6X50MM SPINE PEDICLE VIPER 2 TITANIUM CANNULATED POLYAXIAL SELF TAPPING DUAL THREAD CORTICAL","SUP-ITM-10132437","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","385.32","55.36","1815.62","58","1215","1906.34","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","554.95","91.85","1421.75","94","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","2490.03","2490.03","2490.03","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","699.60","58.3","","750.00","750.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","636.00","53","","1192.50","120.84","4149.90","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1020.00","85","","750.00","75.00","750.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1200.00","100","","657.00","121.50","1971.00","14","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1200.00","100","","75.00","75.00","75.00","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1200.00","100","","366.00","144.00","1971.00","45","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","667.50","667.50","667.50","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","123.77","123.77","123.77","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","483.51","229.32","1316.08","96","533.4","1200","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","439.50","225.34","1872.27","197","600","941.4","percent of total billed charges",""
"SCREW BONE 6X55MM SPINE POLYAXIAL EXPEDIUM TITANIUM","SUP-ITM-10021529","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","385.32","55.36","1815.62","58","600","941.4","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB CH AETNA HMO / PPO","363.79","58.3","","554.95","91.85","1421.75","94","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","2490.03","2490.03","2490.03","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.79","58.3","","750.00","750.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.72","53","","1192.50","120.84","4149.90","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","530.40","85","","750.00","75.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","624.00","100","","657.00","121.50","1971.00","14","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","624.00","100","","75.00","75.00","75.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","624.00","100","","366.00","144.00","1971.00","45","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","667.50","667.50","667.50","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","123.77","123.77","123.77","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB CH WELLPOINT","486.16","77.91","","483.51","229.32","1316.08","96","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","370.03","59.3","","439.50","225.34","1872.27","197","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0 DIAX23MM INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10015772","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","385.32","55.36","1815.62","58","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB CH AETNA HMO / PPO","363.79","58.3","","554.95","91.85","1421.75","94","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","2490.03","2490.03","2490.03","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.79","58.3","","750.00","750.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.72","53","","1192.50","120.84","4149.90","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","530.40","85","","750.00","75.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","624.00","100","","657.00","121.50","1971.00","14","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","624.00","100","","75.00","75.00","75.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","624.00","100","","366.00","144.00","1971.00","45","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","667.50","667.50","667.50","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","123.77","123.77","123.77","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB CH WELLPOINT","486.16","77.91","","483.51","229.32","1316.08","96","277.37","624","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","370.03","59.3","","439.50","225.34","1872.27","197","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MM DIAMETER 30 INTERFERENCE MILAGRO ADVANCE BIOCRYL RAPIDE BIOABSORBABLE","SUP-ITM-10021229","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","385.32","55.36","1815.62","58","312","489.53","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","AETNA [1001]","HB CH AETNA HMO / PPO","1338.54","58.3","","554.95","91.85","1421.75","94","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1676.05","73","","2490.03","2490.03","2490.03","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1338.54","58.3","","750.00","750.00","750.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1216.86","53","","1192.50","120.84","4149.90","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1951.57","85","","750.00","75.00","750.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2295.96","100","","657.00","121.50","1971.00","14","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2295.96","100","","75.00","75.00","75.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2295.96","100","","366.00","144.00","1971.00","45","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1676.05","73","","667.50","667.50","667.50","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1020.55","44.45","","123.77","123.77","123.77","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","WELLPOINT [1015]","HB CH WELLPOINT","1788.78","77.91","","483.51","229.32","1316.08","96","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2295.96","1721.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","1361.50","59.3","","439.50","225.34","1872.27","197","1147.98","1801.18","percent of total billed charges",""
"SCREW BONE 7.0MMX100MM COMPRESSION HEADLESS","SUP-ITM-10144897","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2295.96","1721.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1801.18","78.45","","385.32","55.36","1815.62","58","1147.98","1801.18","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","AETNA [1001]","HB CH AETNA HMO / PPO","1338.54","58.3","","554.95","91.85","1421.75","94","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1676.05","73","","2490.03","2490.03","2490.03","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1338.54","58.3","","750.00","750.00","750.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1216.86","53","","1192.50","120.84","4149.90","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1951.57","85","","750.00","75.00","750.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2295.96","100","","657.00","121.50","1971.00","14","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2295.96","100","","75.00","75.00","75.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2295.96","100","","366.00","144.00","1971.00","45","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1676.05","73","","667.50","667.50","667.50","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1020.55","44.45","","123.77","123.77","123.77","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","WELLPOINT [1015]","HB CH WELLPOINT","1788.78","77.91","","483.51","229.32","1316.08","96","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2295.96","1721.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","1361.50","59.3","","439.50","225.34","1872.27","197","1147.98","1801.18","percent of total billed charges",""
"SCREW BONE 7.0MMX60MM COMPRESSION HEADLESS","SUP-ITM-10144889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2295.96","1721.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1801.18","78.45","","385.32","55.36","1815.62","58","1147.98","1801.18","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","AETNA [1001]","HB CH AETNA HMO / PPO","1338.54","58.3","","554.95","91.85","1421.75","94","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1676.05","73","","2490.03","2490.03","2490.03","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1338.54","58.3","","750.00","750.00","750.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1216.86","53","","1192.50","120.84","4149.90","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1951.57","85","","750.00","75.00","750.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2295.96","100","","657.00","121.50","1971.00","14","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2295.96","100","","75.00","75.00","75.00","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2295.96","100","","366.00","144.00","1971.00","45","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1676.05","73","","667.50","667.50","667.50","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1020.55","44.45","","123.77","123.77","123.77","1 through 10","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","both","","","2295.96","1721.97","WELLPOINT [1015]","HB CH WELLPOINT","1788.78","77.91","","483.51","229.32","1316.08","96","1020.55","2295.96","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2295.96","1721.97","CIGNA [1006]","HB CH CIGNA HMO / PPO","1361.50","59.3","","439.50","225.34","1872.27","197","1147.98","1801.18","percent of total billed charges",""
"SCREW BONE 7.0X40MM CANNULATED COMPERSSION FIXOS TITANIUM ALLOY SELF TAPPING DRILLING HEADLESS SHORT THREAD","SUP-ITM-10144868","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2295.96","1721.97","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1801.18","78.45","","385.32","55.36","1815.62","58","1147.98","1801.18","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","AETNA [1001]","HB CH AETNA HMO / PPO","1463.91","58.3","","554.95","91.85","1421.75","94","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","2490.03","2490.03","2490.03","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.91","58.3","","750.00","750.00","750.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.83","53","","1192.50","120.84","4149.90","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2134.35","85","","750.00","75.00","750.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2511.00","100","","657.00","121.50","1971.00","14","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2511.00","100","","75.00","75.00","75.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2511.00","100","","366.00","144.00","1971.00","45","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","667.50","667.50","667.50","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","123.77","123.77","123.77","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","WELLPOINT [1015]","HB CH WELLPOINT","1956.32","77.91","","483.51","229.32","1316.08","96","1116.14","2511","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1489.02","59.3","","439.50","225.34","1872.27","197","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 7.0X50MM SPINE VIPER 2 CANNULATED POLYAXIAL TITANIUM","SUP-ITM-10046180","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","385.32","55.36","1815.62","58","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","AETNA [1001]","HB CH AETNA HMO / PPO","282.08","58.3","","554.95","91.85","1421.75","94","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","353.20","73","","2490.03","2490.03","2490.03","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","282.08","58.3","","750.00","750.00","750.00","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","256.44","53","","1192.50","120.84","4149.90","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","411.26","85","","750.00","75.00","750.00","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","483.84","100","","657.00","121.50","1971.00","14","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","483.84","100","","75.00","75.00","75.00","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","483.84","100","","366.00","144.00","1971.00","45","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","353.20","73","","667.50","667.50","667.50","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","215.07","44.45","","123.77","123.77","123.77","1 through 10","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","both","","","483.84","362.88","WELLPOINT [1015]","HB CH WELLPOINT","376.96","77.91","","483.51","229.32","1316.08","96","215.07","483.84","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.84","362.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","286.92","59.3","","439.50","225.34","1872.27","197","241.92","379.57","percent of total billed charges",""
"SCREW BONE 7.3X135MM 16MM THREAD CANNULATED SS HEXAGONAL SOCKET","SUP-ITM-10024723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","483.84","362.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","379.57","78.45","","385.32","55.36","1815.62","58","241.92","379.57","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","AETNA [1001]","HB CH AETNA HMO / PPO","310.06","58.3","","554.95","91.85","1421.75","94","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","388.24","73","","2490.03","2490.03","2490.03","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","310.06","58.3","","750.00","750.00","750.00","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","281.88","53","","1192.50","120.84","4149.90","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","452.06","85","","750.00","75.00","750.00","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","531.84","100","","657.00","121.50","1971.00","14","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","531.84","100","","75.00","75.00","75.00","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","531.84","100","","366.00","144.00","1971.00","45","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","388.24","73","","667.50","667.50","667.50","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.40","44.45","","123.77","123.77","123.77","1 through 10","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","both","","","531.84","398.88","WELLPOINT [1015]","HB CH WELLPOINT","414.36","77.91","","483.51","229.32","1316.08","96","236.4","531.84","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.84","398.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","315.38","59.3","","439.50","225.34","1872.27","197","265.92","417.23","percent of total billed charges",""
"SCREW BONE 7.3X16X80MM CANNULATED TITANIUM SELF DRILLING TAPPING THREAD LG HEXAGONAL SOCKET","SUP-ITM-10026547","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","531.84","398.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","417.23","78.45","","385.32","55.36","1815.62","58","265.92","417.23","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","AETNA [1001]","HB CH AETNA HMO / PPO","308.68","58.3","","554.95","91.85","1421.75","94","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","386.51","73","","2490.03","2490.03","2490.03","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","308.68","58.3","","750.00","750.00","750.00","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","280.62","53","","1192.50","120.84","4149.90","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","450.05","85","","750.00","75.00","750.00","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","529.47","100","","657.00","121.50","1971.00","14","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","529.47","100","","75.00","75.00","75.00","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","529.47","100","","366.00","144.00","1971.00","45","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","386.51","73","","667.50","667.50","667.50","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","235.35","44.45","","123.77","123.77","123.77","1 through 10","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","both","","","529.47","397.10","WELLPOINT [1015]","HB CH WELLPOINT","412.51","77.91","","483.51","229.32","1316.08","96","235.35","529.47","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","529.47","397.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","313.98","59.3","","439.50","225.34","1872.27","197","264.74","415.37","percent of total billed charges",""
"SCREW BONE 7.3X50MM CONICAL CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011658","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","529.47","397.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","415.37","78.45","","385.32","55.36","1815.62","58","264.74","415.37","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","AETNA [1001]","HB CH AETNA HMO / PPO","346.21","58.3","","554.95","91.85","1421.75","94","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","433.51","73","","2490.03","2490.03","2490.03","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","346.21","58.3","","750.00","750.00","750.00","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","314.74","53","","1192.50","120.84","4149.90","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","504.77","85","","750.00","75.00","750.00","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","593.85","100","","657.00","121.50","1971.00","14","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","593.85","100","","75.00","75.00","75.00","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","593.85","100","","366.00","144.00","1971.00","45","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","433.51","73","","667.50","667.50","667.50","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","263.97","44.45","","123.77","123.77","123.77","1 through 10","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","both","","","593.85","445.39","WELLPOINT [1015]","HB CH WELLPOINT","462.67","77.91","","483.51","229.32","1316.08","96","263.97","593.85","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.85","445.39","CIGNA [1006]","HB CH CIGNA HMO / PPO","352.15","59.3","","439.50","225.34","1872.27","197","296.93","465.88","percent of total billed charges",""
"SCREW BONE 7.3X60MM CANNULATED SS LOCKING SELF DRILLING TAPPING FULL THREAD","SUP-ITM-10011647","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","593.85","445.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","465.88","78.45","","385.32","55.36","1815.62","58","296.93","465.88","percent of total billed charges",""
"SCREW BONE 7.5X25MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086529","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1830.28","315.58","1830.28","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X25MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086529","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","4170.85","4170.85","4170.85","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X25MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086529","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","649.55","649.55","649.55","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X25MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086529","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","8998.38","2542.37","8998.38","20","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X25MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086529","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1891.61","1609.14","3664.18","25","600","941.4","percent of total billed charges",""
"SCREW BONE 7.5X25MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086529","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1470.68","1310.06","2481.69","19","600","941.4","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1830.28","315.58","1830.28","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","4170.85","4170.85","4170.85","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","649.55","649.55","649.55","1 through 10","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","8998.38","2542.37","8998.38","20","533.4","1200","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1891.61","1609.14","3664.18","25","600","941.4","percent of total billed charges",""
"SCREW BONE 7.5X45.0MM SPINE XIA 3 POLYAXIAL TITANIUM","SUP-ITM-10086533","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1470.68","1310.06","2481.69","19","600","941.4","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","AETNA [1001]","HB CH AETNA HMO / PPO","1635.32","58.3","","554.95","91.85","1421.75","94","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","2490.03","2490.03","2490.03","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1635.32","58.3","","750.00","750.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1486.65","53","","1192.50","120.84","4149.90","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2384.25","85","","750.00","75.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2805.00","100","","657.00","121.50","1971.00","14","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2805.00","100","","75.00","75.00","75.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2805.00","100","","366.00","144.00","1971.00","45","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","667.50","667.50","667.50","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.82","44.45","","123.77","123.77","123.77","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","WELLPOINT [1015]","HB CH WELLPOINT","2185.38","77.91","","483.51","229.32","1316.08","96","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1663.37","59.3","","439.50","225.34","1872.27","197","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 7.5X45MM SPINE VIPER 2 CALLULATED XTAB TITANIUM","SUP-ITM-10046212","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2200.52","78.45","","385.32","55.36","1815.62","58","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","AETNA [1001]","HB CH AETNA HMO / PPO","1635.32","58.3","","554.95","91.85","1421.75","94","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","2490.03","2490.03","2490.03","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1635.32","58.3","","750.00","750.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1486.65","53","","1192.50","120.84","4149.90","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2384.25","85","","750.00","75.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2805.00","100","","657.00","121.50","1971.00","14","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2805.00","100","","75.00","75.00","75.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2805.00","100","","366.00","144.00","1971.00","45","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","667.50","667.50","667.50","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.82","44.45","","123.77","123.77","123.77","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","WELLPOINT [1015]","HB CH WELLPOINT","2185.38","77.91","","483.51","229.32","1316.08","96","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1663.37","59.3","","439.50","225.34","1872.27","197","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 7.5X55MM SPINE SPINALCANNULATED MIS XTAB TITANIUM","SUP-ITM-10046214","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2200.52","78.45","","385.32","55.36","1815.62","58","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","AETNA [1001]","HB CH AETNA HMO / PPO","903.78","58.3","","554.95","91.85","1421.75","94","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1131.66","73","","2490.03","2490.03","2490.03","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","903.78","58.3","","750.00","750.00","750.00","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","821.62","53","","1192.50","120.84","4149.90","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1317.69","85","","750.00","75.00","750.00","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1550.22","100","","657.00","121.50","1971.00","14","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1550.22","100","","75.00","75.00","75.00","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1550.22","100","","366.00","144.00","1971.00","45","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1131.66","73","","667.50","667.50","667.50","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","689.07","44.45","","123.77","123.77","123.77","1 through 10","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","both","","","1550.22","1162.66","WELLPOINT [1015]","HB CH WELLPOINT","1207.78","77.91","","483.51","229.32","1316.08","96","689.07","1550.22","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1550.22","1162.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","919.28","59.3","","439.50","225.34","1872.27","197","775.11","1216.15","percent of total billed charges",""
"SCREW BONE 7.5X90MM CANNULATEDCOMPR FIX SELF TAP SS QWIX","SUP-ITM-10073319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1550.22","1162.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1216.15","78.45","","385.32","55.36","1815.62","58","775.11","1216.15","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","AETNA [1001]","HB CH AETNA HMO / PPO","142.32","58.3","","554.95","91.85","1421.75","94","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","178.20","73","","2490.03","2490.03","2490.03","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","142.32","58.3","","750.00","750.00","750.00","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","129.38","53","","1192.50","120.84","4149.90","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","207.49","85","","750.00","75.00","750.00","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","244.11","100","","657.00","121.50","1971.00","14","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","244.11","100","","75.00","75.00","75.00","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","244.11","100","","366.00","144.00","1971.00","45","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","178.20","73","","667.50","667.50","667.50","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","108.51","44.45","","123.77","123.77","123.77","1 through 10","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","both","","","244.11","183.08","WELLPOINT [1015]","HB CH WELLPOINT","190.19","77.91","","483.51","229.32","1316.08","96","108.51","244.11","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","244.11","183.08","CIGNA [1006]","HB CH CIGNA HMO / PPO","144.76","59.3","","439.50","225.34","1872.27","197","122.06","191.5","percent of total billed charges",""
"SCREW BONE 75X6.5MM CANCELLOUS FULL THREAD HEX HEAD","SUP-ITM-10072158","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","244.11","183.08","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","191.50","78.45","","385.32","55.36","1815.62","58","122.06","191.5","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","AETNA [1001]","HB CH AETNA HMO / PPO","332.31","58.3","","554.95","91.85","1421.75","94","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","2490.03","2490.03","2490.03","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","332.31","58.3","","750.00","750.00","750.00","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.10","53","","1192.50","120.84","4149.90","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","484.50","85","","750.00","75.00","750.00","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","570.00","100","","657.00","121.50","1971.00","14","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","570.00","100","","75.00","75.00","75.00","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","570.00","100","","366.00","144.00","1971.00","45","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","667.50","667.50","667.50","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","123.77","123.77","123.77","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","WELLPOINT [1015]","HB CH WELLPOINT","444.09","77.91","","483.51","229.32","1316.08","96","253.37","570","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.01","59.3","","439.50","225.34","1872.27","197","285","447.17","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIORCI CANNULATED HYDROXYAPATITE BIOABSORBABLE","SUP-ITM-10009835","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","385.32","55.36","1815.62","58","285","447.17","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","463.49","58.3","","554.95","91.85","1421.75","94","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","2490.03","2490.03","2490.03","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","463.49","58.3","","750.00","750.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","421.35","53","","1192.50","120.84","4149.90","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","675.75","85","","750.00","75.00","750.00","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","795.00","100","","657.00","121.50","1971.00","14","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","795.00","100","","75.00","75.00","75.00","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","795.00","100","","366.00","144.00","1971.00","45","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","580.35","73","","667.50","667.50","667.50","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","123.77","123.77","123.77","1 through 10","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","both","","","795.00","596.25","WELLPOINT [1015]","HB CH WELLPOINT","619.38","77.91","","483.51","229.32","1316.08","96","353.38","795","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","439.50","225.34","1872.27","197","397.5","623.68","percent of total billed charges",""
"SCREW BONE 7X20MM INTERFERENCE BIOSURE REGENESORB BIOCOMPOSITE ABSORABLE","SUP-ITM-10191588","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","385.32","55.36","1815.62","58","397.5","623.68","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","AETNA [1001]","HB CH AETNA HMO / PPO","1205.06","58.3","","554.95","91.85","1421.75","94","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1508.91","73","","2490.03","2490.03","2490.03","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1205.06","58.3","","750.00","750.00","750.00","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1095.51","53","","1192.50","120.84","4149.90","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1756.95","85","","750.00","75.00","750.00","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2067.00","100","","657.00","121.50","1971.00","14","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2067.00","100","","75.00","75.00","75.00","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2067.00","100","","366.00","144.00","1971.00","45","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1508.91","73","","667.50","667.50","667.50","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","918.78","44.45","","123.77","123.77","123.77","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","WELLPOINT [1015]","HB CH WELLPOINT","1610.40","77.91","","483.51","229.32","1316.08","96","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.00","1550.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1225.73","59.3","","439.50","225.34","1872.27","197","1033.5","1621.56","percent of total billed charges",""
"SCREW BONE 7X32X75MM DARCO COMPRESSION HEADLESS","SUP-ITM-10133831","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1621.56","78.45","","385.32","55.36","1815.62","58","1033.5","1621.56","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","AETNA [1001]","HB CH AETNA HMO / PPO","1635.32","58.3","","554.95","91.85","1421.75","94","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","2490.03","2490.03","2490.03","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1635.32","58.3","","750.00","750.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1486.65","53","","1192.50","120.84","4149.90","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2384.25","85","","750.00","75.00","750.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2805.00","100","","657.00","121.50","1971.00","14","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2805.00","100","","75.00","75.00","75.00","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2805.00","100","","366.00","144.00","1971.00","45","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2047.65","73","","667.50","667.50","667.50","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1246.82","44.45","","123.77","123.77","123.77","1 through 10","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","both","","","2805.00","2103.75","WELLPOINT [1015]","HB CH WELLPOINT","2185.38","77.91","","483.51","229.32","1316.08","96","1246.82","2805","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1663.37","59.3","","439.50","225.34","1872.27","197","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 7X45MM SPINE SPINAL CANNULATED MIS XTAB TITANIUM","SUP-ITM-10046206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2805.00","2103.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2200.52","78.45","","385.32","55.36","1815.62","58","1402.5","2200.52","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","AETNA [1001]","HB CH AETNA HMO / PPO","1205.06","58.3","","554.95","91.85","1421.75","94","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1508.91","73","","2490.03","2490.03","2490.03","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1205.06","58.3","","750.00","750.00","750.00","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1095.51","53","","1192.50","120.84","4149.90","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1756.95","85","","750.00","75.00","750.00","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2067.00","100","","657.00","121.50","1971.00","14","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2067.00","100","","75.00","75.00","75.00","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2067.00","100","","366.00","144.00","1971.00","45","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1508.91","73","","667.50","667.50","667.50","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","918.78","44.45","","123.77","123.77","123.77","1 through 10","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","both","","","2067.00","1550.25","WELLPOINT [1015]","HB CH WELLPOINT","1610.40","77.91","","483.51","229.32","1316.08","96","918.78","2067","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.00","1550.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1225.73","59.3","","439.50","225.34","1872.27","197","1033.5","1621.56","percent of total billed charges",""
"SCREW BONE 7X50MM DARCO TI COMPRESSION HEADLESS SHORT","SUP-ITM-10133821","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2067.00","1550.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1621.56","78.45","","385.32","55.36","1815.62","58","1033.5","1621.56","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","AETNA [1001]","HB CH AETNA HMO / PPO","1215.56","58.3","","554.95","91.85","1421.75","94","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1522.05","73","","2490.03","2490.03","2490.03","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1215.56","58.3","","750.00","750.00","750.00","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1105.05","53","","1192.50","120.84","4149.90","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1772.25","85","","750.00","75.00","750.00","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2085.00","100","","657.00","121.50","1971.00","14","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2085.00","100","","75.00","75.00","75.00","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2085.00","100","","366.00","144.00","1971.00","45","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1522.05","73","","667.50","667.50","667.50","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","926.78","44.45","","123.77","123.77","123.77","1 through 10","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","both","","","2085.00","1563.75","WELLPOINT [1015]","HB CH WELLPOINT","1624.42","77.91","","483.51","229.32","1316.08","96","926.78","2085","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1236.41","59.3","","439.50","225.34","1872.27","197","1042.5","1635.68","percent of total billed charges",""
"SCREW BONE 7X50MM XL COMPRESSION FT","SUP-ITM-10274379","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2085.00","1563.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1635.68","78.45","","385.32","55.36","1815.62","58","1042.5","1635.68","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","AETNA [1001]","HB CH AETNA HMO / PPO","367.71","58.3","","554.95","91.85","1421.75","94","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","460.43","73","","2490.03","2490.03","2490.03","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","367.71","58.3","","750.00","750.00","750.00","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","334.28","53","","1192.50","120.84","4149.90","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","536.11","85","","750.00","75.00","750.00","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","630.72","100","","657.00","121.50","1971.00","14","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","630.72","100","","75.00","75.00","75.00","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","630.72","100","","366.00","144.00","1971.00","45","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","460.43","73","","667.50","667.50","667.50","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","280.36","44.45","","123.77","123.77","123.77","1 through 10","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","both","","","630.72","473.04","WELLPOINT [1015]","HB CH WELLPOINT","491.39","77.91","","483.51","229.32","1316.08","96","280.36","630.72","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.72","473.04","CIGNA [1006]","HB CH CIGNA HMO / PPO","374.02","59.3","","439.50","225.34","1872.27","197","315.36","494.8","percent of total billed charges",""
"SCREW BONE 7X85MM 32MM THREAD CANCELLOUS SS CANNULATED HEXAGONAL SOCKET FLAT HEAD","SUP-ITM-10004449","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","630.72","473.04","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","494.80","78.45","","385.32","55.36","1815.62","58","315.36","494.8","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","AETNA [1001]","HB CH AETNA HMO / PPO","518.68","58.3","","554.95","91.85","1421.75","94","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","649.47","73","","2490.03","2490.03","2490.03","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","518.68","58.3","","750.00","750.00","750.00","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","471.53","53","","1192.50","120.84","4149.90","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","756.23","85","","750.00","75.00","750.00","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","889.68","100","","657.00","121.50","1971.00","14","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","889.68","100","","75.00","75.00","75.00","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","889.68","100","","366.00","144.00","1971.00","45","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","649.47","73","","667.50","667.50","667.50","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","395.46","44.45","","123.77","123.77","123.77","1 through 10","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","both","","","889.68","667.26","WELLPOINT [1015]","HB CH WELLPOINT","693.15","77.91","","483.51","229.32","1316.08","96","395.46","889.68","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.68","667.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","527.58","59.3","","439.50","225.34","1872.27","197","444.84","697.95","percent of total billed charges",""
"SCREW BONE 8.0X14.5MM COMPRESSION CANNULATED TITANIUM","SUP-ITM-10030601","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","889.68","667.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","697.95","78.45","","385.32","55.36","1815.62","58","444.84","697.95","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","AETNA [1001]","HB CH AETNA HMO / PPO","339.31","58.3","","554.95","91.85","1421.75","94","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","424.86","73","","2490.03","2490.03","2490.03","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","339.31","58.3","","750.00","750.00","750.00","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","308.46","53","","1192.50","120.84","4149.90","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","494.70","85","","750.00","75.00","750.00","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","582.00","100","","657.00","121.50","1971.00","14","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","582.00","100","","75.00","75.00","75.00","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","582.00","100","","366.00","144.00","1971.00","45","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","424.86","73","","667.50","667.50","667.50","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","258.70","44.45","","123.77","123.77","123.77","1 through 10","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","both","","","582.00","436.50","WELLPOINT [1015]","HB CH WELLPOINT","453.44","77.91","","483.51","229.32","1316.08","96","258.7","582","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.00","436.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","345.13","59.3","","439.50","225.34","1872.27","197","291","456.58","percent of total billed charges",""
"SCREW BONE 8MMX20MM KNEE TIBIAL INTERFERENCE CANNULATED ABSORBABLE PLLA ROUND HEAD BIO-INTERFERENCE","SUP-ITM-10019953","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","582.00","436.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","456.58","78.45","","385.32","55.36","1815.62","58","291","456.58","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","AETNA [1001]","HB CH AETNA HMO / PPO","198.67","58.3","","554.95","91.85","1421.75","94","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","248.76","73","","2490.03","2490.03","2490.03","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.67","58.3","","750.00","750.00","750.00","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.61","53","","1192.50","120.84","4149.90","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","289.65","85","","750.00","75.00","750.00","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","340.77","100","","657.00","121.50","1971.00","14","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","340.77","100","","75.00","75.00","75.00","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","340.77","100","","366.00","144.00","1971.00","45","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.76","73","","667.50","667.50","667.50","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","151.47","44.45","","123.77","123.77","123.77","1 through 10","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","both","","","340.77","255.58","WELLPOINT [1015]","HB CH WELLPOINT","265.49","77.91","","483.51","229.32","1316.08","96","151.47","340.77","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.77","255.58","CIGNA [1006]","HB CH CIGNA HMO / PPO","202.08","59.3","","439.50","225.34","1872.27","197","170.39","267.33","percent of total billed charges",""
"SCREW BONE 8X25MM FIXATION SOFTSILK CANNULATED TITANIUM SOFT THREAD ROUND HEAD CORKSCREW TIP","SUP-ITM-10049303","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","340.77","255.58","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.33","78.45","","385.32","55.36","1815.62","58","170.39","267.33","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","AETNA [1001]","HB CH AETNA HMO / PPO","638.39","58.3","","554.95","91.85","1421.75","94","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","799.35","73","","2490.03","2490.03","2490.03","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","638.39","58.3","","750.00","750.00","750.00","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","580.35","53","","1192.50","120.84","4149.90","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","930.75","85","","750.00","75.00","750.00","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1095.00","100","","657.00","121.50","1971.00","14","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1095.00","100","","75.00","75.00","75.00","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1095.00","100","","366.00","144.00","1971.00","45","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","799.35","73","","667.50","667.50","667.50","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.73","44.45","","123.77","123.77","123.77","1 through 10","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","WELLPOINT [1015]","HB CH WELLPOINT","853.11","77.91","","483.51","229.32","1316.08","96","486.73","1095","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","649.34","59.3","","439.50","225.34","1872.27","197","547.5","859.03","percent of total billed charges",""
"SCREW BONE 8X3MM TENODESIS BIOCOMPOSITE","SUP-ITM-10056629","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","859.03","78.45","","385.32","55.36","1815.62","58","547.5","859.03","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","AETNA [1001]","HB CH AETNA HMO / PPO","498.47","58.3","","554.95","91.85","1421.75","94","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","2490.03","2490.03","2490.03","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","498.47","58.3","","750.00","750.00","750.00","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","453.15","53","","1192.50","120.84","4149.90","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","726.75","85","","750.00","75.00","750.00","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","855.00","100","","657.00","121.50","1971.00","14","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","855.00","100","","75.00","75.00","75.00","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","855.00","100","","366.00","144.00","1971.00","45","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","624.15","73","","667.50","667.50","667.50","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","380.05","44.45","","123.77","123.77","123.77","1 through 10","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","both","","","855.00","641.25","WELLPOINT [1015]","HB CH WELLPOINT","666.13","77.91","","483.51","229.32","1316.08","96","380.05","855","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","507.02","59.3","","439.50","225.34","1872.27","197","427.5","670.75","percent of total billed charges",""
"SCREW BONE 8X5.5MM INTERFERENCE PEEK BIO TENODESIS","SUP-ITM-10019573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","855.00","641.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","670.75","78.45","","385.32","55.36","1815.62","58","427.5","670.75","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","AETNA [1001]","HB CH AETNA HMO / PPO","414.51","58.3","","554.95","91.85","1421.75","94","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","519.03","73","","2490.03","2490.03","2490.03","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","414.51","58.3","","750.00","750.00","750.00","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","376.83","53","","1192.50","120.84","4149.90","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","604.35","85","","750.00","75.00","750.00","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","711.00","100","","657.00","121.50","1971.00","14","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","711.00","100","","75.00","75.00","75.00","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","711.00","100","","366.00","144.00","1971.00","45","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","519.03","73","","667.50","667.50","667.50","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","316.04","44.45","","123.77","123.77","123.77","1 through 10","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","both","","","711.00","533.25","WELLPOINT [1015]","HB CH WELLPOINT","553.94","77.91","","483.51","229.32","1316.08","96","316.04","711","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.62","59.3","","439.50","225.34","1872.27","197","355.5","557.78","percent of total billed charges",""
"SCREW BONE 8X70MM CANCELLOUS POLYAXIAL LOCKING FULLY THREADED","SUP-ITM-10072092","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","711.00","533.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.78","78.45","","385.32","55.36","1815.62","58","355.5","557.78","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","AETNA [1001]","HB CH AETNA HMO / PPO","1463.91","58.3","","554.95","91.85","1421.75","94","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","2490.03","2490.03","2490.03","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.91","58.3","","750.00","750.00","750.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.83","53","","1192.50","120.84","4149.90","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2134.35","85","","750.00","75.00","750.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2511.00","100","","657.00","121.50","1971.00","14","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2511.00","100","","75.00","75.00","75.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2511.00","100","","366.00","144.00","1971.00","45","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","667.50","667.50","667.50","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","123.77","123.77","123.77","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","WELLPOINT [1015]","HB CH WELLPOINT","1956.32","77.91","","483.51","229.32","1316.08","96","1116.14","2511","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1489.02","59.3","","439.50","225.34","1872.27","197","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 8X80MM SPINE EXPEDIUM TITANIUM POLYAXIAL","SUP-ITM-10166576","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","385.32","55.36","1815.62","58","1255.5","1969.88","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","AETNA [1001]","HB CH AETNA HMO / PPO","570.17","58.3","","554.95","91.85","1421.75","94","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","2490.03","2490.03","2490.03","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","570.17","58.3","","750.00","750.00","750.00","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","518.34","53","","1192.50","120.84","4149.90","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","831.30","85","","750.00","75.00","750.00","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","978.00","100","","657.00","121.50","1971.00","14","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","978.00","100","","75.00","75.00","75.00","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","978.00","100","","366.00","144.00","1971.00","45","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","713.94","73","","667.50","667.50","667.50","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","434.72","44.45","","123.77","123.77","123.77","1 through 10","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","both","","","978.00","733.50","WELLPOINT [1015]","HB CH WELLPOINT","761.96","77.91","","483.51","229.32","1316.08","96","434.72","978","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","579.95","59.3","","439.50","225.34","1872.27","197","489","767.24","percent of total billed charges",""
"SCREW BONE 9.5X35MM CENTRAL","SUP-ITM-10215296","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","978.00","733.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","767.24","78.45","","385.32","55.36","1815.62","58","489","767.24","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","AETNA [1001]","HB CH AETNA HMO / PPO","363.79","58.3","","554.95","91.85","1421.75","94","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","2490.03","2490.03","2490.03","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","363.79","58.3","","750.00","750.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","330.72","53","","1192.50","120.84","4149.90","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","530.40","85","","750.00","75.00","750.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","624.00","100","","657.00","121.50","1971.00","14","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","624.00","100","","75.00","75.00","75.00","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","624.00","100","","366.00","144.00","1971.00","45","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","455.52","73","","667.50","667.50","667.50","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","277.37","44.45","","123.77","123.77","123.77","1 through 10","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","both","","","624.00","468.00","WELLPOINT [1015]","HB CH WELLPOINT","486.16","77.91","","483.51","229.32","1316.08","96","277.37","624","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","370.03","59.3","","439.50","225.34","1872.27","197","312","489.53","percent of total billed charges",""
"SCREW BONE 9MMX30MM KNEE INTERFERENCE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025204","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","624.00","468.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","489.53","78.45","","385.32","55.36","1815.62","58","312","489.53","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","AETNA [1001]","HB CH AETNA HMO / PPO","1030.16","58.3","","1634.24","1004.95","1718.99","42","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1289.91","73","","2123.89","1900.92","2123.89","1 through 10","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1030.16","58.3","","3729.00","1254.19","3729.00","1 through 10","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","936.51","53","","939.37","939.37","5593.65","1 through 10","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1501.95","85","","2323.25","1864.50","2882.25","16","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1767.00","100","","2909.44","1772.40","10952.08","45","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1767.00","100","","2323.25","2323.25","2323.25","1 through 10","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1767.00","100","","2882.25","1772.40","10169.17","187","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1289.91","73","","1659.41","1659.41","1659.41","1 through 10","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","WELLPOINT [1015]","HB CH WELLPOINT","1376.67","77.91","","2050.91","1468.48","2902.83","52","785.43","1767","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1767.00","1325.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1047.83","59.3","","1548.60","1092.60","3613.79","82","883.5","1386.21","percent of total billed charges",""
"SCREW BONE ELBOW CONDYLE DISCOVERY LOCKING 04","SUP-ITM-10091060","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1767.00","1325.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1386.21","78.45","","2085.51","998.68","6202.11","56","883.5","1386.21","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","AETNA [1001]","HB CH AETNA HMO / PPO","138.38","58.3","","554.95","91.85","1421.75","94","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.27","73","","2490.03","2490.03","2490.03","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.38","58.3","","750.00","750.00","750.00","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.80","53","","1192.50","120.84","4149.90","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.76","85","","750.00","75.00","750.00","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.36","100","","657.00","121.50","1971.00","14","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.36","100","","75.00","75.00","75.00","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.36","100","","366.00","144.00","1971.00","45","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.27","73","","667.50","667.50","667.50","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.51","44.45","","123.77","123.77","123.77","1 through 10","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.36","178.02","WELLPOINT [1015]","HB CH WELLPOINT","184.93","77.91","","483.51","229.32","1316.08","96","105.51","237.36","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.36","178.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.75","59.3","","439.50","225.34","1872.27","197","118.68","186.21","percent of total billed charges",""
"SCREW BONE GLENOSPHERE","SUP-ITM-10233488","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.36","178.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.21","78.45","","385.32","55.36","1815.62","58","118.68","186.21","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","AETNA [1001]","HB CH AETNA HMO / PPO","332.31","58.3","","554.95","91.85","1421.75","94","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","2490.03","2490.03","2490.03","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","332.31","58.3","","750.00","750.00","750.00","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","302.10","53","","1192.50","120.84","4149.90","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","484.50","85","","750.00","75.00","750.00","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","570.00","100","","657.00","121.50","1971.00","14","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","570.00","100","","75.00","75.00","75.00","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","570.00","100","","366.00","144.00","1971.00","45","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","416.10","73","","667.50","667.50","667.50","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","253.37","44.45","","123.77","123.77","123.77","1 through 10","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","both","","","570.00","427.50","WELLPOINT [1015]","HB CH WELLPOINT","444.09","77.91","","483.51","229.32","1316.08","96","253.37","570","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","338.01","59.3","","439.50","225.34","1872.27","197","285","447.17","percent of total billed charges",""
"SCREW BONE INTERFERENCE BIORCI CANNULATED BIOABSORBABLE 8X25MM","SUP-ITM-10049524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","570.00","427.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","447.17","78.45","","385.32","55.36","1815.62","58","285","447.17","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","AETNA [1001]","HB CH AETNA HMO / PPO","160.91","58.3","","554.95","91.85","1421.75","94","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","201.48","73","","2490.03","2490.03","2490.03","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","160.91","58.3","","750.00","750.00","750.00","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","146.28","53","","1192.50","120.84","4149.90","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","234.60","85","","750.00","75.00","750.00","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","276.00","100","","657.00","121.50","1971.00","14","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","276.00","100","","75.00","75.00","75.00","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","276.00","100","","366.00","144.00","1971.00","45","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","201.48","73","","667.50","667.50","667.50","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","122.68","44.45","","123.77","123.77","123.77","1 through 10","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","both","","","276.00","207.00","WELLPOINT [1015]","HB CH WELLPOINT","215.03","77.91","","483.51","229.32","1316.08","96","122.68","276","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.00","207.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","163.67","59.3","","439.50","225.34","1872.27","197","138","216.52","percent of total billed charges",""
"SCREW BONE RADIUS HOOK PLATE GEMINUS TI VOLAR DISTAL","SUP-ITM-10130620","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","276.00","207.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","216.52","78.45","","385.32","55.36","1815.62","58","138","216.52","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","554.95","91.85","1421.75","94","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2490.03","2490.03","2490.03","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","750.00","750.00","750.00","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","1192.50","120.84","4149.90","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","750.00","75.00","750.00","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","657.00","121.50","1971.00","14","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","75.00","75.00","75.00","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","366.00","144.00","1971.00","45","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","667.50","667.50","667.50","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","123.77","123.77","123.77","1 through 10","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","483.51","229.32","1316.08","96","1778","4000","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","439.50","225.34","1872.27","197","2000","3138","percent of total billed charges",""
"SCREW BONE SHOULDER","SUP-ITM-10035496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","385.32","55.36","1815.62","58","2000","3138","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","AETNA [1001]","HB CH AETNA HMO / PPO","1351.98","58.3","","1634.24","1004.95","1718.99","42","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1692.87","73","","2123.89","1900.92","2123.89","1 through 10","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1351.98","58.3","","3729.00","1254.19","3729.00","1 through 10","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1229.07","53","","939.37","939.37","5593.65","1 through 10","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1971.15","85","","2323.25","1864.50","2882.25","16","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2319.00","100","","2909.44","1772.40","10952.08","45","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2319.00","100","","2323.25","2323.25","2323.25","1 through 10","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2319.00","100","","2882.25","1772.40","10169.17","187","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1692.87","73","","1659.41","1659.41","1659.41","1 through 10","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","both","","","2319.00","1739.25","WELLPOINT [1015]","HB CH WELLPOINT","1806.73","77.91","","2050.91","1468.48","2902.83","52","1030.8","2319","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2319.00","1739.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1375.17","59.3","","1548.60","1092.60","3613.79","82","1159.5","1819.26","percent of total billed charges",""
"SCREW BONE SIZE 0 ASSEMBLY HUMERAL AEQUALIS FLEX REVIVE","SUP-ITM-10269600","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2319.00","1739.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1819.26","78.45","","2085.51","998.68","6202.11","56","1159.5","1819.26","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","554.95","91.85","1421.75","94","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","2490.03","2490.03","2490.03","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","750.00","750.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","1192.50","120.84","4149.90","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.75","85","","750.00","75.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.00","100","","657.00","121.50","1971.00","14","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","135.00","100","","75.00","75.00","75.00","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.00","100","","366.00","144.00","1971.00","45","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","667.50","667.50","667.50","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","123.77","123.77","123.77","1 through 10","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","483.51","229.32","1316.08","96","60.01","135","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","439.50","225.34","1872.27","197","67.5","105.91","percent of total billed charges",""
"SCREW BONE SPINE SET TITANIUM MOUNTAINEER INNER","SUP-ITM-10016133","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","385.32","55.36","1815.62","58","67.5","105.91","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","AETNA [1001]","HB CH AETNA HMO / PPO","4664.00","58.3","","554.95","91.85","1421.75","94","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","2490.03","2490.03","2490.03","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4664.00","58.3","","750.00","750.00","750.00","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4240.00","53","","1192.50","120.84","4149.90","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6800.00","85","","750.00","75.00","750.00","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8000.00","100","","657.00","121.50","1971.00","14","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8000.00","100","","75.00","75.00","75.00","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8000.00","100","","366.00","144.00","1971.00","45","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5840.00","73","","667.50","667.50","667.50","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3556.00","44.45","","123.77","123.77","123.77","1 through 10","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","both","","","8000.00","6000.00","WELLPOINT [1015]","HB CH WELLPOINT","6232.80","77.91","","483.51","229.32","1316.08","96","3556","8000","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4744.00","59.3","","439.50","225.34","1872.27","197","4000","6276","percent of total billed charges",""
"SCREW CAGE 35MM MED ECLIPSE","SUP-ITM-10274226","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","8000.00","6000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6276.00","78.45","","385.32","55.36","1815.62","58","4000","6276","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","554.95","91.85","1421.75","94","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","2490.03","2490.03","2490.03","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","349.80","58.3","","750.00","750.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","318.00","53","","1192.50","120.84","4149.90","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","510.00","85","","750.00","75.00","750.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","600.00","100","","657.00","121.50","1971.00","14","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","600.00","100","","75.00","75.00","75.00","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","600.00","100","","366.00","144.00","1971.00","45","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","667.50","667.50","667.50","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","123.77","123.77","123.77","1 through 10","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","483.51","229.32","1316.08","96","266.7","600","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","439.50","225.34","1872.27","197","300","470.7","percent of total billed charges",""
"SCREW CANNULATED 3.75X34MM FULLY THREADED","SUP-ITM-10115627","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","385.32","55.36","1815.62","58","300","470.7","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","554.95","91.85","1421.75","94","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","2490.03","2490.03","2490.03","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","262.35","58.3","","750.00","750.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","238.50","53","","1192.50","120.84","4149.90","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","382.50","85","","750.00","75.00","750.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","450.00","100","","657.00","121.50","1971.00","14","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","450.00","100","","75.00","75.00","75.00","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","366.00","144.00","1971.00","45","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","667.50","667.50","667.50","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","123.77","123.77","123.77","1 through 10","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","483.51","229.32","1316.08","96","200.03","450","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","439.50","225.34","1872.27","197","225","353.03","percent of total billed charges",""
"SCREW COUNTERSINK 4.0MM SS CANNULATED","SUP-ITM-10113969","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","385.32","55.36","1815.62","58","225","353.03","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","554.95","91.85","1421.75","94","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2490.03","2490.03","2490.03","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","750.00","750.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","1192.50","120.84","4149.90","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","750.00","75.00","750.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","657.00","121.50","1971.00","14","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","75.00","75.00","75.00","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","366.00","144.00","1971.00","45","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","667.50","667.50","667.50","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","33.34","44.45","","123.77","123.77","123.77","1 through 10","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","483.51","229.32","1316.08","96","33.34","75","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","439.50","225.34","1872.27","197","37.5","58.84","percent of total billed charges",""
"SCREW HIP 6.5X55MM CANCELLOUS","SUP-ITM-10119967","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","385.32","55.36","1815.62","58","37.5","58.84","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","AETNA [1001]","HB CH AETNA HMO / PPO","729.33","58.3","","554.95","91.85","1421.75","94","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","913.23","73","","2490.03","2490.03","2490.03","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","729.33","58.3","","750.00","750.00","750.00","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","663.03","53","","1192.50","120.84","4149.90","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1063.35","85","","750.00","75.00","750.00","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1251.00","100","","657.00","121.50","1971.00","14","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1251.00","100","","75.00","75.00","75.00","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1251.00","100","","366.00","144.00","1971.00","45","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","913.23","73","","667.50","667.50","667.50","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","556.07","44.45","","123.77","123.77","123.77","1 through 10","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","both","","","1251.00","938.25","WELLPOINT [1015]","HB CH WELLPOINT","974.65","77.91","","483.51","229.32","1316.08","96","556.07","1251","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1251.00","938.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","741.84","59.3","","439.50","225.34","1872.27","197","625.5","981.41","percent of total billed charges",""
"SCREW HV 3X22MM PROSTEP STERILE","SUP-ITM-10279059","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1251.00","938.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","981.41","78.45","","385.32","55.36","1815.62","58","625.5","981.41","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","AETNA [1001]","HB CH AETNA HMO / PPO","1463.91","58.3","","554.95","91.85","1421.75","94","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","2490.03","2490.03","2490.03","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.91","58.3","","750.00","750.00","750.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.83","53","","1192.50","120.84","4149.90","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2134.35","85","","750.00","75.00","750.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2511.00","100","","657.00","121.50","1971.00","14","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2511.00","100","","75.00","75.00","75.00","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2511.00","100","","366.00","144.00","1971.00","45","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1833.03","73","","667.50","667.50","667.50","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1116.14","44.45","","123.77","123.77","123.77","1 through 10","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","both","","","2511.00","1883.25","WELLPOINT [1015]","HB CH WELLPOINT","1956.32","77.91","","483.51","229.32","1316.08","96","1116.14","2511","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1489.02","59.3","","439.50","225.34","1872.27","197","1255.5","1969.88","percent of total billed charges",""
"SCREW ILIAC VIPER T27 8X70 TI","SUP-ITM-10136453","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2511.00","1883.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.88","78.45","","385.32","55.36","1815.62","58","1255.5","1969.88","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","AETNA [1001]","HB CH AETNA HMO / PPO","543.94","58.3","","554.95","91.85","1421.75","94","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","681.09","73","","2490.03","2490.03","2490.03","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","543.94","58.3","","750.00","750.00","750.00","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","494.49","53","","1192.50","120.84","4149.90","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","793.05","85","","750.00","75.00","750.00","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","933.00","100","","657.00","121.50","1971.00","14","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","933.00","100","","75.00","75.00","75.00","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","933.00","100","","366.00","144.00","1971.00","45","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","681.09","73","","667.50","667.50","667.50","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.72","44.45","","123.77","123.77","123.77","1 through 10","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","both","","","933.00","699.75","WELLPOINT [1015]","HB CH WELLPOINT","726.90","77.91","","483.51","229.32","1316.08","96","414.72","933","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","933.00","699.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","553.27","59.3","","439.50","225.34","1872.27","197","466.5","731.94","percent of total billed charges",""
"SCREW INTERFERENCE 11MM DIAMETER 35 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD MILAGRO","SUP-ITM-10022628","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","933.00","699.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","731.94","78.45","","385.32","55.36","1815.62","58","466.5","731.94","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","554.95","91.85","1421.75","94","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","2490.03","2490.03","2490.03","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","750.00","750.00","750.00","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","1192.50","120.84","4149.90","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","650.25","85","","750.00","75.00","750.00","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","765.00","100","","657.00","121.50","1971.00","14","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","765.00","100","","75.00","75.00","75.00","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","765.00","100","","366.00","144.00","1971.00","45","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","667.50","667.50","667.50","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","123.77","123.77","123.77","1 through 10","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","483.51","229.32","1316.08","96","340.04","765","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","439.50","225.34","1872.27","197","382.5","600.14","percent of total billed charges",""
"SCREW INTERFERENCE 6 8MMX30 KNEE CANNULATED ABSORBABLE PLLA TAPERED HEAD BIO INTRAFIX","SUP-ITM-10025206","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","385.32","55.36","1815.62","58","382.5","600.14","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","AETNA [1001]","HB CH AETNA HMO / PPO","1463.65","58.3","","1634.24","1004.95","1718.99","42","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1832.70","73","","2123.89","1900.92","2123.89","1 through 10","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1463.65","58.3","","3729.00","1254.19","3729.00","1 through 10","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1330.59","53","","939.37","939.37","5593.65","1 through 10","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2133.97","85","","2323.25","1864.50","2882.25","16","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2510.55","100","","2909.44","1772.40","10952.08","45","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2510.55","100","","2323.25","2323.25","2323.25","1 through 10","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2510.55","100","","2882.25","1772.40","10169.17","187","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1832.70","73","","1659.41","1659.41","1659.41","1 through 10","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","both","","","2510.55","1882.91","WELLPOINT [1015]","HB CH WELLPOINT","1955.97","77.91","","2050.91","1468.48","2902.83","52","1115.94","2510.55","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2510.55","1882.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1488.76","59.3","","1548.60","1092.60","3613.79","82","1255.28","1969.53","percent of total billed charges",""
"SCREW LOCKING 3.0 4.0X10MM COMPONENT KNEE ARTICULAR SURFACE NEXGEN LCCK COMPLETE UHMWPE STRIPE SIZE CD BX/1EA","SUP-ITM-10017155","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2510.55","1882.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1969.53","78.45","","2085.51","998.68","6202.11","56","1255.28","1969.53","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","AETNA [1001]","HB CH AETNA HMO / PPO","292.29","58.3","","554.95","91.85","1421.75","94","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","365.99","73","","2490.03","2490.03","2490.03","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","292.29","58.3","","750.00","750.00","750.00","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.72","53","","1192.50","120.84","4149.90","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","426.16","85","","750.00","75.00","750.00","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","501.36","100","","657.00","121.50","1971.00","14","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","501.36","100","","75.00","75.00","75.00","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","501.36","100","","366.00","144.00","1971.00","45","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","365.99","73","","667.50","667.50","667.50","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","222.85","44.45","","123.77","123.77","123.77","1 through 10","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","both","","","501.36","376.02","WELLPOINT [1015]","HB CH WELLPOINT","390.61","77.91","","483.51","229.32","1316.08","96","222.85","501.36","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","501.36","376.02","CIGNA [1006]","HB CH CIGNA HMO / PPO","297.31","59.3","","439.50","225.34","1872.27","197","250.68","393.32","percent of total billed charges",""
"SCREW MDS LOCKING 1.5MM 14MM","SUP-ITM-10334903","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","501.36","376.02","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","393.32","78.45","","385.32","55.36","1815.62","58","250.68","393.32","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","AETNA [1001]","HB CH AETNA HMO / PPO","312.11","58.3","","554.95","91.85","1421.75","94","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","390.81","73","","2490.03","2490.03","2490.03","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","312.11","58.3","","750.00","750.00","750.00","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","283.74","53","","1192.50","120.84","4149.90","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","455.05","85","","750.00","75.00","750.00","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","535.35","100","","657.00","121.50","1971.00","14","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","535.35","100","","75.00","75.00","75.00","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","535.35","100","","366.00","144.00","1971.00","45","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","390.81","73","","667.50","667.50","667.50","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","237.96","44.45","","123.77","123.77","123.77","1 through 10","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","both","","","535.35","401.51","WELLPOINT [1015]","HB CH WELLPOINT","417.09","77.91","","483.51","229.32","1316.08","96","237.96","535.35","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.35","401.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","317.46","59.3","","439.50","225.34","1872.27","197","267.68","419.98","percent of total billed charges",""
"SCREW MDS LOCKING 2.4MM 11MM","SUP-ITM-10334644","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","535.35","401.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","419.98","78.45","","385.32","55.36","1815.62","58","267.68","419.98","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","AETNA [1001]","HB CH AETNA HMO / PPO","974.19","58.3","","554.95","91.85","1421.75","94","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1219.83","73","","2490.03","2490.03","2490.03","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","974.19","58.3","","750.00","750.00","750.00","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","885.63","53","","1192.50","120.84","4149.90","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1420.35","85","","750.00","75.00","750.00","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1671.00","100","","657.00","121.50","1971.00","14","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1671.00","100","","75.00","75.00","75.00","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1671.00","100","","366.00","144.00","1971.00","45","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1219.83","73","","667.50","667.50","667.50","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","742.76","44.45","","123.77","123.77","123.77","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","WELLPOINT [1015]","HB CH WELLPOINT","1301.88","77.91","","483.51","229.32","1316.08","96","742.76","1671","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","990.90","59.3","","439.50","225.34","1872.27","197","835.5","1310.9","percent of total billed charges",""
"SCREW MICA 4X42MM PROSTEP STERILE","SUP-ITM-10279080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","385.32","55.36","1815.62","58","835.5","1310.9","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","AETNA [1001]","HB CH AETNA HMO / PPO","399.21","58.3","","554.95","91.85","1421.75","94","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","499.87","73","","2490.03","2490.03","2490.03","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","399.21","58.3","","750.00","750.00","750.00","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","362.92","53","","1192.50","120.84","4149.90","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","582.04","85","","750.00","75.00","750.00","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","684.75","100","","657.00","121.50","1971.00","14","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","684.75","100","","75.00","75.00","75.00","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","684.75","100","","366.00","144.00","1971.00","45","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","499.87","73","","667.50","667.50","667.50","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.37","44.45","","123.77","123.77","123.77","1 through 10","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.75","513.56","WELLPOINT [1015]","HB CH WELLPOINT","533.49","77.91","","483.51","229.32","1316.08","96","304.37","684.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.75","513.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","406.06","59.3","","439.50","225.34","1872.27","197","342.38","537.19","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 2.5X28MM HEADLESS","SUP-ITM-10242622","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.75","513.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","537.19","78.45","","385.32","55.36","1815.62","58","342.38","537.19","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","AETNA [1001]","HB CH AETNA HMO / PPO","437.69","58.3","","554.95","91.85","1421.75","94","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","548.05","73","","2490.03","2490.03","2490.03","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.69","58.3","","750.00","750.00","750.00","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.90","53","","1192.50","120.84","4149.90","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","638.14","85","","750.00","75.00","750.00","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.75","100","","657.00","121.50","1971.00","14","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.75","100","","75.00","75.00","75.00","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.75","100","","366.00","144.00","1971.00","45","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","548.05","73","","667.50","667.50","667.50","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.71","44.45","","123.77","123.77","123.77","1 through 10","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","both","","","750.75","563.06","WELLPOINT [1015]","HB CH WELLPOINT","584.91","77.91","","483.51","229.32","1316.08","96","333.71","750.75","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.75","563.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","445.19","59.3","","439.50","225.34","1872.27","197","375.38","588.96","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED 4X60MM HEADLESS","SUP-ITM-10242524","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","750.75","563.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.96","78.45","","385.32","55.36","1815.62","58","375.38","588.96","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","AETNA [1001]","HB CH AETNA HMO / PPO","336.68","58.3","","554.95","91.85","1421.75","94","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","421.58","73","","2490.03","2490.03","2490.03","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","336.68","58.3","","750.00","750.00","750.00","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","306.08","53","","1192.50","120.84","4149.90","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","490.88","85","","750.00","75.00","750.00","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","577.50","100","","657.00","121.50","1971.00","14","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","577.50","100","","75.00","75.00","75.00","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","577.50","100","","366.00","144.00","1971.00","45","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","421.58","73","","667.50","667.50","667.50","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","256.70","44.45","","123.77","123.77","123.77","1 through 10","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","both","","","577.50","433.12","WELLPOINT [1015]","HB CH WELLPOINT","449.93","77.91","","483.51","229.32","1316.08","96","256.7","577.5","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","342.46","59.3","","439.50","225.34","1872.27","197","288.75","453.05","percent of total billed charges",""
"SCREW MINI MONSTER CANNULATED SHORT THREADED HEADED 2MM 12MM","SUP-ITM-10243318","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","577.50","433.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","453.05","78.45","","385.32","55.36","1815.62","58","288.75","453.05","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","554.95","91.85","1421.75","94","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","2490.03","2490.03","2490.03","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","750.00","750.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","1192.50","120.84","4149.90","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","771.38","85","","750.00","75.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","907.50","100","","657.00","121.50","1971.00","14","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","907.50","100","","75.00","75.00","75.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","907.50","100","","366.00","144.00","1971.00","45","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","667.50","667.50","667.50","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","123.77","123.77","123.77","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","483.51","229.32","1316.08","96","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","439.50","225.34","1872.27","197","453.75","711.93","percent of total billed charges",""
"SCREW MONSTER CANNULATED FULL THREADED HEADED 5.5X70MM","SUP-ITM-10242960","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","385.32","55.36","1815.62","58","453.75","711.93","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","AETNA [1001]","HB CH AETNA HMO / PPO","692.60","58.3","","554.95","91.85","1421.75","94","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","867.24","73","","2490.03","2490.03","2490.03","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","692.60","58.3","","750.00","750.00","750.00","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","629.64","53","","1192.50","120.84","4149.90","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1009.80","85","","750.00","75.00","750.00","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1188.00","100","","657.00","121.50","1971.00","14","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1188.00","100","","75.00","75.00","75.00","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1188.00","100","","366.00","144.00","1971.00","45","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","867.24","73","","667.50","667.50","667.50","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.07","44.45","","123.77","123.77","123.77","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","WELLPOINT [1015]","HB CH WELLPOINT","925.57","77.91","","483.51","229.32","1316.08","96","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","704.48","59.3","","439.50","225.34","1872.27","197","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED LONG THREADED HEADED 7X60MM","SUP-ITM-10242914","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","931.99","78.45","","385.32","55.36","1815.62","58","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","AETNA [1001]","HB CH AETNA HMO / PPO","1245.73","58.3","","554.95","91.85","1421.75","94","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1559.83","73","","2490.03","2490.03","2490.03","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1245.73","58.3","","750.00","750.00","750.00","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1132.48","53","","1192.50","120.84","4149.90","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1816.24","85","","750.00","75.00","750.00","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2136.75","100","","657.00","121.50","1971.00","14","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2136.75","100","","75.00","75.00","75.00","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2136.75","100","","366.00","144.00","1971.00","45","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1559.83","73","","667.50","667.50","667.50","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","949.79","44.45","","123.77","123.77","123.77","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","WELLPOINT [1015]","HB CH WELLPOINT","1664.74","77.91","","483.51","229.32","1316.08","96","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1267.09","59.3","","439.50","225.34","1872.27","197","1068.38","1676.28","percent of total billed charges",""
"SCREW MONSTER CANNULATED MED THREADED HEADLESS 7X50MM","SUP-ITM-10242429","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1676.28","78.45","","385.32","55.36","1815.62","58","1068.38","1676.28","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","554.95","91.85","1421.75","94","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","2490.03","2490.03","2490.03","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","750.00","750.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","1192.50","120.84","4149.90","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","771.38","85","","750.00","75.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","907.50","100","","657.00","121.50","1971.00","14","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","907.50","100","","75.00","75.00","75.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","907.50","100","","366.00","144.00","1971.00","45","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","667.50","667.50","667.50","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","123.77","123.77","123.77","1 through 10","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","483.51","229.32","1316.08","96","403.38","907.5","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","439.50","225.34","1872.27","197","453.75","711.93","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 5.5X42MM","SUP-ITM-10242991","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","385.32","55.36","1815.62","58","453.75","711.93","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","AETNA [1001]","HB CH AETNA HMO / PPO","692.60","58.3","","554.95","91.85","1421.75","94","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","867.24","73","","2490.03","2490.03","2490.03","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","692.60","58.3","","750.00","750.00","750.00","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","629.64","53","","1192.50","120.84","4149.90","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1009.80","85","","750.00","75.00","750.00","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1188.00","100","","657.00","121.50","1971.00","14","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1188.00","100","","75.00","75.00","75.00","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1188.00","100","","366.00","144.00","1971.00","45","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","867.24","73","","667.50","667.50","667.50","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","528.07","44.45","","123.77","123.77","123.77","1 through 10","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","both","","","1188.00","891.00","WELLPOINT [1015]","HB CH WELLPOINT","925.57","77.91","","483.51","229.32","1316.08","96","528.07","1188","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","704.48","59.3","","439.50","225.34","1872.27","197","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADED 7X50MM","SUP-ITM-10242920","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1188.00","891.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","931.99","78.45","","385.32","55.36","1815.62","58","594","931.99","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","AETNA [1001]","HB CH AETNA HMO / PPO","591.60","58.3","","554.95","91.85","1421.75","94","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","740.77","73","","2490.03","2490.03","2490.03","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","591.60","58.3","","750.00","750.00","750.00","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","537.82","53","","1192.50","120.84","4149.90","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","862.54","85","","750.00","75.00","750.00","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1014.75","100","","657.00","121.50","1971.00","14","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1014.75","100","","75.00","75.00","75.00","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1014.75","100","","366.00","144.00","1971.00","45","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","740.77","73","","667.50","667.50","667.50","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","451.06","44.45","","123.77","123.77","123.77","1 through 10","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","both","","","1014.75","761.06","WELLPOINT [1015]","HB CH WELLPOINT","790.59","77.91","","483.51","229.32","1316.08","96","451.06","1014.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.75","761.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","601.75","59.3","","439.50","225.34","1872.27","197","507.38","796.07","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 4.5X65MM","SUP-ITM-10242490","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1014.75","761.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","796.07","78.45","","385.32","55.36","1815.62","58","507.38","796.07","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","AETNA [1001]","HB CH AETNA HMO / PPO","764.75","58.3","","554.95","91.85","1421.75","94","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","957.58","73","","2490.03","2490.03","2490.03","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","764.75","58.3","","750.00","750.00","750.00","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","695.23","53","","1192.50","120.84","4149.90","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1114.99","85","","750.00","75.00","750.00","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1311.75","100","","657.00","121.50","1971.00","14","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1311.75","100","","75.00","75.00","75.00","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1311.75","100","","366.00","144.00","1971.00","45","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","957.58","73","","667.50","667.50","667.50","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","583.07","44.45","","123.77","123.77","123.77","1 through 10","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","both","","","1311.75","983.81","WELLPOINT [1015]","HB CH WELLPOINT","1021.98","77.91","","483.51","229.32","1316.08","96","583.07","1311.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.75","983.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","777.87","59.3","","439.50","225.34","1872.27","197","655.88","1029.07","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 5.5X34MM","SUP-ITM-10242476","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1311.75","983.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1029.07","78.45","","385.32","55.36","1815.62","58","655.88","1029.07","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","AETNA [1001]","HB CH AETNA HMO / PPO","1245.73","58.3","","554.95","91.85","1421.75","94","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1559.83","73","","2490.03","2490.03","2490.03","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1245.73","58.3","","750.00","750.00","750.00","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1132.48","53","","1192.50","120.84","4149.90","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1816.24","85","","750.00","75.00","750.00","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2136.75","100","","657.00","121.50","1971.00","14","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2136.75","100","","75.00","75.00","75.00","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2136.75","100","","366.00","144.00","1971.00","45","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1559.83","73","","667.50","667.50","667.50","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","949.79","44.45","","123.77","123.77","123.77","1 through 10","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","both","","","2136.75","1602.56","WELLPOINT [1015]","HB CH WELLPOINT","1664.74","77.91","","483.51","229.32","1316.08","96","949.79","2136.75","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","1267.09","59.3","","439.50","225.34","1872.27","197","1068.38","1676.28","percent of total billed charges",""
"SCREW MONSTER CANNULATED SHORT THREADED HEADLESS 7X70MM","SUP-ITM-10242417","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2136.75","1602.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1676.28","78.45","","385.32","55.36","1815.62","58","1068.38","1676.28","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","AETNA [1001]","HB CH AETNA HMO / PPO","1529.50","58.3","","554.95","91.85","1421.75","94","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1915.16","73","","2490.03","2490.03","2490.03","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1529.50","58.3","","750.00","750.00","750.00","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1390.46","53","","1192.50","120.84","4149.90","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2229.98","85","","750.00","75.00","750.00","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2623.50","100","","657.00","121.50","1971.00","14","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2623.50","100","","75.00","75.00","75.00","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2623.50","100","","366.00","144.00","1971.00","45","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1915.16","73","","667.50","667.50","667.50","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1166.15","44.45","","123.77","123.77","123.77","1 through 10","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","both","","","2623.50","1967.62","WELLPOINT [1015]","HB CH WELLPOINT","2043.97","77.91","","483.51","229.32","1316.08","96","1166.15","2623.5","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2623.50","1967.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1555.74","59.3","","439.50","225.34","1872.27","197","1311.75","2058.14","percent of total billed charges",""
"SCREW NAIL 7.2X45MM PHANTOM HINDFOOT HEADLESS","SUP-ITM-10285984","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2623.50","1967.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2058.14","78.45","","385.32","55.36","1815.62","58","1311.75","2058.14","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","AETNA [1001]","HB CH AETNA HMO / PPO","264.45","58.3","","554.95","91.85","1421.75","94","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","331.13","73","","2490.03","2490.03","2490.03","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","264.45","58.3","","750.00","750.00","750.00","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","240.41","53","","1192.50","120.84","4149.90","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","385.56","85","","750.00","75.00","750.00","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","453.60","100","","657.00","121.50","1971.00","14","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","453.60","100","","75.00","75.00","75.00","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","453.60","100","","366.00","144.00","1971.00","45","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","331.13","73","","667.50","667.50","667.50","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.63","44.45","","123.77","123.77","123.77","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","WELLPOINT [1015]","HB CH WELLPOINT","353.40","77.91","","483.51","229.32","1316.08","96","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.60","340.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","268.98","59.3","","439.50","225.34","1872.27","197","226.8","355.85","percent of total billed charges",""
"SCREW NON LOCKING BG 2.5X20MM","SUP-ITM-10241871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.60","340.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","355.85","78.45","","385.32","55.36","1815.62","58","226.8","355.85","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","AETNA [1001]","HB CH AETNA HMO / PPO","264.45","58.3","","554.95","91.85","1421.75","94","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","331.13","73","","2490.03","2490.03","2490.03","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","264.45","58.3","","750.00","750.00","750.00","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","240.41","53","","1192.50","120.84","4149.90","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","385.56","85","","750.00","75.00","750.00","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","453.60","100","","657.00","121.50","1971.00","14","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","453.60","100","","75.00","75.00","75.00","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","453.60","100","","366.00","144.00","1971.00","45","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","331.13","73","","667.50","667.50","667.50","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","201.63","44.45","","123.77","123.77","123.77","1 through 10","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","both","","","453.60","340.20","WELLPOINT [1015]","HB CH WELLPOINT","353.40","77.91","","483.51","229.32","1316.08","96","201.63","453.6","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.60","340.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","268.98","59.3","","439.50","225.34","1872.27","197","226.8","355.85","percent of total billed charges",""
"SCREW NON LOCKING BG 2MM 12MM","SUP-ITM-10241902","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","453.60","340.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","355.85","78.45","","385.32","55.36","1815.62","58","226.8","355.85","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","AETNA [1001]","HB CH AETNA HMO / PPO","247.71","58.3","","554.95","91.85","1421.75","94","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.17","73","","2490.03","2490.03","2490.03","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","247.71","58.3","","750.00","750.00","750.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","225.19","53","","1192.50","120.84","4149.90","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","361.16","85","","750.00","75.00","750.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","424.89","100","","657.00","121.50","1971.00","14","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","424.89","100","","75.00","75.00","75.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","424.89","100","","366.00","144.00","1971.00","45","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.17","73","","667.50","667.50","667.50","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.86","44.45","","123.77","123.77","123.77","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","WELLPOINT [1015]","HB CH WELLPOINT","331.03","77.91","","483.51","229.32","1316.08","96","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.89","318.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","251.96","59.3","","439.50","225.34","1872.27","197","212.45","333.33","percent of total billed charges",""
"SCREW NON-LOCKING 1.5MM 11MM","SUP-ITM-10334944","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.89","318.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","333.33","78.45","","385.32","55.36","1815.62","58","212.45","333.33","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","AETNA [1001]","HB CH AETNA HMO / PPO","247.71","58.3","","554.95","91.85","1421.75","94","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.17","73","","2490.03","2490.03","2490.03","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","247.71","58.3","","750.00","750.00","750.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","225.19","53","","1192.50","120.84","4149.90","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","361.16","85","","750.00","75.00","750.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","424.89","100","","657.00","121.50","1971.00","14","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","424.89","100","","75.00","75.00","75.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","424.89","100","","366.00","144.00","1971.00","45","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.17","73","","667.50","667.50","667.50","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.86","44.45","","123.77","123.77","123.77","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","WELLPOINT [1015]","HB CH WELLPOINT","331.03","77.91","","483.51","229.32","1316.08","96","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.89","318.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","251.96","59.3","","439.50","225.34","1872.27","197","212.45","333.33","percent of total billed charges",""
"SCREW NON-LOCKING 2.0MM 9MM","SUP-ITM-10334876","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.89","318.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","333.33","78.45","","385.32","55.36","1815.62","58","212.45","333.33","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","AETNA [1001]","HB CH AETNA HMO / PPO","247.71","58.3","","554.95","91.85","1421.75","94","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","310.17","73","","2490.03","2490.03","2490.03","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","247.71","58.3","","750.00","750.00","750.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","225.19","53","","1192.50","120.84","4149.90","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","361.16","85","","750.00","75.00","750.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","424.89","100","","657.00","121.50","1971.00","14","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","424.89","100","","75.00","75.00","75.00","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","424.89","100","","366.00","144.00","1971.00","45","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","310.17","73","","667.50","667.50","667.50","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","188.86","44.45","","123.77","123.77","123.77","1 through 10","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","both","","","424.89","318.67","WELLPOINT [1015]","HB CH WELLPOINT","331.03","77.91","","483.51","229.32","1316.08","96","188.86","424.89","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.89","318.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","251.96","59.3","","439.50","225.34","1872.27","197","212.45","333.33","percent of total billed charges",""
"SCREW NON-LOCKING 2.4MM 12MM","SUP-ITM-10334722","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","424.89","318.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","333.33","78.45","","385.32","55.36","1815.62","58","212.45","333.33","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","AETNA [1001]","HB CH AETNA HMO / PPO","340.53","58.3","","554.95","91.85","1421.75","94","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","426.39","73","","2490.03","2490.03","2490.03","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","340.53","58.3","","750.00","750.00","750.00","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","309.57","53","","1192.50","120.84","4149.90","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","496.49","85","","750.00","75.00","750.00","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","584.10","100","","657.00","121.50","1971.00","14","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","584.10","100","","75.00","75.00","75.00","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","584.10","100","","366.00","144.00","1971.00","45","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","426.39","73","","667.50","667.50","667.50","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.63","44.45","","123.77","123.77","123.77","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","WELLPOINT [1015]","HB CH WELLPOINT","455.07","77.91","","483.51","229.32","1316.08","96","259.63","584.1","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.37","59.3","","439.50","225.34","1872.27","197","292.05","458.23","percent of total billed charges",""
"SCREW PLATE 3.5X28MM LOCKING","SUP-ITM-10236270","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.23","78.45","","385.32","55.36","1815.62","58","292.05","458.23","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","AETNA [1001]","HB CH AETNA HMO / PPO","260.25","58.3","","554.95","91.85","1421.75","94","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","325.87","73","","2490.03","2490.03","2490.03","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","260.25","58.3","","750.00","750.00","750.00","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","236.59","53","","1192.50","120.84","4149.90","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","379.44","85","","750.00","75.00","750.00","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","446.40","100","","657.00","121.50","1971.00","14","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","446.40","100","","75.00","75.00","75.00","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","446.40","100","","366.00","144.00","1971.00","45","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","325.87","73","","667.50","667.50","667.50","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","198.42","44.45","","123.77","123.77","123.77","1 through 10","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","both","","","446.40","334.80","WELLPOINT [1015]","HB CH WELLPOINT","347.79","77.91","","483.51","229.32","1316.08","96","198.42","446.4","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","CIGNA [1006]","HB CH CIGNA HMO / PPO","264.72","59.3","","439.50","225.34","1872.27","197","223.2","350.2","percent of total billed charges",""
"SCREW PLATE 3.5X50MM NONLOCKING R3CON","SUP-ITM-10232313","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","446.40","334.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","350.20","78.45","","385.32","55.36","1815.62","58","223.2","350.2","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","AETNA [1001]","HB CH AETNA HMO / PPO","1416.69","58.3","","554.95","91.85","1421.75","94","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","2490.03","2490.03","2490.03","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1416.69","58.3","","750.00","750.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1287.90","53","","1192.50","120.84","4149.90","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2065.50","85","","750.00","75.00","750.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2430.00","100","","657.00","121.50","1971.00","14","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2430.00","100","","75.00","75.00","75.00","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2430.00","100","","366.00","144.00","1971.00","45","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1773.90","73","","667.50","667.50","667.50","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1080.14","44.45","","123.77","123.77","123.77","1 through 10","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","both","","","2430.00","1822.50","WELLPOINT [1015]","HB CH WELLPOINT","1893.21","77.91","","483.51","229.32","1316.08","96","1080.14","2430","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1440.99","59.3","","439.50","225.34","1872.27","197","1215","1906.34","percent of total billed charges",""
"SCREW POLY 7X40MM SOLID TRIALTIS","SUP-ITM-10330675","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2430.00","1822.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1906.34","78.45","","385.32","55.36","1815.62","58","1215","1906.34","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","AETNA [1001]","HB CH AETNA HMO / PPO","1335.80","58.3","","554.95","91.85","1421.75","94","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1672.61","73","","2490.03","2490.03","2490.03","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1335.80","58.3","","750.00","750.00","750.00","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1214.36","53","","1192.50","120.84","4149.90","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1947.56","85","","750.00","75.00","750.00","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2291.25","100","","657.00","121.50","1971.00","14","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2291.25","100","","75.00","75.00","75.00","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2291.25","100","","366.00","144.00","1971.00","45","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1672.61","73","","667.50","667.50","667.50","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1018.46","44.45","","123.77","123.77","123.77","1 through 10","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","both","","","2291.25","1718.44","WELLPOINT [1015]","HB CH WELLPOINT","1785.11","77.91","","483.51","229.32","1316.08","96","1018.46","2291.25","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2291.25","1718.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","1358.71","59.3","","439.50","225.34","1872.27","197","1145.63","1797.49","percent of total billed charges",""
"SCREW PRECISION JMF SOLID SHORT THREADED BLUNT TIP 4.5X38MM","SUP-ITM-10242234","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2291.25","1718.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1797.49","78.45","","385.32","55.36","1815.62","58","1145.63","1797.49","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","554.95","91.85","1421.75","94","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","2490.03","2490.03","2490.03","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","750.00","750.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","1192.50","120.84","4149.90","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.75","85","","750.00","75.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.00","100","","657.00","121.50","1971.00","14","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","135.00","100","","75.00","75.00","75.00","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.00","100","","366.00","144.00","1971.00","45","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","667.50","667.50","667.50","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","123.77","123.77","123.77","1 through 10","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","483.51","229.32","1316.08","96","60.01","135","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","439.50","225.34","1872.27","197","67.5","105.91","percent of total billed charges",""
"SCREW SET","SUP-ITM-10191321","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","385.32","55.36","1815.62","58","67.5","105.91","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","AETNA [1001]","HB CH AETNA HMO / PPO","156.10","58.3","","554.95","91.85","1421.75","94","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","2490.03","2490.03","2490.03","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","156.10","58.3","","750.00","750.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","141.91","53","","1192.50","120.84","4149.90","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","227.59","85","","750.00","75.00","750.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","267.75","100","","657.00","121.50","1971.00","14","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","267.75","100","","75.00","75.00","75.00","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","267.75","100","","366.00","144.00","1971.00","45","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","195.46","73","","667.50","667.50","667.50","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","119.01","44.45","","123.77","123.77","123.77","1 through 10","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","both","","","267.75","200.81","WELLPOINT [1015]","HB CH WELLPOINT","208.60","77.91","","483.51","229.32","1316.08","96","119.01","267.75","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","158.78","59.3","","439.50","225.34","1872.27","197","133.88","210.05","percent of total billed charges",""
"SCREW SHOULDER 6.5X45MM COMPRESSION HEXAGONAL","SUP-ITM-10202060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","267.75","200.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","210.05","78.45","","385.32","55.36","1815.62","58","133.88","210.05","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","554.95","91.85","1421.75","94","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2490.03","2490.03","2490.03","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","750.00","750.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","1192.50","120.84","4149.90","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","750.00","75.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","657.00","121.50","1971.00","14","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","75.00","75.00","75.00","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","366.00","144.00","1971.00","45","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","667.50","667.50","667.50","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","123.77","123.77","123.77","1 through 10","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","483.51","229.32","1316.08","96","133.35","300","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","439.50","225.34","1872.27","197","150","235.35","percent of total billed charges",""
"SCREW SPINAL 20MM REVISION VARAIBLE ANGLE SELF TAPPING","SUP-ITM-10104316","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","385.32","55.36","1815.62","58","150","235.35","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1830.28","315.58","1830.28","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","4170.85","4170.85","4170.85","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","666.75","44.45","","649.55","649.55","649.55","1 through 10","666.75","1500","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","8998.38","2542.37","8998.38","20","666.75","1500","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1891.61","1609.14","3664.18","25","750","1176.75","percent of total billed charges",""
"SCREW SPINAL 3.5X14MM LINEUM TITANIUM SELF TAPPING","SUP-ITM-10114467","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","1470.68","1310.06","2481.69","19","750","1176.75","percent of total billed charges",""
"SCREW SPINAL 4.5X14MM CERVICAL MAXAN FIXED ANGLE TITANIUM SELF DRILLING","SUP-ITM-10088205","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","1830.28","315.58","1830.28","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINAL 4.5X14MM CERVICAL MAXAN FIXED ANGLE TITANIUM SELF DRILLING","SUP-ITM-10088205","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","4170.85","4170.85","4170.85","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINAL 4.5X14MM CERVICAL MAXAN FIXED ANGLE TITANIUM SELF DRILLING","SUP-ITM-10088205","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","649.55","649.55","649.55","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINAL 4.5X14MM CERVICAL MAXAN FIXED ANGLE TITANIUM SELF DRILLING","SUP-ITM-10088205","CDM","C1889","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","8998.38","2542.37","8998.38","20","120.02","270","percent of total billed charges",""
"SCREW SPINAL 4.5X14MM CERVICAL MAXAN FIXED ANGLE TITANIUM SELF DRILLING","SUP-ITM-10088205","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","1891.61","1609.14","3664.18","25","135","211.82","percent of total billed charges",""
"SCREW SPINAL 4.5X14MM CERVICAL MAXAN FIXED ANGLE TITANIUM SELF DRILLING","SUP-ITM-10088205","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","1470.68","1310.06","2481.69","19","135","211.82","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","AETNA [1001]","HB CH AETNA HMO / PPO","218.63","58.3","","554.95","91.85","1421.75","94","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","2490.03","2490.03","2490.03","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","218.63","58.3","","750.00","750.00","750.00","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.75","53","","1192.50","120.84","4149.90","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","318.75","85","","750.00","75.00","750.00","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","375.00","100","","657.00","121.50","1971.00","14","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","375.00","100","","75.00","75.00","75.00","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","375.00","100","","366.00","144.00","1971.00","45","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","273.75","73","","667.50","667.50","667.50","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","166.69","44.45","","123.77","123.77","123.77","1 through 10","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","both","","","375.00","281.25","WELLPOINT [1015]","HB CH WELLPOINT","292.16","77.91","","483.51","229.32","1316.08","96","166.69","375","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","439.50","225.34","1872.27","197","187.5","294.19","percent of total billed charges",""
"SCREW SPINAL 5.5X35MM TIMBERLINE SELF TAPPING VARIABLE","SUP-ITM-10140284","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","385.32","55.36","1815.62","58","187.5","294.19","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","AETNA [1001]","HB CH AETNA HMO / PPO","340.53","58.3","","554.95","91.85","1421.75","94","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","426.39","73","","2490.03","2490.03","2490.03","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","340.53","58.3","","750.00","750.00","750.00","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","309.57","53","","1192.50","120.84","4149.90","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","496.49","85","","750.00","75.00","750.00","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","584.10","100","","657.00","121.50","1971.00","14","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","584.10","100","","75.00","75.00","75.00","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","584.10","100","","366.00","144.00","1971.00","45","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","426.39","73","","667.50","667.50","667.50","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","259.63","44.45","","123.77","123.77","123.77","1 through 10","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","both","","","584.10","438.07","WELLPOINT [1015]","HB CH WELLPOINT","455.07","77.91","","483.51","229.32","1316.08","96","259.63","584.1","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","346.37","59.3","","439.50","225.34","1872.27","197","292.05","458.23","percent of total billed charges",""
"SCREW SPINE 3.5X16MM PLATE R3CON LOCKING","SUP-ITM-10217384","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","584.10","438.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","458.23","78.45","","385.32","55.36","1815.62","58","292.05","458.23","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","AETNA [1001]","HB CH AETNA HMO / PPO","1537.37","58.3","","554.95","91.85","1421.75","94","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1925.01","73","","2490.03","2490.03","2490.03","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1537.37","58.3","","750.00","750.00","750.00","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1397.61","53","","1192.50","120.84","4149.90","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2241.45","85","","750.00","75.00","750.00","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2637.00","100","","657.00","121.50","1971.00","14","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2637.00","100","","75.00","75.00","75.00","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2637.00","100","","366.00","144.00","1971.00","45","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1925.01","73","","667.50","667.50","667.50","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1172.15","44.45","","123.77","123.77","123.77","1 through 10","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","both","","","2637.00","1977.75","WELLPOINT [1015]","HB CH WELLPOINT","2054.49","77.91","","483.51","229.32","1316.08","96","1172.15","2637","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2637.00","1977.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1563.74","59.3","","439.50","225.34","1872.27","197","1318.5","2068.73","percent of total billed charges",""
"SCREW SPINE 4.5X20MM POLYAXIAL 4.0 CFX","SUP-ITM-10243808","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2637.00","1977.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2068.73","78.45","","385.32","55.36","1815.62","58","1318.5","2068.73","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","AETNA [1001]","HB CH AETNA HMO / PPO","857.01","58.3","","1830.28","315.58","1830.28","1 through 10","653.42","1470","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","4170.85","4170.85","4170.85","1 through 10","653.42","1470","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","653.42","44.45","","649.55","649.55","649.55","1 through 10","653.42","1470","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB CH WELLPOINT","1145.28","77.91","","8998.38","2542.37","8998.38","20","653.42","1470","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","871.71","59.3","","1891.61","1609.14","3664.18","25","735","1153.22","percent of total billed charges",""
"SCREW SPINE 4.5X25MM MESA POLYAXIAL TI PEDICLE","SUP-ITM-10085580","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","1470.68","1310.06","2481.69","19","735","1153.22","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","554.95","91.85","1421.75","94","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","2490.03","2490.03","2490.03","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","157.41","58.3","","750.00","750.00","750.00","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","1192.50","120.84","4149.90","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","229.50","85","","750.00","75.00","750.00","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","270.00","100","","657.00","121.50","1971.00","14","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","270.00","100","","75.00","75.00","75.00","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","270.00","100","","366.00","144.00","1971.00","45","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","197.10","73","","667.50","667.50","667.50","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","120.02","44.45","","123.77","123.77","123.77","1 through 10","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","483.51","229.32","1316.08","96","120.02","270","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","160.11","59.3","","439.50","225.34","1872.27","197","135","211.82","percent of total billed charges",""
"SCREW SPINE 4X14MM SPINE SKYLINE TITANIUM CONSTRAINED SELF DRILLING GOLD","SUP-ITM-10171598","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","385.32","55.36","1815.62","58","135","211.82","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","AETNA [1001]","HB CH AETNA HMO / PPO","773.06","58.3","","554.95","91.85","1421.75","94","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","967.98","73","","2490.03","2490.03","2490.03","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","773.06","58.3","","750.00","750.00","750.00","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","702.78","53","","1192.50","120.84","4149.90","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1127.10","85","","750.00","75.00","750.00","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1326.00","100","","657.00","121.50","1971.00","14","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1326.00","100","","75.00","75.00","75.00","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1326.00","100","","366.00","144.00","1971.00","45","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","967.98","73","","667.50","667.50","667.50","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","589.41","44.45","","123.77","123.77","123.77","1 through 10","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","both","","","1326.00","994.50","WELLPOINT [1015]","HB CH WELLPOINT","1033.09","77.91","","483.51","229.32","1316.08","96","589.41","1326","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","786.32","59.3","","439.50","225.34","1872.27","197","663","1040.25","percent of total billed charges",""
"SCREW SPINE 5.5X45MM RELINE O TRACTION 13175545","SUP-ITM-10170475","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1326.00","994.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1040.25","78.45","","385.32","55.36","1815.62","58","663","1040.25","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE","SUP-ITM-10170634","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","1830.28","315.58","1830.28","1 through 10","520.07","1170","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE","SUP-ITM-10170634","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","4170.85","4170.85","4170.85","1 through 10","520.07","1170","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE","SUP-ITM-10170634","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","649.55","649.55","649.55","1 through 10","520.07","1170","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE","SUP-ITM-10170634","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","8998.38","2542.37","8998.38","20","520.07","1170","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE","SUP-ITM-10170634","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","1891.61","1609.14","3664.18","25","585","917.87","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE","SUP-ITM-10170634","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","1470.68","1310.06","2481.69","19","585","917.87","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","554.95","91.85","1421.75","94","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","2490.03","2490.03","2490.03","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1110.62","58.3","","750.00","750.00","750.00","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1009.65","53","","1192.50","120.84","4149.90","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1619.25","85","","750.00","75.00","750.00","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1905.00","100","","657.00","121.50","1971.00","14","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1905.00","100","","75.00","75.00","75.00","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1905.00","100","","366.00","144.00","1971.00","45","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","667.50","667.50","667.50","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","123.77","123.77","123.77","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","483.51","229.32","1316.08","96","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","439.50","225.34","1872.27","197","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X50MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229444","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","385.32","55.36","1815.62","58","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","AETNA [1001]","HB CH AETNA HMO / PPO","1110.62","58.3","","554.95","91.85","1421.75","94","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","2490.03","2490.03","2490.03","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1110.62","58.3","","750.00","750.00","750.00","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1009.65","53","","1192.50","120.84","4149.90","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1619.25","85","","750.00","75.00","750.00","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1905.00","100","","657.00","121.50","1971.00","14","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1905.00","100","","75.00","75.00","75.00","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1905.00","100","","366.00","144.00","1971.00","45","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1390.65","73","","667.50","667.50","667.50","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","846.77","44.45","","123.77","123.77","123.77","1 through 10","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","both","","","1905.00","1428.75","WELLPOINT [1015]","HB CH WELLPOINT","1484.19","77.91","","483.51","229.32","1316.08","96","846.77","1905","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1129.67","59.3","","439.50","225.34","1872.27","197","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 6.5X55MM RELINE MAS 2C POLYAXIAL","SUP-ITM-10229443","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1905.00","1428.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1494.47","78.45","","385.32","55.36","1815.62","58","952.5","1494.47","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","AETNA [1001]","HB CH AETNA HMO / PPO","1547.87","58.3","","554.95","91.85","1421.75","94","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1938.15","73","","2490.03","2490.03","2490.03","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1547.87","58.3","","750.00","750.00","750.00","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1407.15","53","","1192.50","120.84","4149.90","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2256.75","85","","750.00","75.00","750.00","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2655.00","100","","657.00","121.50","1971.00","14","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2655.00","100","","75.00","75.00","75.00","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2655.00","100","","366.00","144.00","1971.00","45","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1938.15","73","","667.50","667.50","667.50","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1180.15","44.45","","123.77","123.77","123.77","1 through 10","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","both","","","2655.00","1991.25","WELLPOINT [1015]","HB CH WELLPOINT","2068.51","77.91","","483.51","229.32","1316.08","96","1180.15","2655","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2655.00","1991.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1574.42","59.3","","439.50","225.34","1872.27","197","1327.5","2082.85","percent of total billed charges",""
"SCREW SPINE 7X45MM CORTICAL 5.5 TITANIUM FIX FENESTRATED POLYAXIAL","SUP-ITM-10189265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2655.00","1991.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2082.85","78.45","","385.32","55.36","1815.62","58","1327.5","2082.85","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","554.95","91.85","1421.75","94","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2490.03","2490.03","2490.03","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","750.00","750.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","1192.50","120.84","4149.90","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","750.00","75.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","657.00","121.50","1971.00","14","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","75.00","75.00","75.00","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","366.00","144.00","1971.00","45","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","667.50","667.50","667.50","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","123.77","123.77","123.77","1 through 10","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","483.51","229.32","1316.08","96","1066.8","2400","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","439.50","225.34","1872.27","197","1200","1882.8","percent of total billed charges",""
"SCREW SPINE 7X45MM ROMEO POLYAXIAL PK/1EA","SUP-ITM-10102026","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","385.32","55.36","1815.62","58","1200","1882.8","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","AETNA [1001]","HB CH AETNA HMO / PPO","818.53","58.3","","554.95","91.85","1421.75","94","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1024.92","73","","2490.03","2490.03","2490.03","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","818.53","58.3","","750.00","750.00","750.00","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","744.12","53","","1192.50","120.84","4149.90","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1193.40","85","","750.00","75.00","750.00","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1404.00","100","","657.00","121.50","1971.00","14","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1404.00","100","","75.00","75.00","75.00","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1404.00","100","","366.00","144.00","1971.00","45","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1024.92","73","","667.50","667.50","667.50","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","624.08","44.45","","123.77","123.77","123.77","1 through 10","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","both","","","1404.00","1053.00","WELLPOINT [1015]","HB CH WELLPOINT","1093.86","77.91","","483.51","229.32","1316.08","96","624.08","1404","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1404.00","1053.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","832.57","59.3","","439.50","225.34","1872.27","197","702","1101.44","percent of total billed charges",""
"SCREW SURGICAL 10X30MM INTRAFIX ADVANCE","SUP-ITM-10194676","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1404.00","1053.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1101.44","78.45","","385.32","55.36","1815.62","58","702","1101.44","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","AETNA [1001]","HB CH AETNA HMO / PPO","974.19","58.3","","554.95","91.85","1421.75","94","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1219.83","73","","2490.03","2490.03","2490.03","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","974.19","58.3","","750.00","750.00","750.00","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","885.63","53","","1192.50","120.84","4149.90","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1420.35","85","","750.00","75.00","750.00","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1671.00","100","","657.00","121.50","1971.00","14","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1671.00","100","","75.00","75.00","75.00","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1671.00","100","","366.00","144.00","1971.00","45","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1219.83","73","","667.50","667.50","667.50","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","742.76","44.45","","123.77","123.77","123.77","1 through 10","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","both","","","1671.00","1253.25","WELLPOINT [1015]","HB CH WELLPOINT","1301.88","77.91","","483.51","229.32","1316.08","96","742.76","1671","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","990.90","59.3","","439.50","225.34","1872.27","197","835.5","1310.9","percent of total billed charges",""
"SCREW SURGICAL 4X40MM MICA","SUP-ITM-10193373","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1671.00","1253.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1310.90","78.45","","385.32","55.36","1815.62","58","835.5","1310.9","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","554.95","91.85","1421.75","94","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2490.03","2490.03","2490.03","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","750.00","750.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","1192.50","120.84","4149.90","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","750.00","75.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","657.00","121.50","1971.00","14","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","75.00","75.00","75.00","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","366.00","144.00","1971.00","45","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","667.50","667.50","667.50","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","123.77","123.77","123.77","1 through 10","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","483.51","229.32","1316.08","96","72.01","162","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","439.50","225.34","1872.27","197","81","127.09","percent of total billed charges",""
"SCREW TRAY 6.5X60MM KNEE PFC SIGMA POROCOAT LOW PROFILE","SUP-ITM-10118374","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","385.32","55.36","1815.62","58","81","127.09","percent of total billed charges",""
"SEALANT HEMOSTATIC 4.0ML COSEAL POWDER PRELOADED DELIVERY HOUSING 2 APPLICATOR TIP VASCULAR RECONSTRUCTION","SUP-ITM-10013653","CDM","C2615","HCPCS","0278","RC","","","","both","","","1879.94","1409.95","WELLPOINT [1015]","HB CH WELLPOINT","1464.66","77.91","","3114.50","3114.50","3114.50","1 through 10","835.63","1879.94","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","75","2.65","24.09","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","17.49","53","","16.96","16.96","16.96","1 through 10","2.65","24.09","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","both","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","14.67","44.45","","24.60","14.37","24.60","1 through 10","2.65","24.09","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.75","18.75","56.25","54","2.8","25.89","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","33.00","24.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","23.51","23.51","23.51","1 through 10","2.8","25.89","percent of total billed charges",""
"Sed Rate RBC Auto","PX-30001124","CDM","85652","CPT","0305","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","14.58","24.60","73","2.8","25.89","percent of total billed charges",""
"Seizure,EXTREME","053","DRG","","","","","","","","inpatient","","","83088.18","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","43899.01","","Standard inlier is a Case rate ($43,899.01). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $56,683, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,231.64) for the length of stay and the standard reimbursement.","41904.17","41904.17","41904.17","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","34315.67","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","9077.6056","","Fee schedule rate ($18,719.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9077.6056","18719.48","18719.48","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","34315.67","","MASSHEALTH [3001]","HB BWF MEDICAID","9788.93","","Case rate ($10,823.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,253.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11259.13","11259.13","11259.13","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","34315.67","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","22211.46","","Fee schedule rate ($22,211.46). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","21564.73","21564.73","21564.73","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","34315.67","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9788.93","","Case rate ($10,823.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,253.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10820.69","10820.69","10820.69","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MAJOR","053","DRG","","","","","","","","inpatient","","","34315.67","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9788.93","","Case rate ($10,823.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,253.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10820.69","10820.69","10820.69","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","12948.37","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","11610.30","","Standard inlier is a Case rate ($11,610.30). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $23,559, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,648.13) for the length of stay and the standard reimbursement.","11610.30","11610.30","11610.30","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","12948.37","","MASSHEALTH [3001]","HB BWF MEDICAID","5318.86","","Case rate ($5,880.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,310.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4209.64","4209.64","4209.64","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","12948.37","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","5318.86","","Case rate ($5,880.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,310.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","12948.37","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5318.86","","Case rate ($5,880.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,310.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5879.47","5879.47","5879.47","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MINOR","053","DRG","","","","","","","","inpatient","","","12948.37","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","5318.86","","Case rate ($5,880.91). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $48,310.91, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5879.47","5879.47","5879.47","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","37529.83","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15905.74","","Standard inlier is a Case rate ($15,905.74). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,838, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,257.75) for the length of stay and the standard reimbursement.","15905.73","15905.73","15905.73","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","37529.83","","MASSHEALTH [3001]","HB BWF MEDICAID","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6807.61","6807.61","10820.69","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","37529.83","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6807.60","6807.60","6807.60","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","37529.83","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6807.60","6807.60","6807.60","1 through 10","5318.86","95052.09","case rate",""
"Seizure,MODERATE","053","DRG","","","","","","","","inpatient","","","37529.83","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6158.50","","Case rate ($6,809.28). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,239.28, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","908.87","908.87","6807.60","1 through 10","5318.86","95052.09","case rate",""
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","38419.57","28814.68","MEDICARE [2001]","HB BWF MEDICARE","19877.25","","Case rate ($19,877.25). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,201.33, add-ons for qualifying new technology services are included. If operating cost exceeds $63,725.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,930.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $18,168.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,862.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,369.24. The transfer capital threshold is the transfer adjustment factor * $1,369.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19858.83","1108.54","19991.94","15","17808.81","19877.25","other","Inpatient DRG"
"Seizures With McC","100","MS-DRG","","","","","","","","inpatient","","","38419.57","28814.68","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","17808.81","","Case rate ($18,172.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,201.33, add-ons for qualifying new technology services are included. If operating cost exceeds $63,725.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,930.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.3. The base transfer operating payment is the transfer adjustment factor * $16,463.78 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,862.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,369.24. The transfer capital threshold is the transfer adjustment factor * $1,369.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17986.81","17986.81","17986.81","1 through 10","17808.81","19877.25","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","30589.93","22942.45","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8476.89","","Case rate ($8,649.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,663.44, add-ons for qualifying new technology services are included. If operating cost exceeds $54,187.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,198.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,672.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,324.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $638.10. The transfer capital threshold is the transfer adjustment factor * $638.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8498.57","8498.57","8498.57","1 through 10","8476.89","8995.0344","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","30589.93","22942.45","MEDICARE [2001]","HB BWF MEDICARE","8649.89","","Case rate ($8,649.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,663.44, add-ons for qualifying new technology services are included. If operating cost exceeds $54,187.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,198.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,672.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,324.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $638.10. The transfer capital threshold is the transfer adjustment factor * $638.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9416.06","9354.25","9416.06","12","8476.89","8995.0344","other","Inpatient Replacement Plans DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","30589.93","22942.45","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8476.89","","Case rate ($8,649.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,663.44, add-ons for qualifying new technology services are included. If operating cost exceeds $54,187.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,198.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,672.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,324.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $638.10. The transfer capital threshold is the transfer adjustment factor * $638.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9508.84","9508.84","9508.84","1 through 10","8476.89","8995.0344","other","Inpatient DRG"
"Seizures Without McC","101","MS-DRG","","","","","","","","inpatient","","","30589.93","22942.45","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8476.89","","Case rate ($8,649.89). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,663.44, add-ons for qualifying new technology services are included. If operating cost exceeds $54,187.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,198.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $7,672.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,324.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $638.10. The transfer capital threshold is the transfer adjustment factor * $638.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8497.69","8497.69","8497.69","1 through 10","8476.89","8995.0344","other","Inpatient DRG"
"Selenium","PX-30000669","CDM","84255","CPT","0301","RC","","","","both","","","214.00","160.50","AETNA [1001]","HB CH AETNA HMO / PPO","124.76","58.3","","117.94","117.94","117.94","1 through 10","25.02","156.22","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","both","","","32516.00","24387.00","WELLPOINT [1015]","HB CH WELLPOINT","25333.22","77.91","","17681.62","17681.62","17681.62","1 through 10","17233.48","32516","percent of total billed charges",""
"SENSOR STIMULATOR 54X9.0MM SPINAL CORD RESTORE NEURO SURESCAN MRI SAFE RECHARGEABLE OCTAPOLAR CONNECTOR","SUP-ITM-10124360","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","32516.00","24387.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","19281.99","59.3","","74853.32","74853.32","74853.32","1 through 10","14453.36","25508.8","percent of total billed charges",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","45134.57","","Standard inlier is a Case rate ($45,134.57). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $57,951, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,407.03) for the length of stay and the standard reimbursement.","43083.58","43083.58","45134.56","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","48483.53","","Standard inlier is a Case rate ($48,483.53). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $57,951, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,882.03) for the length of stay and the standard reimbursement.","48483.52","48483.52","48483.52","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","13212.1841","","Fee schedule rate ($147,853.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13212.1841","69473.24","69473.24","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","154893.73","","Fee schedule rate ($154,893.73). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","69974.32","69974.32","69974.32","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","MASSHEALTH [3001]","HB BWF MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","2614.02","22832.18","14","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","MASSHEALTH ALTERNATE [3003]","HB BWF MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","695.29","695.29","695.29","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","58910.54","","Fee schedule rate ($58,910.54). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","58910.54","58910.54","58910.54","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","2448.50","112423.00","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,EXTREME","720","DRG","","","","","","","","inpatient","","","51736.85","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","20655.12","","Case rate ($22,837.79). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,267.79, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22832.18","3271.09","22832.18","13","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","25873.13","","Standard inlier is a Case rate ($25,873.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,672.79) for the length of stay and the standard reimbursement.","20698.50","20698.50","20698.50","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","27792.90","","Standard inlier is a Case rate ($27,792.90). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,190, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,945.09) for the length of stay and the standard reimbursement.","20844.68","20844.68","20844.68","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12583.0938","","Fee schedule rate ($30,972.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12583.0938","30972.12","30972.12","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","MASSHEALTH [3001]","HB BWF MEDICAID","9871.18","","Case rate ($10,914.29). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,344.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10911.62","10911.62","11566.31","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","29615.57","","Fee schedule rate ($29,615.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","29615.57","29615.57","29615.57","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9871.18","","Case rate ($10,914.29). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,344.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10911.61","631.62","10911.61","11","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","9871.18","","Case rate ($10,914.29). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,344.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10911.61","10911.61","10911.61","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MAJOR","720","DRG","","","","","","","","inpatient","","","35071.93","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9871.18","","Case rate ($10,914.29). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,344.29, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10911.61","1734.69","11566.31","13","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","34557.80","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14702.27","","Standard inlier is a Case rate ($14,702.27). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,690, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,086.93) for the length of stay and the standard reimbursement.","14033.98","14033.98","14033.98","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","34557.80","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","20176.04","","Fee schedule rate ($20,176.04). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","15363.37","15363.37","15363.37","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","34557.80","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","4604.88","","Case rate ($5,091.48). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,521.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5090.23","5090.23","5090.23","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MINOR","720","DRG","","","","","","","","inpatient","","","34557.80","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","4604.88","","Case rate ($5,091.48). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,521.48, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5090.23","1826.94","6810.13","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17601.77","","Standard inlier is a Case rate ($17,601.77). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,690, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,498.64) for the length of stay and the standard reimbursement.","16801.91","13441.53","17601.77","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","18907.81","","Standard inlier is a Case rate ($18,907.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $29,706, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,683.88) for the length of stay and the standard reimbursement.","18048.36","18048.36","18907.81","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","12583.0938","","Fee schedule rate ($18,082.21). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12583.0938","18082.22","18082.22","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","19890.25","","Fee schedule rate ($19,890.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","19123.16","19123.16","19123.16","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","MASSHEALTH [3001]","HB BWF MEDICAID","6160.78","","Case rate ($6,811.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,241.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6810.13","3279.99","33747.27","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6160.78","","Case rate ($6,811.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,241.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6810.13","3152.00","6810.13","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","6160.78","","Case rate ($6,811.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,241.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6810.13","6810.13","6810.13","1 through 10","4604.88","232340.59","case rate",""
"Septicemia And Disseminated Infections,MODERATE","720","DRG","","","","","","","","inpatient","","","28891.25","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6160.78","","Case rate ($6,811.80). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,241.80, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6810.13","2201.46","6810.13","1 through 10","4604.88","232340.59","case rate",""
"Septicemia Or Severe Sepsis With Mv >96 Hours","870","MS-DRG","","","","","","","","inpatient","","","186862.73","140147.05","MEDICARE [2001]","HB BWF MEDICARE","70063.95","","Case rate ($70,063.95). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $64,083.13, add-ons for qualifying new technology services are included. If operating cost exceeds $109,606.86 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $7,447.14, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 12.7. The base transfer operating payment is the transfer adjustment factor * $64,838.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $63,743.89 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,886.37. The transfer capital threshold is the transfer adjustment factor * $4,886.37. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","69422.87","68956.41","69422.87","1 through 10","62699.81","70063.95","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","18771.49","","Case rate ($18,224.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,512.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","18649.34","18629.54","18676.90","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","19934.76","","Case rate ($19,934.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,222.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17842.43","17792.87","17842.43","12","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","17860.26","","Case rate ($18,224.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,512.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17775.93","17693.05","112487.30","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","HUMANA [1012]","HB BWF MEDICARE","19934.76","","Case rate ($19,934.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,222.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17775.41","17775.41","17775.41","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","MEDICARE [2001]","HB BWF MEDICARE","19934.76","","Case rate ($19,934.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,222.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19629.66","0.03","19761.22","215","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","19934.76","","Case rate ($19,934.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,222.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17728.05","17728.05","17777.38","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","MOLINA [1014]","HB BWF MEDICARE","19934.76","","Case rate ($19,934.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,222.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35747.18","35747.18","35747.18","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","17860.26","","Case rate ($18,224.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,512.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17728.05","17693.04","17769.90","14","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","17860.26","","Case rate ($18,224.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,512.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","20132.34","20132.34","20132.34","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","17860.26","","Case rate ($18,224.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $16,512.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","17742.41","14488.06","17772.41","16","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours With McC","871","MS-DRG","","","","","","","","inpatient","","","47887.24","35915.43","WELLSENSE [1003]","HB BWF MEDICARE","19934.76","","Case rate ($19,934.76). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,253.90, add-ons for qualifying new technology services are included. If operating cost exceeds $63,777.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,934.05, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $18,222.24 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,914.65 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,373.27. The transfer capital threshold is the transfer adjustment factor * $1,373.27. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17775.93","17775.93","17775.93","1 through 10","17860.26","19939.76","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","10662.06","","Case rate ($10,662.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,599.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9492.73","9492.73","9492.73","1 through 10","9566.01","10662.06","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9566.01","","Case rate ($9,761.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,698.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9473.21","9473.21","9473.21","1 through 10","9566.01","10662.06","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","MEDICARE [2001]","HB BWF MEDICARE","10662.06","","Case rate ($10,662.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,599.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","10433.75","0.03","10502.89","33","9566.01","10662.06","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9566.01","","Case rate ($9,761.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,698.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9442.29","9442.29","9442.29","1 through 10","9566.01","10662.06","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","9566.01","","Case rate ($9,761.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,698.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","10606.55","10606.55","10606.55","1 through 10","9566.01","10662.06","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","9566.01","","Case rate ($9,761.23). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $8,698.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9413.76","9413.76","9413.77","1 through 10","9566.01","10662.06","other","Inpatient DRG"
"Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC","872","MS-DRG","","","","","","","","inpatient","","","31432.45","23574.34","WELLSENSE [1003]","HB BWF MEDICARE","10662.06","","Case rate ($10,662.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,776.60, add-ons for qualifying new technology services are included. If operating cost exceeds $55,300.33 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,284.21, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.4. The base transfer operating payment is the transfer adjustment factor * $9,599.39 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,437.36 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $723.43. The transfer capital threshold is the transfer adjustment factor * $723.43. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9447.28","9447.28","9447.28","1 through 10","9566.01","10662.06","other","Inpatient DRG"
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","73.32","75.98","1 through 10","13.33","100.74","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","235.56","235.56","235.56","1 through 10","11.72","108.26","percent of total billed charges",""
"Serum Free Kappa L C","PX-30002126","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","11.72","108.26","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","both","","","138.00","103.50","AETNA [1001]","HB CH AETNA HMO / PPO","80.45","58.3","","75.98","73.32","75.98","1 through 10","13.33","100.74","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.83","59.3","","235.56","235.56","235.56","1 through 10","11.72","108.26","percent of total billed charges",""
"Serum Free Lambda L C","PX-30002127","CDM","83883","CPT","0301","RC","","","","outpatient","","","138.00","103.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.26","78.45","","103.02","61.05","103.02","1 through 10","11.72","108.26","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","both","","","450.00","337.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","450.00","100","","153.75","153.75","153.75","1 through 10","238.5","450","percent of total billed charges",""
"SET BEAD TANTALUM","SUP-ITM-10188480","CDM","A4648","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","90.10","90.10","90.10","1 through 10","200.03","353.03","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.70","440.77","AETNA [1001]","HB CH AETNA HMO / PPO","342.63","58.3","","161.55","62.25","161.55","1 through 10","261.23","587.7","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.70","440.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","311.48","53","","52.44","22.90","505.57","1 through 10","261.23","587.7","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.70","440.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","499.55","85","","68.52","68.52","68.52","1 through 10","261.23","587.7","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.70","440.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","587.70","100","","62.20","62.19","81.17","14","261.23","587.7","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.70","440.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","587.70","100","","43.22","31.95","953.91","1 through 10","261.23","587.7","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","both","","","587.70","440.77","WELLPOINT [1015]","HB CH WELLPOINT","457.88","77.91","","63.92","25.16","245.73","18","261.23","587.7","percent of total billed charges",""
"SET CATHETER 4.0MMX4.2CM CRICOTHYROTOMY MELKER EMERGENCY","SUP-ITM-10015634","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","587.70","440.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","461.05","78.45","","97.25","24.56","207.80","18","293.85","461.05","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","both","","","615.69","461.77","AETNA [1001]","HB CH AETNA HMO / PPO","358.95","58.3","","161.55","62.25","161.55","1 through 10","273.67","615.69","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","both","","","615.69","461.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","326.32","53","","52.44","22.90","505.57","1 through 10","273.67","615.69","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","both","","","615.69","461.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","523.34","85","","68.52","68.52","68.52","1 through 10","273.67","615.69","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","both","","","615.69","461.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","615.69","100","","62.20","62.19","81.17","14","273.67","615.69","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","both","","","615.69","461.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","615.69","100","","43.22","31.95","953.91","1 through 10","273.67","615.69","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","both","","","615.69","461.77","WELLPOINT [1015]","HB CH WELLPOINT","479.68","77.91","","63.92","25.16","245.73","18","273.67","615.69","percent of total billed charges",""
"SET CATHETER 6.0MM 7.5CM AIRWAY MELKER EMERGENCY CRICOTHYROTOMY ID G04652","SUP-ITM-10008577","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","615.69","461.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","483.01","78.45","","97.25","24.56","207.80","18","307.85","483.01","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","AETNA [1001]","HB CH AETNA HMO / PPO","1106.59","58.3","","1634.24","1004.95","1718.99","42","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1385.61","73","","2123.89","1900.92","2123.89","1 through 10","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1106.59","58.3","","3729.00","1254.19","3729.00","1 through 10","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1005.99","53","","939.37","939.37","5593.65","1 through 10","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1613.39","85","","2323.25","1864.50","2882.25","16","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1898.10","100","","2909.44","1772.40","10952.08","45","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1898.10","100","","2323.25","2323.25","2323.25","1 through 10","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1898.10","100","","2882.25","1772.40","10169.17","187","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1385.61","73","","1659.41","1659.41","1659.41","1 through 10","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","both","","","1898.10","1423.57","WELLPOINT [1015]","HB CH WELLPOINT","1478.81","77.91","","2050.91","1468.48","2902.83","52","843.71","1898.1","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1898.10","1423.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","1125.57","59.3","","1548.60","1092.60","3613.79","82","949.05","1489.06","percent of total billed charges",""
"SET CLIP ENDO JAW AND O RING","SUP-ITM-10211724","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1898.10","1423.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1489.06","78.45","","2085.51","998.68","6202.11","56","949.05","1489.06","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","AETNA [1001]","HB CH AETNA HMO / PPO","3031.60","58.3","","1634.24","1004.95","1718.99","42","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3796.00","73","","2123.89","1900.92","2123.89","1 through 10","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3031.60","58.3","","3729.00","1254.19","3729.00","1 through 10","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2756.00","53","","939.37","939.37","5593.65","1 through 10","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4420.00","85","","2323.25","1864.50","2882.25","16","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5200.00","100","","2909.44","1772.40","10952.08","45","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5200.00","100","","2323.25","2323.25","2323.25","1 through 10","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5200.00","100","","2882.25","1772.40","10169.17","187","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3796.00","73","","1659.41","1659.41","1659.41","1 through 10","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","both","","","5200.00","3900.00","WELLPOINT [1015]","HB CH WELLPOINT","4051.32","77.91","","2050.91","1468.48","2902.83","52","2311.4","5200","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3083.60","59.3","","1548.60","1092.60","3613.79","82","2600","4079.4","percent of total billed charges",""
"SET COMPONENT 15MM 2.5X4.5 ARTICULAR SURFACE METATARSAL HEMICAP TOEMOTION TITANIUM OFF","SUP-ITM-10094390","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5200.00","3900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4079.40","78.45","","2085.51","998.68","6202.11","56","2600","4079.4","percent of total billed charges",""
"SET DILATOR 8X10 12 14 16 18 20FR SIDEPORT URETHRAL CURVE AQ HYDROPHILIC COATING MALE","SUP-ITM-10078605","CDM","C1758","HCPCS","0272","RC","","","","both","","","698.40","523.80","AETNA [1001]","HB CH AETNA HMO / PPO","407.17","58.3","","41.25","41.25","41.25","1 through 10","310.44","698.4","percent of total billed charges",""
"SET DILATOR 8X10 12 14 16 18 20FR SIDEPORT URETHRAL CURVE AQ HYDROPHILIC COATING MALE","SUP-ITM-10078605","CDM","C1758","HCPCS","0272","RC","","","","both","","","698.40","523.80","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","698.40","100","","39.24","39.24","39.24","1 through 10","310.44","698.4","percent of total billed charges",""
"SET DILATOR 8X10 12 14 16 18 20FR SIDEPORT URETHRAL CURVE AQ HYDROPHILIC COATING MALE","SUP-ITM-10078605","CDM","C1758","HCPCS","0272","RC","","","","both","","","698.40","523.80","WELLPOINT [1015]","HB CH WELLPOINT","544.12","77.91","","157.50","30.92","221.94","11","310.44","698.4","percent of total billed charges",""
"SET DILATOR 8X10 12 14 16 18 20FR SIDEPORT URETHRAL CURVE AQ HYDROPHILIC COATING MALE","SUP-ITM-10078605","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","698.40","523.80","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","547.89","78.45","","32.43","30.18","307.47","11","349.2","547.89","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","AETNA [1001]","HB CH AETNA HMO / PPO","1054.17","58.3","","554.95","91.85","1421.75","94","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1319.98","73","","2490.03","2490.03","2490.03","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1054.17","58.3","","750.00","750.00","750.00","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","958.34","53","","1192.50","120.84","4149.90","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1536.96","85","","750.00","75.00","750.00","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1808.19","100","","657.00","121.50","1971.00","14","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1808.19","100","","75.00","75.00","75.00","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1808.19","100","","366.00","144.00","1971.00","45","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1319.98","73","","667.50","667.50","667.50","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","803.74","44.45","","123.77","123.77","123.77","1 through 10","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","both","","","1808.19","1356.14","WELLPOINT [1015]","HB CH WELLPOINT","1408.76","77.91","","483.51","229.32","1316.08","96","803.74","1808.19","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.19","1356.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","1072.26","59.3","","439.50","225.34","1872.27","197","904.1","1418.53","percent of total billed charges",""
"SET FILLER 3ML BONE VOID CALCIUM PHOSPHATE INJECTABLE GRAFT PUTTY SYNTHETIC DRILLABLE FAST NORIAN","SUP-ITM-10118183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1808.19","1356.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1418.53","78.45","","385.32","55.36","1815.62","58","904.1","1418.53","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"SET GUIDE 1.5F SIZE 1.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION RT T CUSTOM","SUP-ITM-10082537","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"SET GUIDE 3.0F SIZE 2.5 TIBIAL FEMORAL KNEE TRUMATCH RESECTION LT T CUSTOM","SUP-ITM-10082575","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","161.55","62.25","161.55","1 through 10","520.07","1170","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","both","","","1170.00","877.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","620.10","53","","52.44","22.90","505.57","1 through 10","520.07","1170","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","994.50","85","","68.52","68.52","68.52","1 through 10","520.07","1170","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1170.00","100","","62.20","62.19","81.17","14","520.07","1170","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","both","","","1170.00","877.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1170.00","100","","43.22","31.95","953.91","1 through 10","520.07","1170","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","63.92","25.16","245.73","18","520.07","1170","percent of total billed charges",""
"SET INTRODUCER 7.5/8.5/9MM BLUE RHINO G2-MULTI PERCUTANEOUS TRACHEOSTOMY DILATOR W/O TUBE","SUP-ITM-10287991","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","97.25","24.56","207.80","18","585","917.87","percent of total billed charges",""
"SET INTRODUCER 7FR PERCUTANEOUS GUIDE WIRE-DILATOR/SHEATH ADELANTE PEEL AWAY","SUP-ITM-10318533","CDM","C1894","HCPCS","0272","RC","","","","both","","","1143.45","857.59","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","606.03","53","","69.13","15.86","85.00","1 through 10","508.26","1143.45","percent of total billed charges",""
"SET INTRODUCER 7FR PERCUTANEOUS GUIDE WIRE-DILATOR/SHEATH ADELANTE PEEL AWAY","SUP-ITM-10318533","CDM","C1894","HCPCS","0272","RC","","","","both","","","1143.45","857.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","971.93","85","","29.94","29.94","29.94","1 through 10","508.26","1143.45","percent of total billed charges",""
"SET INTRODUCER 7FR PERCUTANEOUS GUIDE WIRE-DILATOR/SHEATH ADELANTE PEEL AWAY","SUP-ITM-10318533","CDM","C1894","HCPCS","0272","RC","","","","both","","","1143.45","857.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1143.45","100","","60.23","29.94","60.23","12","508.26","1143.45","percent of total billed charges",""
"SET INTRODUCER 7FR PERCUTANEOUS GUIDE WIRE-DILATOR/SHEATH ADELANTE PEEL AWAY","SUP-ITM-10318533","CDM","C1894","HCPCS","0272","RC","","","","both","","","1143.45","857.59","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1143.45","100","","65.22","29.94","360.69","1 through 10","508.26","1143.45","percent of total billed charges",""
"SET INTRODUCER 7FR PERCUTANEOUS GUIDE WIRE-DILATOR/SHEATH ADELANTE PEEL AWAY","SUP-ITM-10318533","CDM","C1894","HCPCS","0272","RC","","","","both","","","1143.45","857.59","WELLPOINT [1015]","HB CH WELLPOINT","890.86","77.91","","51.37","51.37","284.08","1 through 10","508.26","1143.45","percent of total billed charges",""
"SET INTRODUCER 7FR PERCUTANEOUS GUIDE WIRE-DILATOR/SHEATH ADELANTE PEEL AWAY","SUP-ITM-10318533","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","1143.45","857.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","897.04","78.45","","123.30","23.02","333.57","1 through 10","571.73","897.04","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019834","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.50","75.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","53.27","53","","69.13","15.86","85.00","1 through 10","44.67","100.5","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019834","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.50","75.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","85.43","85","","29.94","29.94","29.94","1 through 10","44.67","100.5","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019834","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.50","75.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","100.50","100","","60.23","29.94","60.23","12","44.67","100.5","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019834","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.50","75.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","100.50","100","","65.22","29.94","360.69","1 through 10","44.67","100.5","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019834","CDM","C1894","HCPCS","0272","RC","","","","both","","","100.50","75.37","WELLPOINT [1015]","HB CH WELLPOINT","78.30","77.91","","51.37","51.37","284.08","1 through 10","44.67","100.5","percent of total billed charges",""
"SET INTRODUCER MICROPUNCTURE 5FR/10CM .018IN/40CM 21G/7CM ACCESS TRANSITIONLESS TIP NITINOL WIRE PLATINUM TIP ECHOGENIC NEEDLE NO BASEPLATE WIRE GUIDE COAXIAL CATHETER PAIR","SUP-ITM-10019834","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","100.50","75.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","78.84","78.45","","123.30","23.02","333.57","1 through 10","50.25","78.84","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","2736.54","2052.40","AETNA [1001]","HB CH AETNA HMO / PPO","1595.40","58.3","","1952.48","1952.48","1952.48","1 through 10","1216.39","2736.54","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","2736.54","2052.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1450.37","53","","1825.07","1825.07","1825.07","1 through 10","1216.39","2736.54","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","both","","","2736.54","2052.40","WELLPOINT [1015]","HB CH WELLPOINT","2132.04","77.91","","2712.12","2712.12","2712.12","1 through 10","1216.39","2736.54","percent of total billed charges",""
"SET KIT 1.1X45CM SLING URETHRAL FEMALE POLYPROPYLENE MESH TAPE 2 NEEDLE ABDOMINAL GUIDES BX/1EA","SUP-ITM-10009729","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","2736.54","2052.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","1622.77","59.3","","2017.91","2017.91","2017.91","1 through 10","1368.27","2146.82","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 1.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082579","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 2.0 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082580","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 2.5 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082581","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"SET KIT SIZE 4 GUIDE FEMORAL KNEE TRUMATCH RESECTION CUSTOM","SUP-ITM-10082583","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","AETNA [1001]","HB CH AETNA HMO / PPO","341.40","58.3","","554.95","91.85","1421.75","94","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","427.49","73","","2490.03","2490.03","2490.03","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","341.40","58.3","","750.00","750.00","750.00","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","310.37","53","","1192.50","120.84","4149.90","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","497.76","85","","750.00","75.00","750.00","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","585.60","100","","657.00","121.50","1971.00","14","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","585.60","100","","75.00","75.00","75.00","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","585.60","100","","366.00","144.00","1971.00","45","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","427.49","73","","667.50","667.50","667.50","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","260.30","44.45","","123.77","123.77","123.77","1 through 10","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","both","","","585.60","439.20","WELLPOINT [1015]","HB CH WELLPOINT","456.24","77.91","","483.51","229.32","1316.08","96","260.3","585.6","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.60","439.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","347.26","59.3","","439.50","225.34","1872.27","197","292.8","459.4","percent of total billed charges",""
"SET NAIL 1.1MM SMALL .045 BONE FIXATION REPLACEMENT","SUP-ITM-10028132","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","585.60","439.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","459.40","78.45","","385.32","55.36","1815.62","58","292.8","459.4","percent of total billed charges",""
"SET PERICARDIOCENTESIS 8.5FR 40CM 70CM .038IN 6SIDEPORTS LOCK RADIOPAQUE POLYURETHANE PIGTAIL CATHETER TFE COATED S/S J GUIDEWIRE","SUP-ITM-10022016","CDM","C1729","HCPCS","0272","RC","","","","both","","","381.60","286.20","WELLPOINT [1015]","HB CH WELLPOINT","297.30","77.91","","60.00","47.26","60.00","1 through 10","169.62","381.6","percent of total billed charges",""
"SET PERICARDIOCENTESIS 8.5FR 40CM 70CM .038IN 6SIDEPORTS LOCK RADIOPAQUE POLYURETHANE PIGTAIL CATHETER TFE COATED S/S J GUIDEWIRE","SUP-ITM-10022016","CDM","C1729","HCPCS","0272","RC","","","","outpatient","","","381.60","286.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","299.37","78.45","","28.02","28.02","28.02","1 through 10","190.8","299.37","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","960.00","720.00","AETNA [1001]","HB CH AETNA HMO / PPO","559.68","58.3","","161.55","62.25","161.55","1 through 10","426.72","960","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","960.00","720.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","508.80","53","","52.44","22.90","505.57","1 through 10","426.72","960","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","816.00","85","","68.52","68.52","68.52","1 through 10","426.72","960","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","960.00","100","","62.20","62.19","81.17","14","426.72","960","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","960.00","720.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","960.00","100","","43.22","31.95","953.91","1 through 10","426.72","960","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","both","","","960.00","720.00","WELLPOINT [1015]","HB CH WELLPOINT","747.94","77.91","","63.92","25.16","245.73","18","426.72","960","percent of total billed charges",""
"SET PIN 2.4MM 2.8 UNIVERS REVERS INCLUDES DRILL TIP GUIDE OSTEOTOMY AND GUIDEWIRE PK/1EA","SUP-ITM-10136728","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","960.00","720.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","753.12","78.45","","97.25","24.56","207.80","18","480","753.12","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","1830.28","315.58","1830.28","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","4170.85","4170.85","4170.85","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","649.55","649.55","649.55","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","8998.38","2542.37","8998.38","20","60.01","135","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","1891.61","1609.14","3664.18","25","67.5","105.91","percent of total billed charges",""
"SET SCREW 5.5MM SPINE CD HORIZON LEGACY SS BREAK OFF","SUP-ITM-10018981","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1470.68","1310.06","2481.69","19","67.5","105.91","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","554.95","91.85","1421.75","94","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","2490.03","2490.03","2490.03","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","78.71","58.3","","750.00","750.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","71.55","53","","1192.50","120.84","4149.90","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","114.75","85","","750.00","75.00","750.00","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","135.00","100","","657.00","121.50","1971.00","14","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","135.00","100","","75.00","75.00","75.00","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","135.00","100","","366.00","144.00","1971.00","45","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","667.50","667.50","667.50","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","123.77","123.77","123.77","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","483.51","229.32","1316.08","96","60.01","135","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","439.50","225.34","1872.27","197","67.5","105.91","percent of total billed charges",""
"SET SCREW 5.5X55MM SPINE CD HORIZON MULTIAXIAL COBALT OSTEOGRIP DUAL LEAD THREAD","SUP-ITM-10103194","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","385.32","55.36","1815.62","58","67.5","105.91","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","AETNA [1001]","HB CH AETNA HMO / PPO","612.15","58.3","","554.95","91.85","1421.75","94","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","2490.03","2490.03","2490.03","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","612.15","58.3","","750.00","750.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","556.50","53","","1192.50","120.84","4149.90","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","892.50","85","","750.00","75.00","750.00","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1050.00","100","","657.00","121.50","1971.00","14","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1050.00","100","","75.00","75.00","75.00","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1050.00","100","","366.00","144.00","1971.00","45","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","766.50","73","","667.50","667.50","667.50","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","466.73","44.45","","123.77","123.77","123.77","1 through 10","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","both","","","1050.00","787.50","WELLPOINT [1015]","HB CH WELLPOINT","818.06","77.91","","483.51","229.32","1316.08","96","466.73","1050","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","622.65","59.3","","439.50","225.34","1872.27","197","525","823.73","percent of total billed charges",""
"SET SCREW MAS PK/4EA","SUP-ITM-10307440","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1050.00","787.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","823.73","78.45","","385.32","55.36","1815.62","58","525","823.73","percent of total billed charges",""
"SET SCREW SPINE XIA 3 CLOSED HEAD","SUP-ITM-10106931","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","1830.28","315.58","1830.28","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA 3 CLOSED HEAD","SUP-ITM-10106931","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","4170.85","4170.85","4170.85","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA 3 CLOSED HEAD","SUP-ITM-10106931","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","649.55","649.55","649.55","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA 3 CLOSED HEAD","SUP-ITM-10106931","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","8998.38","2542.37","8998.38","20","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA 3 CLOSED HEAD","SUP-ITM-10106931","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","1891.61","1609.14","3664.18","25","67.5","105.91","percent of total billed charges",""
"SET SCREW SPINE XIA 3 CLOSED HEAD","SUP-ITM-10106931","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1470.68","1310.06","2481.69","19","67.5","105.91","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","AETNA [1001]","HB CH AETNA HMO / PPO","78.71","58.3","","1830.28","315.58","1830.28","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","98.55","73","","4170.85","4170.85","4170.85","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","60.01","44.45","","649.55","649.55","649.55","1 through 10","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","both","","","135.00","101.25","WELLPOINT [1015]","HB CH WELLPOINT","105.18","77.91","","8998.38","2542.37","8998.38","20","60.01","135","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","80.06","59.3","","1891.61","1609.14","3664.18","25","67.5","105.91","percent of total billed charges",""
"SET SCREW SPINE XIA TITANIUM MULTIAXIAL NONLOCKING BUTTRESS THREAD LOW PROFILE POSTERIOR","SUP-ITM-10086645","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","135.00","101.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","105.91","78.45","","1470.68","1310.06","2481.69","19","67.5","105.91","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","554.95","91.85","1421.75","94","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","2490.03","2490.03","2490.03","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","750.00","750.00","750.00","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","1192.50","120.84","4149.90","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.50","85","","750.00","75.00","750.00","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.00","100","","657.00","121.50","1971.00","14","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.00","100","","75.00","75.00","75.00","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","366.00","144.00","1971.00","45","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","667.50","667.50","667.50","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","123.77","123.77","123.77","1 through 10","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","483.51","229.32","1316.08","96","66.68","150","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","439.50","225.34","1872.27","197","75","117.68","percent of total billed charges",""
"SET SCREW T27 TRIALTIS","SUP-ITM-10331501","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","385.32","55.36","1815.62","58","75","117.68","percent of total billed charges",""
"SET SEALANT 10ML FIBRIN HEMOSTATIC TISSEEL FROZEN PREFILLED DUO SYRINGE","SUP-ITM-10042044","CDM","C2615","HCPCS","0278","RC","","","","both","","","1742.28","1306.71","WELLPOINT [1015]","HB CH WELLPOINT","1357.41","77.91","","3114.50","3114.50","3114.50","1 through 10","774.44","1742.28","percent of total billed charges",""
"SET SHEATH 8 30FR 17CM DILATOR RENAL TEFLON GUIDING CATHETER","SUP-ITM-10042145","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","973.11","729.83","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","763.40","78.45","","2644.76","2644.76","2644.76","1 through 10","486.56","763.4","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","554.95","91.85","1421.75","94","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","2490.03","2490.03","2490.03","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","750.00","750.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","1192.50","120.84","4149.90","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","771.38","85","","750.00","75.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","907.50","100","","657.00","121.50","1971.00","14","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","907.50","100","","75.00","75.00","75.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","907.50","100","","366.00","144.00","1971.00","45","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","667.50","667.50","667.50","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","123.77","123.77","123.77","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","483.51","229.32","1316.08","96","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","439.50","225.34","1872.27","197","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 1.6MM BONE DALL MILES VITALLIUM COBALT ALLOY CABLE FIXATION BEADED ST/1EA","SUP-ITM-10015804","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","385.32","55.36","1815.62","58","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","AETNA [1001]","HB CH AETNA HMO / PPO","529.07","58.3","","554.95","91.85","1421.75","94","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","2490.03","2490.03","2490.03","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","529.07","58.3","","750.00","750.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","480.98","53","","1192.50","120.84","4149.90","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","771.38","85","","750.00","75.00","750.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","907.50","100","","657.00","121.50","1971.00","14","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","907.50","100","","75.00","75.00","75.00","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","907.50","100","","366.00","144.00","1971.00","45","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","662.48","73","","667.50","667.50","667.50","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","403.38","44.45","","123.77","123.77","123.77","1 through 10","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","both","","","907.50","680.62","WELLPOINT [1015]","HB CH WELLPOINT","707.03","77.91","","483.51","229.32","1316.08","96","403.38","907.5","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","538.15","59.3","","439.50","225.34","1872.27","197","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM CABLE HIP DALL MILES BEADED VITALIUM MEDUM ST/1EA","SUP-ITM-10015347","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","907.50","680.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","711.93","78.45","","385.32","55.36","1815.62","58","453.75","711.93","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","AETNA [1001]","HB CH AETNA HMO / PPO","494.09","58.3","","554.95","91.85","1421.75","94","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","618.68","73","","2490.03","2490.03","2490.03","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","494.09","58.3","","750.00","750.00","750.00","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","449.18","53","","1192.50","120.84","4149.90","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","720.38","85","","750.00","75.00","750.00","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","847.50","100","","657.00","121.50","1971.00","14","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","847.50","100","","75.00","75.00","75.00","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","847.50","100","","366.00","144.00","1971.00","45","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","618.68","73","","667.50","667.50","667.50","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","376.71","44.45","","123.77","123.77","123.77","1 through 10","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","both","","","847.50","635.62","WELLPOINT [1015]","HB CH WELLPOINT","660.29","77.91","","483.51","229.32","1316.08","96","376.71","847.5","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.50","635.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","502.57","59.3","","439.50","225.34","1872.27","197","423.75","664.86","percent of total billed charges",""
"SET SLEEVE 2MM MEDIUM CABLE HIP DALL MILES NON BEADED VITALIUM ST/1CS/1BX/1EA","SUP-ITM-10006053","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","847.50","635.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","664.86","78.45","","385.32","55.36","1815.62","58","423.75","664.86","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","AETNA [1001]","HB CH AETNA HMO / PPO","451.05","58.3","","188.13","188.13","188.13","1 through 10","343.9","773.67","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","773.67","100","","331.80","331.80","331.80","1 through 10","343.9","773.67","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","both","","","773.67","580.25","WELLPOINT [1015]","HB CH WELLPOINT","602.77","77.91","","593.13","261.33","593.13","1 through 10","343.9","773.67","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","773.67","580.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","458.79","59.3","","194.44","194.43","583.31","13","386.84","606.94","percent of total billed charges",""
"SET STENT 7.0FRX80CM 0.038IN URINARY DIVERSION PERCUFLEX CLOSED TIP PTFE COAT GUIDEWIRE CATHETER ADAPTER BAG CONNECTOR","SUP-ITM-10154998","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","773.67","580.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","606.94","78.45","","255.09","255.09","255.09","1 through 10","386.84","606.94","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","both","","","178.00","133.50","AETNA [1001]","HB CH AETNA HMO / PPO","103.77","58.3","","98.09","98.09","98.09","1 through 10","21.3","129.94","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","22.41","139.64","percent of total billed charges",""
"Sex Hormone Binding Globulin","PX-30000671","CDM","84270","CPT","0301","RC","","","","outpatient","","","178.00","133.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.64","78.45","","78.82","78.82","78.82","1 through 10","22.41","139.64","percent of total billed charges",""
"Sgmdsc Flx With Endoscopic Mucosal Resection","PX-75000416","CDM","45349","CPT","0750","RC","","","","both","","","3540.00","2655.00","MEDICARE [2001]","HB BWF MEDICARE","3256.75","","APC Price ($3,256.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3064.49","3064.49","3064.49","1 through 10","979.79","3354.46","other","OPPS APC"
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1606.50","1204.87","AETNA [1001]","HB CH AETNA HMO / PPO","936.59","58.3","","1830.28","315.58","1830.28","1 through 10","714.09","1606.5","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1606.50","1204.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1172.75","73","","4170.85","4170.85","4170.85","1 through 10","714.09","1606.5","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1606.50","1204.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","714.09","44.45","","649.55","649.55","649.55","1 through 10","714.09","1606.5","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","both","","","1606.50","1204.87","WELLPOINT [1015]","HB CH WELLPOINT","1251.62","77.91","","8998.38","2542.37","8998.38","20","714.09","1606.5","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1606.50","1204.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","952.65","59.3","","1891.61","1609.14","3664.18","25","803.25","1260.3","percent of total billed charges",""
"SHAFT FIBULA 100MM TISSUE FREEZE DRIED MATRIGRAFT SEGMENT IMPLANTABLE","SUP-ITM-10010283","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1606.50","1204.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1260.30","78.45","","1470.68","1310.06","2481.69","19","803.25","1260.3","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","AETNA [1001]","HB CH AETNA HMO / PPO","2181.63","58.3","","554.95","91.85","1421.75","94","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2731.72","73","","2490.03","2490.03","2490.03","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2181.63","58.3","","750.00","750.00","750.00","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1983.30","53","","1192.50","120.84","4149.90","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3180.77","85","","750.00","75.00","750.00","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3742.08","100","","657.00","121.50","1971.00","14","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3742.08","100","","75.00","75.00","75.00","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3742.08","100","","366.00","144.00","1971.00","45","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2731.72","73","","667.50","667.50","667.50","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1663.35","44.45","","123.77","123.77","123.77","1 through 10","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","both","","","3742.08","2806.56","WELLPOINT [1015]","HB CH WELLPOINT","2915.45","77.91","","483.51","229.32","1316.08","96","1663.35","3742.08","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.08","2806.56","CIGNA [1006]","HB CH CIGNA HMO / PPO","2219.05","59.3","","439.50","225.34","1872.27","197","1871.04","2935.66","percent of total billed charges",""
"SHAFT HUMERAL 3.5X160MM LONG 6 HOLE SHOULDER BONE LCP SS PROXIMALIMAL","SUP-ITM-10018137","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3742.08","2806.56","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2935.66","78.45","","385.32","55.36","1815.62","58","1871.04","2935.66","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.12","53","","69.13","15.86","85.00","1 through 10","206.41","464.37","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","394.71","85","","29.94","29.94","29.94","1 through 10","206.41","464.37","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","464.37","100","","60.23","29.94","60.23","12","206.41","464.37","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","464.37","100","","65.22","29.94","360.69","1 through 10","206.41","464.37","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","both","","","464.37","348.28","WELLPOINT [1015]","HB CH WELLPOINT","361.79","77.91","","51.37","51.37","284.08","1 through 10","206.41","464.37","percent of total billed charges",""
"SHEATH ACCESS 11FR 13 46CM URETERAL NAVIGATOR HYDROPLUS COATED ID OD","SUP-ITM-10027253","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","464.37","348.28","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.30","78.45","","123.30","23.02","333.57","1 through 10","232.19","364.3","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","69.13","15.86","85.00","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","650.25","85","","29.94","29.94","29.94","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","765.00","100","","60.23","29.94","60.23","12","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","765.00","100","","65.22","29.94","360.69","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","51.37","51.37","284.08","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 10.7X30MM LG FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10025201","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","123.30","23.02","333.57","1 through 10","382.5","600.14","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","AETNA [1001]","HB CH AETNA HMO / PPO","446.00","58.3","","554.95","91.85","1421.75","94","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","2490.03","2490.03","2490.03","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","446.00","58.3","","750.00","750.00","750.00","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","405.45","53","","1192.50","120.84","4149.90","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","650.25","85","","750.00","75.00","750.00","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","765.00","100","","657.00","121.50","1971.00","14","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","765.00","100","","75.00","75.00","75.00","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","765.00","100","","366.00","144.00","1971.00","45","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","558.45","73","","667.50","667.50","667.50","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","340.04","44.45","","123.77","123.77","123.77","1 through 10","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","both","","","765.00","573.75","WELLPOINT [1015]","HB CH WELLPOINT","596.01","77.91","","483.51","229.32","1316.08","96","340.04","765","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.65","59.3","","439.50","225.34","1872.27","197","382.5","600.14","percent of total billed charges",""
"SHEATH TIBIAL 8.9X30MM SM ACL BIO INTRAFIX INTERFERENCE BIOABSORBABLE IMPLANTABLE","SUP-ITM-10025202","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","765.00","573.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","600.14","78.45","","385.32","55.36","1815.62","58","382.5","600.14","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","AETNA [1001]","HB CH AETNA HMO / PPO","379.53","58.3","","554.95","91.85","1421.75","94","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","475.23","73","","2490.03","2490.03","2490.03","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","379.53","58.3","","750.00","750.00","750.00","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","345.03","53","","1192.50","120.84","4149.90","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","553.35","85","","750.00","75.00","750.00","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","651.00","100","","657.00","121.50","1971.00","14","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","651.00","100","","75.00","75.00","75.00","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","651.00","100","","366.00","144.00","1971.00","45","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","475.23","73","","667.50","667.50","667.50","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","289.37","44.45","","123.77","123.77","123.77","1 through 10","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","both","","","651.00","488.25","WELLPOINT [1015]","HB CH WELLPOINT","507.19","77.91","","483.51","229.32","1316.08","96","289.37","651","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","386.04","59.3","","439.50","225.34","1872.27","197","325.5","510.71","percent of total billed charges",""
"SHEATH TIBIAL 9.0MM DIAMETER 30 FIXATION BIOINTRAFIX TRICALCIUM PHOSPHATE POLYLACTIC ACID","SUP-ITM-10007414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","651.00","488.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","510.71","78.45","","385.32","55.36","1815.62","58","325.5","510.71","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","AETNA [1001]","HB CH AETNA HMO / PPO","291.89","58.3","","41.25","41.25","41.25","1 through 10","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","500.67","100","","39.24","39.24","39.24","1 through 10","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","both","","","500.67","375.50","WELLPOINT [1015]","HB CH WELLPOINT","390.07","77.91","","157.50","30.92","221.94","11","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 12 14FR 36CM ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115606","CDM","C1758","HCPCS","0272","RC","","","","outpatient","","","500.67","375.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","392.78","78.45","","32.43","30.18","307.47","11","250.34","392.78","percent of total billed charges",""
"SHEATH URETERAL 46CM OD 14FR ID 12 ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115607","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","265.36","53","","69.13","15.86","85.00","1 through 10","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 46CM OD 14FR ID 12 ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115607","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","425.57","85","","29.94","29.94","29.94","1 through 10","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 46CM OD 14FR ID 12 ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115607","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","500.67","100","","60.23","29.94","60.23","12","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 46CM OD 14FR ID 12 ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115607","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","500.67","100","","65.22","29.94","360.69","1 through 10","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 46CM OD 14FR ID 12 ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115607","CDM","C1894","HCPCS","0272","RC","","","","both","","","500.67","375.50","WELLPOINT [1015]","HB CH WELLPOINT","390.07","77.91","","51.37","51.37","284.08","1 through 10","222.55","500.67","percent of total billed charges",""
"SHEATH URETERAL 46CM OD 14FR ID 12 ACCESS NAVIGATOR HD SS COIL HYDROPHILIC COATED DUAL DUROMETER DILATOR","SUP-ITM-10115607","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","500.67","375.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","392.78","78.45","","123.30","23.02","333.57","1 through 10","250.34","392.78","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016040","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","244.38","53","","69.13","15.86","85.00","1 through 10","204.96","461.1","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016040","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","391.94","85","","29.94","29.94","29.94","1 through 10","204.96","461.1","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016040","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","461.10","100","","60.23","29.94","60.23","12","204.96","461.1","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016040","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","461.10","100","","65.22","29.94","360.69","1 through 10","204.96","461.1","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016040","CDM","C1894","HCPCS","0272","RC","","","","both","","","461.10","345.82","WELLPOINT [1015]","HB CH WELLPOINT","359.24","77.91","","51.37","51.37","284.08","1 through 10","204.96","461.1","percent of total billed charges",""
"SHEATH UROLOGICAL 12FR 35CM URETERAL HYDROPHILIC RADIOPAQUE 2 LUER LOCK STOPCOCK OUTER FLEXOR DOUBLE LUMEN","SUP-ITM-10016040","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","461.10","345.82","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","361.73","78.45","","123.30","23.02","333.57","1 through 10","230.55","361.73","percent of total billed charges",""
"SHEET ALLOGRAFT L 4.15.0CM CARTILAGE PROFILE TM COSTAL LRG FROZEN","SUP-ITM-10191662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.40","1705.05","AETNA [1001]","HB CH AETNA HMO / PPO","1325.39","58.3","","1830.28","315.58","1830.28","1 through 10","1010.53","2273.4","percent of total billed charges",""
"SHEET ALLOGRAFT L 4.15.0CM CARTILAGE PROFILE TM COSTAL LRG FROZEN","SUP-ITM-10191662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.40","1705.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1659.58","73","","4170.85","4170.85","4170.85","1 through 10","1010.53","2273.4","percent of total billed charges",""
"SHEET ALLOGRAFT L 4.15.0CM CARTILAGE PROFILE TM COSTAL LRG FROZEN","SUP-ITM-10191662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.40","1705.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1010.53","44.45","","649.55","649.55","649.55","1 through 10","1010.53","2273.4","percent of total billed charges",""
"SHEET ALLOGRAFT L 4.15.0CM CARTILAGE PROFILE TM COSTAL LRG FROZEN","SUP-ITM-10191662","CDM","C1889","HCPCS","0278","RC","","","","both","","","2273.40","1705.05","WELLPOINT [1015]","HB CH WELLPOINT","1771.21","77.91","","8998.38","2542.37","8998.38","20","1010.53","2273.4","percent of total billed charges",""
"SHEET ALLOGRAFT L 4.15.0CM CARTILAGE PROFILE TM COSTAL LRG FROZEN","SUP-ITM-10191662","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2273.40","1705.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","1348.13","59.3","","1891.61","1609.14","3664.18","25","1136.7","1783.48","percent of total billed charges",""
"SHEET ALLOGRAFT L 4.15.0CM CARTILAGE PROFILE TM COSTAL LRG FROZEN","SUP-ITM-10191662","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2273.40","1705.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1783.48","78.45","","1470.68","1310.06","2481.69","19","1136.7","1783.48","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","1634.24","1004.95","1718.99","42","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","2123.89","1900.92","2123.89","1 through 10","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2565.20","58.3","","3729.00","1254.19","3729.00","1 through 10","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2332.00","53","","939.37","939.37","5593.65","1 through 10","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3740.00","85","","2323.25","1864.50","2882.25","16","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4400.00","100","","2909.44","1772.40","10952.08","45","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4400.00","100","","2323.25","2323.25","2323.25","1 through 10","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4400.00","100","","2882.25","1772.40","10169.17","187","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","1659.41","1659.41","1659.41","1 through 10","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","2050.91","1468.48","2902.83","52","1955.8","4400","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","1548.60","1092.60","3613.79","82","2200","3451.8","percent of total billed charges",""
"SHELL HUMERAL 36+8 REVERSE MEDIUM","SUP-ITM-10320896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","2085.51","998.68","6202.11","56","2200","3451.8","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1634.24","1004.95","1718.99","42","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","2123.89","1900.92","2123.89","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","909.48","58.3","","3729.00","1254.19","3729.00","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","939.37","939.37","5593.65","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1326.00","85","","2323.25","1864.50","2882.25","16","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1560.00","100","","2909.44","1772.40","10952.08","45","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1560.00","100","","2323.25","2323.25","2323.25","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1560.00","100","","2882.25","1772.40","10169.17","187","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","1659.41","1659.41","1659.41","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","2050.91","1468.48","2902.83","52","693.42","1560","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1548.60","1092.60","3613.79","82","780","1223.82","percent of total billed charges",""
"SHOULDER 40X17 REUNION TSA SR STANDARD","SUP-ITM-10175590","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","2085.51","998.68","6202.11","56","780","1223.82","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"SHOULDER 48X19MM II UNIVERSAL","SUP-ITM-10135872","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"SHOULDER 50X16MM AEQUALIS ASCEND FLEXIBLE TITANIUM OFFSET HIGH","SUP-ITM-10136053","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"SHOULDER 52X20MM UNIVERS II COBALT CHROMIUM","SUP-ITM-10135877","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"Shoulder And Elbow Joint Replacement,MINOR","322","DRG","","","","","","","","inpatient","","","65424.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","43489.61","","Standard inlier is a Case rate ($43,489.61). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $56,262, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,173.52) for the length of stay and the standard reimbursement.","41513.37","41513.37","41513.37","1 through 10","13467.42","50724.55","case rate",""
"Shoulder And Elbow Joint Replacement,MINOR","322","DRG","","","","","","","","inpatient","","","65424.69","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","46716.52","","Standard inlier is a Case rate ($46,716.52). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $56,262, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,631.21) for the length of stay and the standard reimbursement.","46716.52","46716.52","46716.52","1 through 10","13467.42","50724.55","case rate",""
"Shoulder And Elbow Joint Replacement,MINOR","322","DRG","","","","","","","","inpatient","","","65424.69","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","22215.59","","Case rate ($24,563.16). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $66,993.16, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $13,877.49 and the sum of the standard inlier and any outlier amount.","24557.13","24557.13","24557.13","1 through 10","13467.42","50724.55","case rate",""
"Shoulder And Elbow Joint Replacement,MODERATE","322","DRG","","","","","","","","inpatient","","","80448.28","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","50724.55","","Standard inlier is a Case rate ($50,724.55). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $60,090, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($7,200.14) for the length of stay and the standard reimbursement.","48418.88","48418.88","48418.88","1 through 10","13467.42","50724.55","case rate",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","AETNA [1001]","HB CH AETNA HMO / PPO","2295.56","58.3","","1634.24","1004.95","1718.99","42","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2874.38","73","","2123.89","1900.92","2123.89","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2295.56","58.3","","3729.00","1254.19","3729.00","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2086.88","53","","939.37","939.37","5593.65","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3346.88","85","","2323.25","1864.50","2882.25","16","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3937.50","100","","2909.44","1772.40","10952.08","45","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3937.50","100","","2323.25","2323.25","2323.25","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3937.50","100","","2882.25","1772.40","10169.17","187","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2874.38","73","","1659.41","1659.41","1659.41","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB CH WELLPOINT","3067.71","77.91","","2050.91","1468.48","2902.83","52","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1548.60","1092.60","3613.79","82","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 15MM PLATE BASE METAL TRABECULAR POST REVERSE 06","SUP-ITM-10118150","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3088.97","78.45","","2085.51","998.68","6202.11","56","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","1634.24","1004.95","1718.99","42","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","2123.89","1900.92","2123.89","1 through 10","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2565.20","58.3","","3729.00","1254.19","3729.00","1 through 10","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2332.00","53","","939.37","939.37","5593.65","1 through 10","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3740.00","85","","2323.25","1864.50","2882.25","16","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4400.00","100","","2909.44","1772.40","10952.08","45","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4400.00","100","","2323.25","2323.25","2323.25","1 through 10","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4400.00","100","","2882.25","1772.40","10169.17","187","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","1659.41","1659.41","1659.41","1 through 10","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","2050.91","1468.48","2902.83","52","1955.8","4400","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","1548.60","1092.60","3613.79","82","2200","3451.8","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM 10DEG FULL AUGMENT OBLIQUE","SUP-ITM-10275285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","2085.51","998.68","6202.11","56","2200","3451.8","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","1634.24","1004.95","1718.99","42","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","2123.89","1900.92","2123.89","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1965.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","939.37","939.37","5593.65","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2866.30","85","","2323.25","1864.50","2882.25","16","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3372.12","100","","2909.44","1772.40","10952.08","45","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3372.12","100","","2323.25","2323.25","2323.25","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3372.12","100","","2882.25","1772.40","10169.17","187","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","1659.41","1659.41","1659.41","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","2050.91","1468.48","2902.83","52","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1548.60","1092.60","3613.79","82","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE 24MM MODULAR","SUP-ITM-10233543","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","2085.51","998.68","6202.11","56","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","AETNA [1001]","HB CH AETNA HMO / PPO","3148.20","58.3","","1634.24","1004.95","1718.99","42","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3942.00","73","","2123.89","1900.92","2123.89","1 through 10","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3148.20","58.3","","3729.00","1254.19","3729.00","1 through 10","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2862.00","53","","939.37","939.37","5593.65","1 through 10","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4590.00","85","","2323.25","1864.50","2882.25","16","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5400.00","100","","2909.44","1772.40","10952.08","45","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5400.00","100","","2323.25","2323.25","2323.25","1 through 10","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5400.00","100","","2882.25","1772.40","10169.17","187","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3942.00","73","","1659.41","1659.41","1659.41","1 through 10","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","both","","","5400.00","4050.00","WELLPOINT [1015]","HB CH WELLPOINT","4207.14","77.91","","2050.91","1468.48","2902.83","52","2400.3","5400","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3202.20","59.3","","1548.60","1092.60","3613.79","82","2700","4236.3","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 15DEG AEQUALIS REVERSE FULL WEDGE","SUP-ITM-10215284","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5400.00","4050.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4236.30","78.45","","2085.51","998.68","6202.11","56","2700","4236.3","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","AETNA [1001]","HB CH AETNA HMO / PPO","2915.00","58.3","","1634.24","1004.95","1718.99","42","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","2123.89","1900.92","2123.89","1 through 10","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2915.00","58.3","","3729.00","1254.19","3729.00","1 through 10","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2650.00","53","","939.37","939.37","5593.65","1 through 10","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4250.00","85","","2323.25","1864.50","2882.25","16","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5000.00","100","","2909.44","1772.40","10952.08","45","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5000.00","100","","2323.25","2323.25","2323.25","1 through 10","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5000.00","100","","2882.25","1772.40","10169.17","187","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3650.00","73","","1659.41","1659.41","1659.41","1 through 10","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","both","","","5000.00","3750.00","WELLPOINT [1015]","HB CH WELLPOINT","3895.50","77.91","","2050.91","1468.48","2902.83","52","2222.5","5000","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2965.00","59.3","","1548.60","1092.60","3613.79","82","2500","3922.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM 35 DEGREE HALF WEDGE","SUP-ITM-10215285","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5000.00","3750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3922.50","78.45","","2085.51","998.68","6202.11","56","2500","3922.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","AETNA [1001]","HB CH AETNA HMO / PPO","2295.56","58.3","","1634.24","1004.95","1718.99","42","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2874.38","73","","2123.89","1900.92","2123.89","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2295.56","58.3","","3729.00","1254.19","3729.00","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2086.88","53","","939.37","939.37","5593.65","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3346.88","85","","2323.25","1864.50","2882.25","16","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3937.50","100","","2909.44","1772.40","10952.08","45","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3937.50","100","","2323.25","2323.25","2323.25","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3937.50","100","","2882.25","1772.40","10169.17","187","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2874.38","73","","1659.41","1659.41","1659.41","1 through 10","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","both","","","3937.50","2953.12","WELLPOINT [1015]","HB CH WELLPOINT","3067.71","77.91","","2050.91","1468.48","2902.83","52","1750.22","3937.5","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2334.94","59.3","","1548.60","1092.60","3613.79","82","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 25MM COBALT ALLOY COMPREHENSIVE REVERSE TAPER ADAPTER MINI","SUP-ITM-10122608","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3937.50","2953.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3088.97","78.45","","2085.51","998.68","6202.11","56","1968.75","3088.97","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB CH AETNA HMO / PPO","1967.63","58.3","","1634.24","1004.95","1718.99","42","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2463.75","73","","2123.89","1900.92","2123.89","1 through 10","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1967.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.75","53","","939.37","939.37","5593.65","1 through 10","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2868.75","85","","2323.25","1864.50","2882.25","16","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3375.00","100","","2909.44","1772.40","10952.08","45","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3375.00","100","","2323.25","2323.25","2323.25","1 through 10","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3375.00","100","","2882.25","1772.40","10169.17","187","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2463.75","73","","1659.41","1659.41","1659.41","1 through 10","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB CH WELLPOINT","2629.46","77.91","","2050.91","1468.48","2902.83","52","1500.19","3375","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2001.38","59.3","","1548.60","1092.60","3613.79","82","1687.5","2647.69","percent of total billed charges",""
"SHOULDER BASEPLATE 28MM GLENOID REUNION RSA REVERSE HUMERAL","SUP-ITM-10138620","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","2085.51","998.68","6202.11","56","1687.5","2647.69","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","AETNA [1001]","HB CH AETNA HMO / PPO","3978.39","58.3","","1634.24","1004.95","1718.99","42","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4981.52","73","","2123.89","1900.92","2123.89","1 through 10","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3978.39","58.3","","3729.00","1254.19","3729.00","1 through 10","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3616.72","53","","939.37","939.37","5593.65","1 through 10","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5800.40","85","","2323.25","1864.50","2882.25","16","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6824.00","100","","2909.44","1772.40","10952.08","45","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6824.00","100","","2323.25","2323.25","2323.25","1 through 10","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6824.00","100","","2882.25","1772.40","10169.17","187","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4981.52","73","","1659.41","1659.41","1659.41","1 through 10","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","both","","","6824.00","5118.00","WELLPOINT [1015]","HB CH WELLPOINT","5316.58","77.91","","2050.91","1468.48","2902.83","52","3033.27","6824","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6824.00","5118.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4046.63","59.3","","1548.60","1092.60","3613.79","82","3412","5353.43","percent of total billed charges",""
"SHOULDER BASEPLATE 36MMX25 AEQUALIS REVERSED TITANIUM CENTERED","SUP-ITM-10192115","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6824.00","5118.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5353.43","78.45","","2085.51","998.68","6202.11","56","3412","5353.43","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","AETNA [1001]","HB CH AETNA HMO / PPO","2218.43","58.3","","1634.24","1004.95","1718.99","42","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2777.80","73","","2123.89","1900.92","2123.89","1 through 10","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2218.43","58.3","","3729.00","1254.19","3729.00","1 through 10","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2016.76","53","","939.37","939.37","5593.65","1 through 10","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3234.42","85","","2323.25","1864.50","2882.25","16","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3805.20","100","","2909.44","1772.40","10952.08","45","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3805.20","100","","2323.25","2323.25","2323.25","1 through 10","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3805.20","100","","2882.25","1772.40","10169.17","187","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2777.80","73","","1659.41","1659.41","1659.41","1 through 10","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","both","","","3805.20","2853.90","WELLPOINT [1015]","HB CH WELLPOINT","2964.63","77.91","","2050.91","1468.48","2902.83","52","1691.41","3805.2","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","CIGNA [1006]","HB CH CIGNA HMO / PPO","2256.48","59.3","","1548.60","1092.60","3613.79","82","1902.6","2985.18","percent of total billed charges",""
"SHOULDER BASEPLATE 40MM IMPLANT GLENOSPHERE REVERSE TRABECULAR METAL POLYETHYLENE 05","SUP-ITM-10022742","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3805.20","2853.90","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2985.18","78.45","","2085.51","998.68","6202.11","56","1902.6","2985.18","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","1634.24","1004.95","1718.99","42","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","2123.89","1900.92","2123.89","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1965.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","939.37","939.37","5593.65","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2866.30","85","","2323.25","1864.50","2882.25","16","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3372.12","100","","2909.44","1772.40","10952.08","45","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3372.12","100","","2323.25","2323.25","2323.25","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3372.12","100","","2882.25","1772.40","10169.17","187","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","1659.41","1659.41","1659.41","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","2050.91","1468.48","2902.83","52","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1548.60","1092.60","3613.79","82","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE MEDIUM UNIVERSAL REVERSE TITANIUM UNCEMENTED","SUP-ITM-10133127","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","2085.51","998.68","6202.11","56","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","AETNA [1001]","HB CH AETNA HMO / PPO","1923.90","58.3","","1634.24","1004.95","1718.99","42","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","2123.89","1900.92","2123.89","1 through 10","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1923.90","58.3","","3729.00","1254.19","3729.00","1 through 10","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1749.00","53","","939.37","939.37","5593.65","1 through 10","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2805.00","85","","2323.25","1864.50","2882.25","16","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3300.00","100","","2909.44","1772.40","10952.08","45","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3300.00","100","","2323.25","2323.25","2323.25","1 through 10","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3300.00","100","","2882.25","1772.40","10169.17","187","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2409.00","73","","1659.41","1659.41","1659.41","1 through 10","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3300.00","2475.00","WELLPOINT [1015]","HB CH WELLPOINT","2571.03","77.91","","2050.91","1468.48","2902.83","52","1466.85","3300","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1956.90","59.3","","1548.60","1092.60","3613.79","82","1650","2588.85","percent of total billed charges",""
"SHOULDER BASEPLATE SM.24MM INHANCE MODULAR","SUP-ITM-10311997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3300.00","2475.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2588.85","78.45","","2085.51","998.68","6202.11","56","1650","2588.85","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","554.95","91.85","1421.75","94","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","2490.03","2490.03","2490.03","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1965.95","58.3","","750.00","750.00","750.00","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","1192.50","120.84","4149.90","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2866.30","85","","750.00","75.00","750.00","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3372.12","100","","657.00","121.50","1971.00","14","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3372.12","100","","75.00","75.00","75.00","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3372.12","100","","366.00","144.00","1971.00","45","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","667.50","667.50","667.50","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1498.91","44.45","","123.77","123.77","123.77","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","483.51","229.32","1316.08","96","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","439.50","225.34","1872.27","197","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE SMALL UNIVERSAL TITANIUM","SUP-ITM-10126754","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","385.32","55.36","1815.62","58","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","AETNA [1001]","HB CH AETNA HMO / PPO","1965.95","58.3","","1634.24","1004.95","1718.99","42","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","2123.89","1900.92","2123.89","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1965.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1787.22","53","","939.37","939.37","5593.65","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2866.30","85","","2323.25","1864.50","2882.25","16","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3372.12","100","","2909.44","1772.40","10952.08","45","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3372.12","100","","2323.25","2323.25","2323.25","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3372.12","100","","2882.25","1772.40","10169.17","187","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2461.65","73","","1659.41","1659.41","1659.41","1 through 10","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","both","","","3372.12","2529.09","WELLPOINT [1015]","HB CH WELLPOINT","2627.22","77.91","","2050.91","1468.48","2902.83","52","1498.91","3372.12","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","CIGNA [1006]","HB CH CIGNA HMO / PPO","1999.67","59.3","","1548.60","1092.60","3613.79","82","1686.06","2645.43","percent of total billed charges",""
"SHOULDER BASEPLATE UNIVERSAL LG REVERSE TITANIUM UNCEMENTED","SUP-ITM-10135359","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3372.12","2529.09","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2645.43","78.45","","2085.51","998.68","6202.11","56","1686.06","2645.43","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","AETNA [1001]","HB CH AETNA HMO / PPO","2620.00","58.3","","1634.24","1004.95","1718.99","42","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3280.62","73","","2123.89","1900.92","2123.89","1 through 10","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2620.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2381.82","53","","939.37","939.37","5593.65","1 through 10","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3819.90","85","","2323.25","1864.50","2882.25","16","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4494.00","100","","2909.44","1772.40","10952.08","45","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4494.00","100","","2323.25","2323.25","2323.25","1 through 10","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4494.00","100","","2882.25","1772.40","10169.17","187","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3280.62","73","","1659.41","1659.41","1659.41","1 through 10","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","both","","","4494.00","3370.50","WELLPOINT [1015]","HB CH WELLPOINT","3501.28","77.91","","2050.91","1468.48","2902.83","52","1997.58","4494","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4494.00","3370.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2664.94","59.3","","1548.60","1092.60","3613.79","82","2247","3525.54","percent of total billed charges",""
"SHOULDER COMPONENT 10MM METAGLENE PLUS PLUS10 CEMENTLESS MODULAR REVERSE","SUP-ITM-10125992","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4494.00","3370.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3525.54","78.45","","2085.51","998.68","6202.11","56","2247","3525.54","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"SHOULDER COMPONENT 38MM GLENOID GLENOSPHERE DELTA XTEND COBALT STANDARD","SUP-ITM-10024324","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","AETNA [1001]","HB CH AETNA HMO / PPO","874.50","58.3","","1634.24","1004.95","1718.99","42","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","2123.89","1900.92","2123.89","1 through 10","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","874.50","58.3","","3729.00","1254.19","3729.00","1 through 10","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","795.00","53","","939.37","939.37","5593.65","1 through 10","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1275.00","85","","2323.25","1864.50","2882.25","16","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1500.00","100","","2909.44","1772.40","10952.08","45","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1500.00","100","","2323.25","2323.25","2323.25","1 through 10","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1500.00","100","","2882.25","1772.40","10169.17","187","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1095.00","73","","1659.41","1659.41","1659.41","1 through 10","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","2050.91","1468.48","2902.83","52","666.75","1500","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","1548.60","1092.60","3613.79","82","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 44MM GLENOID AFFINITI","SUP-ITM-10090972","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1176.75","78.45","","2085.51","998.68","6202.11","56","750","1176.75","percent of total billed charges",""
"SHOULDER COMPONENT 48MM GLENOID ADV CROSSLINK FIN","SUP-ITM-10019398","CDM","C1889","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","AETNA [1001]","HB CH AETNA HMO / PPO","1323.99","58.3","","1830.28","315.58","1830.28","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 48MM GLENOID ADV CROSSLINK FIN","SUP-ITM-10019398","CDM","C1889","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","4170.85","4170.85","4170.85","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 48MM GLENOID ADV CROSSLINK FIN","SUP-ITM-10019398","CDM","C1889","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1009.46","44.45","","649.55","649.55","649.55","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 48MM GLENOID ADV CROSSLINK FIN","SUP-ITM-10019398","CDM","C1889","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","WELLPOINT [1015]","HB CH WELLPOINT","1769.34","77.91","","8998.38","2542.37","8998.38","20","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 48MM GLENOID ADV CROSSLINK FIN","SUP-ITM-10019398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1891.61","1609.14","3664.18","25","1135.5","1781.6","percent of total billed charges",""
"SHOULDER COMPONENT 48MM GLENOID ADV CROSSLINK FIN","SUP-ITM-10019398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1781.60","78.45","","1470.68","1310.06","2481.69","19","1135.5","1781.6","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","AETNA [1001]","HB CH AETNA HMO / PPO","1323.99","58.3","","1634.24","1004.95","1718.99","42","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","2123.89","1900.92","2123.89","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1323.99","58.3","","3729.00","1254.19","3729.00","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1203.63","53","","939.37","939.37","5593.65","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1930.35","85","","2323.25","1864.50","2882.25","16","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2271.00","100","","2909.44","1772.40","10952.08","45","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2271.00","100","","2323.25","2323.25","2323.25","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2271.00","100","","2882.25","1772.40","10169.17","187","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","1659.41","1659.41","1659.41","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","WELLPOINT [1015]","HB CH WELLPOINT","1769.34","77.91","","2050.91","1468.48","2902.83","52","1009.46","2271","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1548.60","1092.60","3613.79","82","1135.5","1781.6","percent of total billed charges",""
"SHOULDER COMPONENT 52MM GLBL ADV CROSSLINK FN GLENOID","SUP-ITM-10022765","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1781.60","78.45","","2085.51","998.68","6202.11","56","1135.5","1781.6","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","AETNA [1001]","HB CH AETNA HMO / PPO","2353.72","58.3","","1634.24","1004.95","1718.99","42","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2947.19","73","","2123.89","1900.92","2123.89","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2353.72","58.3","","3729.00","1254.19","3729.00","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2139.74","53","","939.37","939.37","5593.65","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3431.66","85","","2323.25","1864.50","2882.25","16","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4037.25","100","","2909.44","1772.40","10952.08","45","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4037.25","100","","2323.25","2323.25","2323.25","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4037.25","100","","2882.25","1772.40","10169.17","187","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2947.19","73","","1659.41","1659.41","1659.41","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","WELLPOINT [1015]","HB CH WELLPOINT","3145.42","77.91","","2050.91","1468.48","2902.83","52","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4037.25","3027.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2394.09","59.3","","1548.60","1092.60","3613.79","82","2018.63","3167.22","percent of total billed charges",""
"SHOULDER CUP 36MM 9 IMPLANT PLUS HUMERAL DELTA LATERAL REVERSE 03","SUP-ITM-10015558","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4037.25","3027.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3167.22","78.45","","2085.51","998.68","6202.11","56","2018.63","3167.22","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","AETNA [1001]","HB CH AETNA HMO / PPO","2046.33","58.3","","1634.24","1004.95","1718.99","42","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2562.30","73","","2123.89","1900.92","2123.89","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2046.33","58.3","","3729.00","1254.19","3729.00","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1860.30","53","","939.37","939.37","5593.65","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2983.50","85","","2323.25","1864.50","2882.25","16","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3510.00","100","","2909.44","1772.40","10952.08","45","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3510.00","100","","2323.25","2323.25","2323.25","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3510.00","100","","2882.25","1772.40","10169.17","187","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2562.30","73","","1659.41","1659.41","1659.41","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","WELLPOINT [1015]","HB CH WELLPOINT","2734.64","77.91","","2050.91","1468.48","2902.83","52","1560.2","3510","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.43","59.3","","1548.60","1092.60","3613.79","82","1755","2753.6","percent of total billed charges",""
"SHOULDER CUP 36MMX4 THICK REVERSE 03","SUP-ITM-10138618","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.60","78.45","","2085.51","998.68","6202.11","56","1755","2753.6","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","AETNA [1001]","HB CH AETNA HMO / PPO","1803.22","58.3","","1634.24","1004.95","1718.99","42","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2257.89","73","","2123.89","1900.92","2123.89","1 through 10","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1803.22","58.3","","3729.00","1254.19","3729.00","1 through 10","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1639.29","53","","939.37","939.37","5593.65","1 through 10","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2629.05","85","","2323.25","1864.50","2882.25","16","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3093.00","100","","2909.44","1772.40","10952.08","45","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3093.00","100","","2323.25","2323.25","2323.25","1 through 10","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3093.00","100","","2882.25","1772.40","10169.17","187","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2257.89","73","","1659.41","1659.41","1659.41","1 through 10","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","both","","","3093.00","2319.75","WELLPOINT [1015]","HB CH WELLPOINT","2409.76","77.91","","2050.91","1468.48","2902.83","52","1374.84","3093","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3093.00","2319.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1834.15","59.3","","1548.60","1092.60","3613.79","82","1546.5","2426.46","percent of total billed charges",""
"SHOULDER CUP 38MM METAGLENE DELTA EXTENDED REVERSE 06","SUP-ITM-10022561","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3093.00","2319.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2426.46","78.45","","2085.51","998.68","6202.11","56","1546.5","2426.46","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","AETNA [1001]","HB CH AETNA HMO / PPO","2353.72","58.3","","1634.24","1004.95","1718.99","42","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2947.19","73","","2123.89","1900.92","2123.89","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2353.72","58.3","","3729.00","1254.19","3729.00","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2139.74","53","","939.37","939.37","5593.65","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3431.66","85","","2323.25","1864.50","2882.25","16","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4037.25","100","","2909.44","1772.40","10952.08","45","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4037.25","100","","2323.25","2323.25","2323.25","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4037.25","100","","2882.25","1772.40","10169.17","187","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2947.19","73","","1659.41","1659.41","1659.41","1 through 10","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","both","","","4037.25","3027.94","WELLPOINT [1015]","HB CH WELLPOINT","3145.42","77.91","","2050.91","1468.48","2902.83","52","1794.56","4037.25","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4037.25","3027.94","CIGNA [1006]","HB CH CIGNA HMO / PPO","2394.09","59.3","","1548.60","1092.60","3613.79","82","2018.63","3167.22","percent of total billed charges",""
"SHOULDER CUP 42MM 9 LATERALIZED HUMERAL 0 /+ 42/+9","SUP-ITM-10016137","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4037.25","3027.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3167.22","78.45","","2085.51","998.68","6202.11","56","2018.63","3167.22","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","AETNA [1001]","HB CH AETNA HMO / PPO","1885.42","58.3","","1634.24","1004.95","1718.99","42","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2360.82","73","","2123.89","1900.92","2123.89","1 through 10","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1885.42","58.3","","3729.00","1254.19","3729.00","1 through 10","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1714.02","53","","939.37","939.37","5593.65","1 through 10","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2748.90","85","","2323.25","1864.50","2882.25","16","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3234.00","100","","2909.44","1772.40","10952.08","45","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3234.00","100","","2323.25","2323.25","2323.25","1 through 10","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3234.00","100","","2882.25","1772.40","10169.17","187","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2360.82","73","","1659.41","1659.41","1659.41","1 through 10","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","both","","","3234.00","2425.50","WELLPOINT [1015]","HB CH WELLPOINT","2519.61","77.91","","2050.91","1468.48","2902.83","52","1437.51","3234","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3234.00","2425.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1917.76","59.3","","1548.60","1092.60","3613.79","82","1617","2537.07","percent of total billed charges",""
"SHOULDER CUP DIA 38MM PLUS 3 DELTA XTEND PREMIERONXLINKED POLYETHYLENE HIGH MOBILITY","SUP-ITM-10119280","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3234.00","2425.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2537.07","78.45","","2085.51","998.68","6202.11","56","1617","2537.07","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","AETNA [1001]","HB CH AETNA HMO / PPO","2046.19","58.3","","1634.24","1004.95","1718.99","42","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2562.12","73","","2123.89","1900.92","2123.89","1 through 10","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2046.19","58.3","","3729.00","1254.19","3729.00","1 through 10","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1860.17","53","","939.37","939.37","5593.65","1 through 10","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2983.30","85","","2323.25","1864.50","2882.25","16","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3509.76","100","","2909.44","1772.40","10952.08","45","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3509.76","100","","2323.25","2323.25","2323.25","1 through 10","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3509.76","100","","2882.25","1772.40","10169.17","187","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2562.12","73","","1659.41","1659.41","1659.41","1 through 10","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","both","","","3509.76","2632.32","WELLPOINT [1015]","HB CH WELLPOINT","2734.45","77.91","","2050.91","1468.48","2902.83","52","1560.09","3509.76","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3509.76","2632.32","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.29","59.3","","1548.60","1092.60","3613.79","82","1754.88","2753.41","percent of total billed charges",""
"SHOULDER CUP SZ 36 REVERSE COAT 36NEUTRAL UNIVERSAL 03","SUP-ITM-10169046","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3509.76","2632.32","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.41","78.45","","2085.51","998.68","6202.11","56","1754.88","2753.41","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","AETNA [1001]","HB CH AETNA HMO / PPO","2046.33","58.3","","1634.24","1004.95","1718.99","42","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2562.30","73","","2123.89","1900.92","2123.89","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2046.33","58.3","","3729.00","1254.19","3729.00","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1860.30","53","","939.37","939.37","5593.65","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2983.50","85","","2323.25","1864.50","2882.25","16","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3510.00","100","","2909.44","1772.40","10952.08","45","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3510.00","100","","2323.25","2323.25","2323.25","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3510.00","100","","2882.25","1772.40","10169.17","187","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2562.30","73","","1659.41","1659.41","1659.41","1 through 10","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","both","","","3510.00","2632.50","WELLPOINT [1015]","HB CH WELLPOINT","2734.64","77.91","","2050.91","1468.48","2902.83","52","1560.2","3510","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2081.43","59.3","","1548.60","1092.60","3613.79","82","1755","2753.6","percent of total billed charges",""
"SHOULDER CUPHUMERAL 40MM DIAX10 THICK REVERSE 03","SUP-ITM-10139309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3510.00","2632.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2753.60","78.45","","2085.51","998.68","6202.11","56","1755","2753.6","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","AETNA [1001]","HB CH AETNA HMO / PPO","1323.99","58.3","","1634.24","1004.95","1718.99","42","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","2123.89","1900.92","2123.89","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1323.99","58.3","","3729.00","1254.19","3729.00","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1203.63","53","","939.37","939.37","5593.65","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1930.35","85","","2323.25","1864.50","2882.25","16","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2271.00","100","","2909.44","1772.40","10952.08","45","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2271.00","100","","2323.25","2323.25","2323.25","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2271.00","100","","2882.25","1772.40","10169.17","187","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1657.83","73","","1659.41","1659.41","1659.41","1 through 10","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","both","","","2271.00","1703.25","WELLPOINT [1015]","HB CH WELLPOINT","1769.34","77.91","","2050.91","1468.48","2902.83","52","1009.46","2271","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1346.70","59.3","","1548.60","1092.60","3613.79","82","1135.5","1781.6","percent of total billed charges",""
"SHOULDER GLENOID SIZE 48 KEELED REUNION TSAX02","SUP-ITM-10092645","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2271.00","1703.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1781.60","78.45","","2085.51","998.68","6202.11","56","1135.5","1781.6","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","AETNA [1001]","HB CH AETNA HMO / PPO","2006.06","58.3","","1634.24","1004.95","1718.99","42","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2511.88","73","","2123.89","1900.92","2123.89","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2006.06","58.3","","3729.00","1254.19","3729.00","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1823.69","53","","939.37","939.37","5593.65","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2924.79","85","","2323.25","1864.50","2882.25","16","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3440.93","100","","2909.44","1772.40","10952.08","45","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3440.93","100","","2323.25","2323.25","2323.25","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3440.93","100","","2882.25","1772.40","10169.17","187","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2511.88","73","","1659.41","1659.41","1659.41","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","WELLPOINT [1015]","HB CH WELLPOINT","2680.83","77.91","","2050.91","1468.48","2902.83","52","1529.49","3440.93","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1548.60","1092.60","3613.79","82","1720.47","2699.41","percent of total billed charges",""
"SHOULDER GLENOSPHERE 36/24","SUP-ITM-10233505","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.41","78.45","","2085.51","998.68","6202.11","56","1720.47","2699.41","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","AETNA [1001]","HB CH AETNA HMO / PPO","2006.06","58.3","","1634.24","1004.95","1718.99","42","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2511.88","73","","2123.89","1900.92","2123.89","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2006.06","58.3","","3729.00","1254.19","3729.00","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1823.69","53","","939.37","939.37","5593.65","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2924.79","85","","2323.25","1864.50","2882.25","16","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3440.93","100","","2909.44","1772.40","10952.08","45","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3440.93","100","","2323.25","2323.25","2323.25","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3440.93","100","","2882.25","1772.40","10169.17","187","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2511.88","73","","1659.41","1659.41","1659.41","1 through 10","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","both","","","3440.93","2580.70","WELLPOINT [1015]","HB CH WELLPOINT","2680.83","77.91","","2050.91","1468.48","2902.83","52","1529.49","3440.93","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","CIGNA [1006]","HB CH CIGNA HMO / PPO","2040.47","59.3","","1548.60","1092.60","3613.79","82","1720.47","2699.41","percent of total billed charges",""
"SHOULDER HEAD 36MM 4 SM SPHERE GLENOID PLUS LATERAL UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126758","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3440.93","2580.70","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2699.41","78.45","","2085.51","998.68","6202.11","56","1720.47","2699.41","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","AETNA [1001]","HB CH AETNA HMO / PPO","3313.77","58.3","","1634.24","1004.95","1718.99","42","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4149.32","73","","2123.89","1900.92","2123.89","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3313.77","58.3","","3729.00","1254.19","3729.00","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3012.52","53","","939.37","939.37","5593.65","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4831.40","85","","2323.25","1864.50","2882.25","16","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5684.00","100","","2909.44","1772.40","10952.08","45","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5684.00","100","","2323.25","2323.25","2323.25","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5684.00","100","","2882.25","1772.40","10169.17","187","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4149.32","73","","1659.41","1659.41","1659.41","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","WELLPOINT [1015]","HB CH WELLPOINT","4428.40","77.91","","2050.91","1468.48","2902.83","52","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5684.00","4263.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3370.61","59.3","","1548.60","1092.60","3613.79","82","2842","4459.1","percent of total billed charges",""
"SHOULDER HEAD 40MM IMPLANT ELBOW HUMERAL MRS PROXIMALIMAL ONC 14 CS/1BX/1EA","SUP-ITM-10005352","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5684.00","4263.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4459.10","78.45","","2085.51","998.68","6202.11","56","2842","4459.1","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","AETNA [1001]","HB CH AETNA HMO / PPO","3313.77","58.3","","1634.24","1004.95","1718.99","42","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4149.32","73","","2123.89","1900.92","2123.89","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3313.77","58.3","","3729.00","1254.19","3729.00","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3012.52","53","","939.37","939.37","5593.65","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4831.40","85","","2323.25","1864.50","2882.25","16","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5684.00","100","","2909.44","1772.40","10952.08","45","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5684.00","100","","2323.25","2323.25","2323.25","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5684.00","100","","2882.25","1772.40","10169.17","187","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4149.32","73","","1659.41","1659.41","1659.41","1 through 10","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","both","","","5684.00","4263.00","WELLPOINT [1015]","HB CH WELLPOINT","4428.40","77.91","","2050.91","1468.48","2902.83","52","2526.54","5684","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5684.00","4263.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3370.61","59.3","","1548.60","1092.60","3613.79","82","2842","4459.1","percent of total billed charges",""
"SHOULDER HEAD 44MM HUMERAL MRS PROXIMALIMAL","SUP-ITM-10005450","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5684.00","4263.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4459.10","78.45","","2085.51","998.68","6202.11","56","2842","4459.1","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","1634.24","1004.95","1718.99","42","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","2123.89","1900.92","2123.89","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","909.48","58.3","","3729.00","1254.19","3729.00","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","939.37","939.37","5593.65","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1326.00","85","","2323.25","1864.50","2882.25","16","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1560.00","100","","2909.44","1772.40","10952.08","45","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1560.00","100","","2323.25","2323.25","2323.25","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1560.00","100","","2882.25","1772.40","10169.17","187","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","1659.41","1659.41","1659.41","1 through 10","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","2050.91","1468.48","2902.83","52","693.42","1560","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","1548.60","1092.60","3613.79","82","780","1223.82","percent of total billed charges",""
"SHOULDER HEAD 44X16 HUMERAL REUNION TSA SR STANDARD","SUP-ITM-10113415","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","2085.51","998.68","6202.11","56","780","1223.82","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","AETNA [1001]","HB CH AETNA HMO / PPO","954.95","58.3","","1634.24","1004.95","1718.99","42","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1195.74","73","","2123.89","1900.92","2123.89","1 through 10","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","954.95","58.3","","3729.00","1254.19","3729.00","1 through 10","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","868.14","53","","939.37","939.37","5593.65","1 through 10","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1392.30","85","","2323.25","1864.50","2882.25","16","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1638.00","100","","2909.44","1772.40","10952.08","45","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1638.00","100","","2323.25","2323.25","2323.25","1 through 10","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1638.00","100","","2882.25","1772.40","10169.17","187","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1195.74","73","","1659.41","1659.41","1659.41","1 through 10","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","both","","","1638.00","1228.50","WELLPOINT [1015]","HB CH WELLPOINT","1276.17","77.91","","2050.91","1468.48","2902.83","52","728.09","1638","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","971.33","59.3","","1548.60","1092.60","3613.79","82","819","1285.01","percent of total billed charges",""
"SHOULDER HEAD 56MM OD 24MM HUMERAL ARTICULATING","SUP-ITM-10201491","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1638.00","1228.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1285.01","78.45","","2085.51","998.68","6202.11","56","819","1285.01","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","AETNA [1001]","HB CH AETNA HMO / PPO","3789.50","58.3","","1634.24","1004.95","1718.99","42","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4745.00","73","","2123.89","1900.92","2123.89","1 through 10","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3789.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3445.00","53","","939.37","939.37","5593.65","1 through 10","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5525.00","85","","2323.25","1864.50","2882.25","16","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6500.00","100","","2909.44","1772.40","10952.08","45","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6500.00","100","","2323.25","2323.25","2323.25","1 through 10","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6500.00","100","","2882.25","1772.40","10169.17","187","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4745.00","73","","1659.41","1659.41","1659.41","1 through 10","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","both","","","6500.00","4875.00","WELLPOINT [1015]","HB CH WELLPOINT","5064.15","77.91","","2050.91","1468.48","2902.83","52","2889.25","6500","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3854.50","59.3","","1548.60","1092.60","3613.79","82","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 6.0X35MM HUMERAL RESURFACING OFFSET REGULAR STEMMED CEMENTED COBALT HEMI CAP 05B2","SUP-ITM-10030547","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6500.00","4875.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5099.25","78.45","","2085.51","998.68","6202.11","56","3250","5099.25","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","AETNA [1001]","HB CH AETNA HMO / PPO","2453.26","58.3","","1634.24","1004.95","1718.99","42","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","2123.89","1900.92","2123.89","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2453.26","58.3","","3729.00","1254.19","3729.00","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2230.24","53","","939.37","939.37","5593.65","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3576.80","85","","2323.25","1864.50","2882.25","16","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4208.00","100","","2909.44","1772.40","10952.08","45","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4208.00","100","","2323.25","2323.25","2323.25","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4208.00","100","","2882.25","1772.40","10169.17","187","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","1659.41","1659.41","1659.41","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","WELLPOINT [1015]","HB CH WELLPOINT","3278.45","77.91","","2050.91","1468.48","2902.83","52","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2495.34","59.3","","1548.60","1092.60","3613.79","82","2104","3301.18","percent of total billed charges",""
"SHOULDER HEAD 7MMX115 HUMERAL MRS PROXIMALIMAL BODY","SUP-ITM-10035499","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3301.18","78.45","","2085.51","998.68","6202.11","56","2104","3301.18","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","AETNA [1001]","HB CH AETNA HMO / PPO","2453.26","58.3","","1634.24","1004.95","1718.99","42","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","2123.89","1900.92","2123.89","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2453.26","58.3","","3729.00","1254.19","3729.00","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2230.24","53","","939.37","939.37","5593.65","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3576.80","85","","2323.25","1864.50","2882.25","16","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4208.00","100","","2909.44","1772.40","10952.08","45","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4208.00","100","","2323.25","2323.25","2323.25","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4208.00","100","","2882.25","1772.40","10169.17","187","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3071.84","73","","1659.41","1659.41","1659.41","1 through 10","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","both","","","4208.00","3156.00","WELLPOINT [1015]","HB CH WELLPOINT","3278.45","77.91","","2050.91","1468.48","2902.83","52","1870.46","4208","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2495.34","59.3","","1548.60","1092.60","3613.79","82","2104","3301.18","percent of total billed charges",""
"SHOULDER HEAD 9X115MM IMPLANT HUMERAL HD MRS PROXIMALIMAL WITHOUT BODY ONC 13B","SUP-ITM-10025233","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4208.00","3156.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3301.18","78.45","","2085.51","998.68","6202.11","56","2104","3301.18","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","AETNA [1001]","HB CH AETNA HMO / PPO","3036.66","58.3","","1634.24","1004.95","1718.99","42","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3802.34","73","","2123.89","1900.92","2123.89","1 through 10","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3036.66","58.3","","3729.00","1254.19","3729.00","1 through 10","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2760.60","53","","939.37","939.37","5593.65","1 through 10","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4427.38","85","","2323.25","1864.50","2882.25","16","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5208.68","100","","2909.44","1772.40","10952.08","45","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5208.68","100","","2323.25","2323.25","2323.25","1 through 10","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5208.68","100","","2882.25","1772.40","10169.17","187","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3802.34","73","","1659.41","1659.41","1659.41","1 through 10","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","both","","","5208.68","3906.51","WELLPOINT [1015]","HB CH WELLPOINT","4058.08","77.91","","2050.91","1468.48","2902.83","52","2315.26","5208.68","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","3088.75","59.3","","1548.60","1092.60","3613.79","82","2604.34","4086.21","percent of total billed charges",""
"SHOULDER HUMERAL 10MM STEM ALTIVATE ANATOMIC SHORT","SUP-ITM-10208204","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5208.68","3906.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4086.21","78.45","","2085.51","998.68","6202.11","56","2604.34","4086.21","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","AETNA [1001]","HB CH AETNA HMO / PPO","2112.79","58.3","","1634.24","1004.95","1718.99","42","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","2123.89","1900.92","2123.89","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2112.79","58.3","","3729.00","1254.19","3729.00","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1920.72","53","","939.37","939.37","5593.65","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3080.40","85","","2323.25","1864.50","2882.25","16","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.00","100","","2909.44","1772.40","10952.08","45","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.00","100","","2323.25","2323.25","2323.25","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.00","100","","2882.25","1772.40","10169.17","187","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2645.52","73","","1659.41","1659.41","1659.41","1 through 10","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","both","","","3624.00","2718.00","WELLPOINT [1015]","HB CH WELLPOINT","2823.46","77.91","","2050.91","1468.48","2902.83","52","1610.87","3624","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.03","59.3","","1548.60","1092.60","3613.79","82","1812","2843.03","percent of total billed charges",""
"SHOULDER IMPLANT 23.1X38MM COMPONENT GLENOID GLENOSPHERE REVERSE EQUINOXE","SUP-ITM-10170081","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3624.00","2718.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.03","78.45","","2085.51","998.68","6202.11","56","1812","2843.03","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","AETNA [1001]","HB CH AETNA HMO / PPO","2215.40","58.3","","1634.24","1004.95","1718.99","42","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2774.00","73","","2123.89","1900.92","2123.89","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2215.40","58.3","","3729.00","1254.19","3729.00","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2014.00","53","","939.37","939.37","5593.65","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3230.00","85","","2323.25","1864.50","2882.25","16","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3800.00","100","","2909.44","1772.40","10952.08","45","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3800.00","100","","2323.25","2323.25","2323.25","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3800.00","100","","2882.25","1772.40","10169.17","187","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2774.00","73","","1659.41","1659.41","1659.41","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","WELLPOINT [1015]","HB CH WELLPOINT","2960.58","77.91","","2050.91","1468.48","2902.83","52","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2253.40","59.3","","1548.60","1092.60","3613.79","82","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 30MM MD COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113811","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2981.10","78.45","","2085.51","998.68","6202.11","56","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","AETNA [1001]","HB CH AETNA HMO / PPO","2255.16","58.3","","1634.24","1004.95","1718.99","42","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2823.79","73","","2123.89","1900.92","2123.89","1 through 10","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2255.16","58.3","","3729.00","1254.19","3729.00","1 through 10","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2050.15","53","","939.37","939.37","5593.65","1 through 10","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3287.97","85","","2323.25","1864.50","2882.25","16","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3868.20","100","","2909.44","1772.40","10952.08","45","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3868.20","100","","2323.25","2323.25","2323.25","1 through 10","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3868.20","100","","2882.25","1772.40","10169.17","187","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2823.79","73","","1659.41","1659.41","1659.41","1 through 10","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","both","","","3868.20","2901.15","WELLPOINT [1015]","HB CH WELLPOINT","3013.71","77.91","","2050.91","1468.48","2902.83","52","1719.41","3868.2","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3868.20","2901.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","2293.84","59.3","","1548.60","1092.60","3613.79","82","1934.1","3034.6","percent of total billed charges",""
"SHOULDER IMPLANT 436 HUMERAL HEAD 0 36/+4 TIH","SUP-ITM-10021702","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3868.20","2901.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3034.60","78.45","","2085.51","998.68","6202.11","56","1934.1","3034.6","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","AETNA [1001]","HB CH AETNA HMO / PPO","2681.80","58.3","","1634.24","1004.95","1718.99","42","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3358.00","73","","2123.89","1900.92","2123.89","1 through 10","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2681.80","58.3","","3729.00","1254.19","3729.00","1 through 10","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2438.00","53","","939.37","939.37","5593.65","1 through 10","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3910.00","85","","2323.25","1864.50","2882.25","16","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4600.00","100","","2909.44","1772.40","10952.08","45","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4600.00","100","","2323.25","2323.25","2323.25","1 through 10","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4600.00","100","","2882.25","1772.40","10169.17","187","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3358.00","73","","1659.41","1659.41","1659.41","1 through 10","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","both","","","4600.00","3450.00","WELLPOINT [1015]","HB CH WELLPOINT","3583.86","77.91","","2050.91","1468.48","2902.83","52","2044.7","4600","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2727.80","59.3","","1548.60","1092.60","3613.79","82","2300","3608.7","percent of total billed charges",""
"SHOULDER IMPLANT 45/24 GLENOSPHERE","SUP-ITM-10285935","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4600.00","3450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3608.70","78.45","","2085.51","998.68","6202.11","56","2300","3608.7","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","AETNA [1001]","HB CH AETNA HMO / PPO","2215.40","58.3","","1634.24","1004.95","1718.99","42","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2774.00","73","","2123.89","1900.92","2123.89","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2215.40","58.3","","3729.00","1254.19","3729.00","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2014.00","53","","939.37","939.37","5593.65","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3230.00","85","","2323.25","1864.50","2882.25","16","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3800.00","100","","2909.44","1772.40","10952.08","45","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3800.00","100","","2323.25","2323.25","2323.25","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3800.00","100","","2882.25","1772.40","10169.17","187","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2774.00","73","","1659.41","1659.41","1659.41","1 through 10","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","both","","","3800.00","2850.00","WELLPOINT [1015]","HB CH WELLPOINT","2960.58","77.91","","2050.91","1468.48","2902.83","52","1689.1","3800","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2253.40","59.3","","1548.60","1092.60","3613.79","82","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT 50MM LG COMPONENT GLENOID AEQUALIS PERFORM CORTILOC","SUP-ITM-10113673","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3800.00","2850.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2981.10","78.45","","2085.51","998.68","6202.11","56","1900","2981.1","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB CH AETNA HMO / PPO","8.75","58.3","","1634.24","1004.95","1718.99","42","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","2123.89","1900.92","2123.89","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8.75","58.3","","3729.00","1254.19","3729.00","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.95","53","","939.37","939.37","5593.65","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","12.75","85","","2323.25","1864.50","2882.25","16","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","15.00","100","","2909.44","1772.40","10952.08","45","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","15.00","100","","2323.25","2323.25","2323.25","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15.00","100","","2882.25","1772.40","10169.17","187","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","1659.41","1659.41","1659.41","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","WELLPOINT [1015]","HB CH WELLPOINT","11.69","77.91","","2050.91","1468.48","2902.83","52","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.90","59.3","","1548.60","1092.60","3613.79","82","7.5","11.77","percent of total billed charges",""
"SHOULDER IMPLANT MEDIUM PROSTHESIS GLENOID UNIVERS II POLYETHYLENE PEGGED","SUP-ITM-10135859","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","2085.51","998.68","6202.11","56","7.5","11.77","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","AETNA [1001]","HB CH AETNA HMO / PPO","8.75","58.3","","1634.24","1004.95","1718.99","42","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","2123.89","1900.92","2123.89","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","8.75","58.3","","3729.00","1254.19","3729.00","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7.95","53","","939.37","939.37","5593.65","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","12.75","85","","2323.25","1864.50","2882.25","16","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","15.00","100","","2909.44","1772.40","10952.08","45","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","15.00","100","","2323.25","2323.25","2323.25","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","15.00","100","","2882.25","1772.40","10169.17","187","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","10.95","73","","1659.41","1659.41","1659.41","1 through 10","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","both","","","15.00","11.25","WELLPOINT [1015]","HB CH WELLPOINT","11.69","77.91","","2050.91","1468.48","2902.83","52","6.67","15","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","8.90","59.3","","1548.60","1092.60","3613.79","82","7.5","11.77","percent of total billed charges",""
"SHOULDER IMPLANT SM GLENOID UNIVERSAL POLYETHYLENE PEGGED","SUP-ITM-10135858","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","15.00","11.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","11.77","78.45","","2085.51","998.68","6202.11","56","7.5","11.77","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","AETNA [1001]","HB CH AETNA HMO / PPO","1896.21","58.3","","1634.24","1004.95","1718.99","42","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2374.33","73","","2123.89","1900.92","2123.89","1 through 10","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1896.21","58.3","","3729.00","1254.19","3729.00","1 through 10","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1723.83","53","","939.37","939.37","5593.65","1 through 10","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2764.63","85","","2323.25","1864.50","2882.25","16","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3252.50","100","","2909.44","1772.40","10952.08","45","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3252.50","100","","2323.25","2323.25","2323.25","1 through 10","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3252.50","100","","2882.25","1772.40","10169.17","187","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2374.33","73","","1659.41","1659.41","1659.41","1 through 10","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","both","","","3252.50","2439.37","WELLPOINT [1015]","HB CH WELLPOINT","2534.02","77.91","","2050.91","1468.48","2902.83","52","1445.74","3252.5","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3252.50","2439.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1928.73","59.3","","1548.60","1092.60","3613.79","82","1626.25","2551.59","percent of total billed charges",""
"SHOULDER IMPLANT SZ1 CENTERED GLOBAL UNITE REVERSE EPIPHYSIS STEM CUP FX RSA","SUP-ITM-10273843","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3252.50","2439.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2551.59","78.45","","2085.51","998.68","6202.11","56","1626.25","2551.59","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","AETNA [1001]","HB CH AETNA HMO / PPO","1049.40","58.3","","1634.24","1004.95","1718.99","42","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","2123.89","1900.92","2123.89","1 through 10","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1049.40","58.3","","3729.00","1254.19","3729.00","1 through 10","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","954.00","53","","939.37","939.37","5593.65","1 through 10","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1530.00","85","","2323.25","1864.50","2882.25","16","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","2909.44","1772.40","10952.08","45","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1800.00","100","","2323.25","2323.25","2323.25","1 through 10","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1800.00","100","","2882.25","1772.40","10169.17","187","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1314.00","73","","1659.41","1659.41","1659.41","1 through 10","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","WELLPOINT [1015]","HB CH WELLPOINT","1402.38","77.91","","2050.91","1468.48","2902.83","52","800.1","1800","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1067.40","59.3","","1548.60","1092.60","3613.79","82","900","1412.1","percent of total billed charges",""
"SHOULDER INSERT 12.5DEG 39MM FLEX PLUS 6MM AEQUALIS ASCEND REVERSED","SUP-ITM-10216743","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","2085.51","998.68","6202.11","56","900","1412.1","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","AETNA [1001]","HB CH AETNA HMO / PPO","1163.52","58.3","","1634.24","1004.95","1718.99","42","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1456.90","73","","2123.89","1900.92","2123.89","1 through 10","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1163.52","58.3","","3729.00","1254.19","3729.00","1 through 10","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1057.75","53","","939.37","939.37","5593.65","1 through 10","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1696.39","85","","2323.25","1864.50","2882.25","16","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1995.75","100","","2909.44","1772.40","10952.08","45","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1995.75","100","","2323.25","2323.25","2323.25","1 through 10","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1995.75","100","","2882.25","1772.40","10169.17","187","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1456.90","73","","1659.41","1659.41","1659.41","1 through 10","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","both","","","1995.75","1496.81","WELLPOINT [1015]","HB CH WELLPOINT","1554.89","77.91","","2050.91","1468.48","2902.83","52","887.11","1995.75","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","1183.48","59.3","","1548.60","1092.60","3613.79","82","997.88","1565.67","percent of total billed charges",""
"SHOULDER INSERT 36MM 6 PLUS UNIVERS REVERS IMPLANTABLE","SUP-ITM-10126760","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1995.75","1496.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1565.67","78.45","","2085.51","998.68","6202.11","56","997.88","1565.67","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","AETNA [1001]","HB CH AETNA HMO / PPO","1932.65","58.3","","1634.24","1004.95","1718.99","42","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2419.95","73","","2123.89","1900.92","2123.89","1 through 10","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1932.65","58.3","","3729.00","1254.19","3729.00","1 through 10","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1756.95","53","","939.37","939.37","5593.65","1 through 10","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2817.75","85","","2323.25","1864.50","2882.25","16","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3315.00","100","","2909.44","1772.40","10952.08","45","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3315.00","100","","2323.25","2323.25","2323.25","1 through 10","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3315.00","100","","2882.25","1772.40","10169.17","187","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2419.95","73","","1659.41","1659.41","1659.41","1 through 10","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","both","","","3315.00","2486.25","WELLPOINT [1015]","HB CH WELLPOINT","2582.72","77.91","","2050.91","1468.48","2902.83","52","1473.52","3315","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1965.80","59.3","","1548.60","1092.60","3613.79","82","1657.5","2600.62","percent of total billed charges",""
"SHOULDER INSERT 36MMX9 AEQUALIS CONSTRAINED REVERSED FRACTURE LATERALIZED","SUP-ITM-10136281","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3315.00","2486.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2600.62","78.45","","2085.51","998.68","6202.11","56","1657.5","2600.62","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","AETNA [1001]","HB CH AETNA HMO / PPO","1226.05","58.3","","1634.24","1004.95","1718.99","42","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1535.19","73","","2123.89","1900.92","2123.89","1 through 10","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1226.05","58.3","","3729.00","1254.19","3729.00","1 through 10","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1114.59","53","","939.37","939.37","5593.65","1 through 10","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1787.55","85","","2323.25","1864.50","2882.25","16","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2103.00","100","","2909.44","1772.40","10952.08","45","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2103.00","100","","2323.25","2323.25","2323.25","1 through 10","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2103.00","100","","2882.25","1772.40","10169.17","187","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1535.19","73","","1659.41","1659.41","1659.41","1 through 10","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","both","","","2103.00","1577.25","WELLPOINT [1015]","HB CH WELLPOINT","1638.45","77.91","","2050.91","1468.48","2902.83","52","934.78","2103","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2103.00","1577.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1247.08","59.3","","1548.60","1092.60","3613.79","82","1051.5","1649.8","percent of total billed charges",""
"SHOULDER INSERT DIAMETER 36MM 6 2 AEQUALIS REVERSED ECCENTRIC LATERALIZD + REVERSE 04","SUP-ITM-10123466","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2103.00","1577.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1649.80","78.45","","2085.51","998.68","6202.11","56","1051.5","1649.8","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"SHOULDER INSERT SZ 1/2 36MM PLUS 0 REVERSED PERFORM","SUP-ITM-10282977","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","AETNA [1001]","HB CH AETNA HMO / PPO","4698.69","58.3","","1634.24","1004.95","1718.99","42","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5883.44","73","","2123.89","1900.92","2123.89","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4698.69","58.3","","3729.00","1254.19","3729.00","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4271.54","53","","939.37","939.37","5593.65","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6850.58","85","","2323.25","1864.50","2882.25","16","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8059.50","100","","2909.44","1772.40","10952.08","45","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8059.50","100","","2323.25","2323.25","2323.25","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8059.50","100","","2882.25","1772.40","10169.17","187","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5883.44","73","","1659.41","1659.41","1659.41","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","WELLPOINT [1015]","HB CH WELLPOINT","6279.16","77.91","","2050.91","1468.48","2902.83","52","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8059.50","6044.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","4779.28","59.3","","1548.60","1092.60","3613.79","82","4029.75","6322.68","percent of total billed charges",""
"SHOULDER KIT 11MM 125 46 22 .8G IMPLANT INTERSPACE GENTAMICIN BASE STEM HEAD","SUP-ITM-10049199","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8059.50","6044.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6322.68","78.45","","2085.51","998.68","6202.11","56","4029.75","6322.68","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","AETNA [1001]","HB CH AETNA HMO / PPO","4698.69","58.3","","1634.24","1004.95","1718.99","42","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5883.44","73","","2123.89","1900.92","2123.89","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4698.69","58.3","","3729.00","1254.19","3729.00","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4271.54","53","","939.37","939.37","5593.65","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6850.58","85","","2323.25","1864.50","2882.25","16","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8059.50","100","","2909.44","1772.40","10952.08","45","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8059.50","100","","2323.25","2323.25","2323.25","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8059.50","100","","2882.25","1772.40","10169.17","187","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5883.44","73","","1659.41","1659.41","1659.41","1 through 10","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","both","","","8059.50","6044.62","WELLPOINT [1015]","HB CH WELLPOINT","6279.16","77.91","","2050.91","1468.48","2902.83","52","3582.45","8059.5","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8059.50","6044.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","4779.28","59.3","","1548.60","1092.60","3613.79","82","4029.75","6322.68","percent of total billed charges",""
"SHOULDER KIT 41MM SMALL CEMENT SPACER CEMEX INTERSPACE","SUP-ITM-10173792","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8059.50","6044.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6322.68","78.45","","2085.51","998.68","6202.11","56","4029.75","6322.68","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","AETNA [1001]","HB CH AETNA HMO / PPO","2170.21","58.3","","554.95","91.85","1421.75","94","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2717.42","73","","2490.03","2490.03","2490.03","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2170.21","58.3","","750.00","750.00","750.00","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1972.92","53","","1192.50","120.84","4149.90","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3164.12","85","","750.00","75.00","750.00","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3722.49","100","","657.00","121.50","1971.00","14","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3722.49","100","","75.00","75.00","75.00","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3722.49","100","","366.00","144.00","1971.00","45","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2717.42","73","","667.50","667.50","667.50","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1654.65","44.45","","123.77","123.77","123.77","1 through 10","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","both","","","3722.49","2791.87","WELLPOINT [1015]","HB CH WELLPOINT","2900.19","77.91","","483.51","229.32","1316.08","96","1654.65","3722.49","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3722.49","2791.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","2207.44","59.3","","439.50","225.34","1872.27","197","1861.25","2920.29","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 109 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090934","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3722.49","2791.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2920.29","78.45","","385.32","55.36","1815.62","58","1861.25","2920.29","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","AETNA [1001]","HB CH AETNA HMO / PPO","2009.21","58.3","","554.95","91.85","1421.75","94","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2515.82","73","","2490.03","2490.03","2490.03","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2009.21","58.3","","750.00","750.00","750.00","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1826.55","53","","1192.50","120.84","4149.90","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2929.38","85","","750.00","75.00","750.00","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3446.33","100","","657.00","121.50","1971.00","14","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3446.33","100","","75.00","75.00","75.00","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3446.33","100","","366.00","144.00","1971.00","45","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2515.82","73","","667.50","667.50","667.50","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1531.89","44.45","","123.77","123.77","123.77","1 through 10","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","both","","","3446.33","2584.75","WELLPOINT [1015]","HB CH WELLPOINT","2685.04","77.91","","483.51","229.32","1316.08","96","1531.89","3446.33","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3446.33","2584.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2043.67","59.3","","439.50","225.34","1872.27","197","1723.17","2703.65","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 199 8 HOLE LCP STAINLESS PROXIMAL PERIARTICULAR HUMERUS RIGHT","SUP-ITM-10090918","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3446.33","2584.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2703.65","78.45","","385.32","55.36","1815.62","58","1723.17","2703.65","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","AETNA [1001]","HB CH AETNA HMO / PPO","2080.57","58.3","","554.95","91.85","1421.75","94","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2605.17","73","","2490.03","2490.03","2490.03","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2080.57","58.3","","750.00","750.00","750.00","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1891.43","53","","1192.50","120.84","4149.90","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3033.42","85","","750.00","75.00","750.00","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3568.73","100","","657.00","121.50","1971.00","14","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3568.73","100","","75.00","75.00","75.00","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3568.73","100","","366.00","144.00","1971.00","45","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2605.17","73","","667.50","667.50","667.50","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1586.30","44.45","","123.77","123.77","123.77","1 through 10","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","both","","","3568.73","2676.55","WELLPOINT [1015]","HB CH WELLPOINT","2780.40","77.91","","483.51","229.32","1316.08","96","1586.3","3568.73","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.73","2676.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","2116.26","59.3","","439.50","225.34","1872.27","197","1784.37","2799.67","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 232 LONG 10 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10017864","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3568.73","2676.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2799.67","78.45","","385.32","55.36","1815.62","58","1784.37","2799.67","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","AETNA [1001]","HB CH AETNA HMO / PPO","2473.69","58.3","","554.95","91.85","1421.75","94","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3097.41","73","","2490.03","2490.03","2490.03","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2473.69","58.3","","750.00","750.00","750.00","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2248.81","53","","1192.50","120.84","4149.90","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3606.58","85","","750.00","75.00","750.00","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4243.03","100","","657.00","121.50","1971.00","14","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4243.03","100","","75.00","75.00","75.00","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4243.03","100","","366.00","144.00","1971.00","45","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3097.41","73","","667.50","667.50","667.50","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1886.03","44.45","","123.77","123.77","123.77","1 through 10","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","both","","","4243.03","3182.27","WELLPOINT [1015]","HB CH WELLPOINT","3305.74","77.91","","483.51","229.32","1316.08","96","1886.03","4243.03","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.03","3182.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","2516.12","59.3","","439.50","225.34","1872.27","197","2121.52","3328.66","percent of total billed charges",""
"SHOULDER PLATE 3.5MM 268 LONG 12 HOLE SHAFT HUMERAL LCP STAINLESS PROXIMAL","SUP-ITM-10021539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4243.03","3182.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3328.66","78.45","","385.32","55.36","1815.62","58","2121.52","3328.66","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","AETNA [1001]","HB CH AETNA HMO / PPO","2380.30","58.3","","554.95","91.85","1421.75","94","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2980.48","73","","2490.03","2490.03","2490.03","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2380.30","58.3","","750.00","750.00","750.00","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2163.91","53","","1192.50","120.84","4149.90","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3470.42","85","","750.00","75.00","750.00","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4082.85","100","","657.00","121.50","1971.00","14","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4082.85","100","","75.00","75.00","75.00","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4082.85","100","","366.00","144.00","1971.00","45","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2980.48","73","","667.50","667.50","667.50","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1814.83","44.45","","123.77","123.77","123.77","1 through 10","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","both","","","4082.85","3062.14","WELLPOINT [1015]","HB CH WELLPOINT","3180.95","77.91","","483.51","229.32","1316.08","96","1814.83","4082.85","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4082.85","3062.14","CIGNA [1006]","HB CH CIGNA HMO / PPO","2421.13","59.3","","439.50","225.34","1872.27","197","2041.43","3203","percent of total billed charges",""
"SHOULDER PLATE 3.5X232MM LONG 10 HOLE SHAFT HUMERUS LCP STAINLESS LOCKING COMPRESSION PROXIMAL","SUP-ITM-10038034","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4082.85","3062.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3203.00","78.45","","385.32","55.36","1815.62","58","2041.43","3203","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","AETNA [1001]","HB CH AETNA HMO / PPO","2113.32","58.3","","554.95","91.85","1421.75","94","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2646.18","73","","2490.03","2490.03","2490.03","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2113.32","58.3","","750.00","750.00","750.00","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1921.20","53","","1192.50","120.84","4149.90","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3081.17","85","","750.00","75.00","750.00","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3624.90","100","","657.00","121.50","1971.00","14","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3624.90","100","","75.00","75.00","75.00","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3624.90","100","","366.00","144.00","1971.00","45","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2646.18","73","","667.50","667.50","667.50","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1611.27","44.45","","123.77","123.77","123.77","1 through 10","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","both","","","3624.90","2718.67","WELLPOINT [1015]","HB CH WELLPOINT","2824.16","77.91","","483.51","229.32","1316.08","96","1611.27","3624.9","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3624.90","2718.67","CIGNA [1006]","HB CH CIGNA HMO / PPO","2149.57","59.3","","439.50","225.34","1872.27","197","1812.45","2843.73","percent of total billed charges",""
"SHOULDER PLATE 3.5X235MM 10 HOLE LCP STAINLESS HUMERAL PROXIMAL PERIARTICULAR RIGHT","SUP-ITM-10090942","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3624.90","2718.67","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2843.73","78.45","","385.32","55.36","1815.62","58","1812.45","2843.73","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","AETNA [1001]","HB CH AETNA HMO / PPO","2012.81","58.3","","554.95","91.85","1421.75","94","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2520.33","73","","2490.03","2490.03","2490.03","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2012.81","58.3","","750.00","750.00","750.00","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1829.83","53","","1192.50","120.84","4149.90","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2934.63","85","","750.00","75.00","750.00","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3452.50","100","","657.00","121.50","1971.00","14","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3452.50","100","","75.00","75.00","75.00","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3452.50","100","","366.00","144.00","1971.00","45","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2520.33","73","","667.50","667.50","667.50","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1534.64","44.45","","123.77","123.77","123.77","1 through 10","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","both","","","3452.50","2589.37","WELLPOINT [1015]","HB CH WELLPOINT","2689.84","77.91","","483.51","229.32","1316.08","96","1534.64","3452.5","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2047.33","59.3","","439.50","225.34","1872.27","197","1726.25","2708.49","percent of total billed charges",""
"SHOULDER PLATE 42MM EQUINOXE REVERSE TOTAL REVISION BIPOLAR UNIPOLAR GLENOSPHERE PRESS FIT CEMENT","SUP-ITM-10170080","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3452.50","2589.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2708.49","78.45","","385.32","55.36","1815.62","58","1726.25","2708.49","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","AETNA [1001]","HB CH AETNA HMO / PPO","1390.19","58.3","","1634.24","1004.95","1718.99","42","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1740.72","73","","2123.89","1900.92","2123.89","1 through 10","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1390.19","58.3","","3729.00","1254.19","3729.00","1 through 10","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1263.81","53","","939.37","939.37","5593.65","1 through 10","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2026.87","85","","2323.25","1864.50","2882.25","16","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2384.55","100","","2909.44","1772.40","10952.08","45","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2384.55","100","","2323.25","2323.25","2323.25","1 through 10","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2384.55","100","","2882.25","1772.40","10169.17","187","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1740.72","73","","1659.41","1659.41","1659.41","1 through 10","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","both","","","2384.55","1788.41","WELLPOINT [1015]","HB CH WELLPOINT","1857.80","77.91","","2050.91","1468.48","2902.83","52","1059.93","2384.55","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2384.55","1788.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","1414.04","59.3","","1548.60","1092.60","3613.79","82","1192.28","1870.68","percent of total billed charges",""
"SHOULDER PLATE MED SOCKET GLENOID REGULAR NON CONSTRAINED CEMENTED PEGGED POLYETHYLENE ANATOMICAL 02","SUP-ITM-10006674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2384.55","1788.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1870.68","78.45","","2085.51","998.68","6202.11","56","1192.28","1870.68","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1634.24","1004.95","1718.99","42","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2123.89","1900.92","2123.89","1 through 10","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","3729.00","1254.19","3729.00","1 through 10","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","939.37","939.37","5593.65","1 through 10","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","2323.25","1864.50","2882.25","16","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","2909.44","1772.40","10952.08","45","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","2323.25","2323.25","2323.25","1 through 10","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","2882.25","1772.40","10169.17","187","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","1659.41","1659.41","1659.41","1 through 10","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","2050.91","1468.48","2902.83","52","1066.8","2400","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1548.60","1092.60","3613.79","82","1200","1882.8","percent of total billed charges",""
"SHOULDER POST 20MM MODULAR UNIVERS REVERS","SUP-ITM-10275309","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","2085.51","998.68","6202.11","56","1200","1882.8","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"SHOULDER POST 25MM DIAMETERX15 BASEPLATE GLENOID HUMERAL AEQUALIS REVERSED II STANDARD","SUP-ITM-10082642","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","1634.24","1004.95","1718.99","42","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","2123.89","1900.92","2123.89","1 through 10","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","3729.00","1254.19","3729.00","1 through 10","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","939.37","939.37","5593.65","1 through 10","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1083.75","85","","2323.25","1864.50","2882.25","16","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1275.00","100","","2909.44","1772.40","10952.08","45","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1275.00","100","","2323.25","2323.25","2323.25","1 through 10","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1275.00","100","","2882.25","1772.40","10169.17","187","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","1659.41","1659.41","1659.41","1 through 10","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","2050.91","1468.48","2902.83","52","566.74","1275","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","1548.60","1092.60","3613.79","82","637.5","1000.24","percent of total billed charges",""
"SHOULDER POST TAPER 10.0MMX31 LG HUMERAL HEAD 05C2","SUP-ITM-10151160","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","2085.51","998.68","6202.11","56","637.5","1000.24","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","AETNA [1001]","HB CH AETNA HMO / PPO","4104.32","58.3","","1634.24","1004.95","1718.99","42","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5139.20","73","","2123.89","1900.92","2123.89","1 through 10","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4104.32","58.3","","3729.00","1254.19","3729.00","1 through 10","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3731.20","53","","939.37","939.37","5593.65","1 through 10","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5984.00","85","","2323.25","1864.50","2882.25","16","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7040.00","100","","2909.44","1772.40","10952.08","45","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7040.00","100","","2323.25","2323.25","2323.25","1 through 10","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7040.00","100","","2882.25","1772.40","10169.17","187","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5139.20","73","","1659.41","1659.41","1659.41","1 through 10","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","both","","","7040.00","5280.00","WELLPOINT [1015]","HB CH WELLPOINT","5484.86","77.91","","2050.91","1468.48","2902.83","52","3129.28","7040","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7040.00","5280.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4174.72","59.3","","1548.60","1092.60","3613.79","82","3520","5522.88","percent of total billed charges",""
"SHOULDER SIMPLICITI SIZE 3 NUCLEUS HUMERAL SYSTEM","SUP-ITM-10152795","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","7040.00","5280.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5522.88","78.45","","2085.51","998.68","6202.11","56","3520","5522.88","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","AETNA [1001]","HB CH AETNA HMO / PPO","857.01","58.3","","1634.24","1004.95","1718.99","42","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","2123.89","1900.92","2123.89","1 through 10","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","857.01","58.3","","3729.00","1254.19","3729.00","1 through 10","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.10","53","","939.37","939.37","5593.65","1 through 10","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1249.50","85","","2323.25","1864.50","2882.25","16","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1470.00","100","","2909.44","1772.40","10952.08","45","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1470.00","100","","2323.25","2323.25","2323.25","1 through 10","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1470.00","100","","2882.25","1772.40","10169.17","187","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","1659.41","1659.41","1659.41","1 through 10","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB CH WELLPOINT","1145.28","77.91","","2050.91","1468.48","2902.83","52","653.42","1470","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","871.71","59.3","","1548.60","1092.60","3613.79","82","735","1153.22","percent of total billed charges",""
"SHOULDER SPACER 33 PLUS 6MM HUMERAL","SUP-ITM-10320350","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","2085.51","998.68","6202.11","56","735","1153.22","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","AETNA [1001]","HB CH AETNA HMO / PPO","567.78","58.3","","1634.24","1004.95","1718.99","42","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","710.94","73","","2123.89","1900.92","2123.89","1 through 10","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","567.78","58.3","","3729.00","1254.19","3729.00","1 through 10","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","516.16","53","","939.37","939.37","5593.65","1 through 10","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","827.81","85","","2323.25","1864.50","2882.25","16","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","973.89","100","","2909.44","1772.40","10952.08","45","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","973.89","100","","2323.25","2323.25","2323.25","1 through 10","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","973.89","100","","2882.25","1772.40","10169.17","187","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","710.94","73","","1659.41","1659.41","1659.41","1 through 10","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","both","","","973.89","730.42","WELLPOINT [1015]","HB CH WELLPOINT","758.76","77.91","","2050.91","1468.48","2902.83","52","432.89","973.89","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","973.89","730.42","CIGNA [1006]","HB CH CIGNA HMO / PPO","577.52","59.3","","1548.60","1092.60","3613.79","82","486.95","764.02","percent of total billed charges",""
"SHOULDER SPACER 36MM 9 PLUS TITANIUM IMPLANTABLE REVERSE 07","SUP-ITM-10130394","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","973.89","730.42","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","764.02","78.45","","2085.51","998.68","6202.11","56","486.95","764.02","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 25X36MM 10DEG GLENOID AEQUALIS REVERSED TILTED","SUP-ITM-10088674","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"SHOULDER SPHERE 29X36MM 10DEG AEQUALIS GLENOID REVERSED TILTED","SUP-ITM-10079586","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","AETNA [1001]","HB CH AETNA HMO / PPO","2726.11","58.3","","1634.24","1004.95","1718.99","42","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3413.48","73","","2123.89","1900.92","2123.89","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2726.11","58.3","","3729.00","1254.19","3729.00","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2478.28","53","","939.37","939.37","5593.65","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3974.60","85","","2323.25","1864.50","2882.25","16","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4676.00","100","","2909.44","1772.40","10952.08","45","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4676.00","100","","2323.25","2323.25","2323.25","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4676.00","100","","2882.25","1772.40","10169.17","187","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3413.48","73","","1659.41","1659.41","1659.41","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","WELLPOINT [1015]","HB CH WELLPOINT","3643.07","77.91","","2050.91","1468.48","2902.83","52","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2772.87","59.3","","1548.60","1092.60","3613.79","82","2338","3668.32","percent of total billed charges",""
"SHOULDER STEM 11X115MM HOW ONC 08","SUP-ITM-10005449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3668.32","78.45","","2085.51","998.68","6202.11","56","2338","3668.32","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","AETNA [1001]","HB CH AETNA HMO / PPO","2726.11","58.3","","1634.24","1004.95","1718.99","42","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3413.48","73","","2123.89","1900.92","2123.89","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2726.11","58.3","","3729.00","1254.19","3729.00","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2478.28","53","","939.37","939.37","5593.65","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3974.60","85","","2323.25","1864.50","2882.25","16","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4676.00","100","","2909.44","1772.40","10952.08","45","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4676.00","100","","2323.25","2323.25","2323.25","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4676.00","100","","2882.25","1772.40","10169.17","187","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3413.48","73","","1659.41","1659.41","1659.41","1 through 10","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","both","","","4676.00","3507.00","WELLPOINT [1015]","HB CH WELLPOINT","3643.07","77.91","","2050.91","1468.48","2902.83","52","2078.48","4676","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2772.87","59.3","","1548.60","1092.60","3613.79","82","2338","3668.32","percent of total billed charges",""
"SHOULDER STEM 11X75MM HUMERAL","SUP-ITM-10035495","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4676.00","3507.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3668.32","78.45","","2085.51","998.68","6202.11","56","2338","3668.32","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","1634.24","1004.95","1718.99","42","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","2123.89","1900.92","2123.89","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","939.37","939.37","5593.65","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3570.00","85","","2323.25","1864.50","2882.25","16","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4200.00","100","","2909.44","1772.40","10952.08","45","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4200.00","100","","2323.25","2323.25","2323.25","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4200.00","100","","2882.25","1772.40","10169.17","187","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","1659.41","1659.41","1659.41","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","2050.91","1468.48","2902.83","52","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1548.60","1092.60","3613.79","82","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 12MM HUMERAL UNIVERS II","SUP-ITM-10135849","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","2085.51","998.68","6202.11","56","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","1634.24","1004.95","1718.99","42","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","2123.89","1900.92","2123.89","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","939.37","939.37","5593.65","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3570.00","85","","2323.25","1864.50","2882.25","16","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4200.00","100","","2909.44","1772.40","10952.08","45","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4200.00","100","","2323.25","2323.25","2323.25","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4200.00","100","","2882.25","1772.40","10169.17","187","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","1659.41","1659.41","1659.41","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","2050.91","1468.48","2902.83","52","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1548.60","1092.60","3613.79","82","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 13MM HUMERAL UNIVERS II","SUP-ITM-10135852","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","2085.51","998.68","6202.11","56","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","1634.24","1004.95","1718.99","42","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","2123.89","1900.92","2123.89","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","3729.00","1254.19","3729.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","939.37","939.37","5593.65","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3570.00","85","","2323.25","1864.50","2882.25","16","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4200.00","100","","2909.44","1772.40","10952.08","45","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4200.00","100","","2323.25","2323.25","2323.25","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4200.00","100","","2882.25","1772.40","10169.17","187","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","1659.41","1659.41","1659.41","1 through 10","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","2050.91","1468.48","2902.83","52","1866.9","4200","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1548.60","1092.60","3613.79","82","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 6.0MM UNIVERS II APEX HUMERAL 14","SUP-ITM-10135833","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","2085.51","998.68","6202.11","56","2100","3294.9","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","AETNA [1001]","HB CH AETNA HMO / PPO","3119.52","58.3","","1634.24","1004.95","1718.99","42","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3906.08","73","","2123.89","1900.92","2123.89","1 through 10","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3119.52","58.3","","3729.00","1254.19","3729.00","1 through 10","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2835.92","53","","939.37","939.37","5593.65","1 through 10","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4548.18","85","","2323.25","1864.50","2882.25","16","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5350.80","100","","2909.44","1772.40","10952.08","45","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5350.80","100","","2323.25","2323.25","2323.25","1 through 10","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5350.80","100","","2882.25","1772.40","10169.17","187","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3906.08","73","","1659.41","1659.41","1659.41","1 through 10","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","both","","","5350.80","4013.10","WELLPOINT [1015]","HB CH WELLPOINT","4168.81","77.91","","2050.91","1468.48","2902.83","52","2378.43","5350.8","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5350.80","4013.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","3173.02","59.3","","1548.60","1092.60","3613.79","82","2675.4","4197.7","percent of total billed charges",""
"SHOULDER STEM 6X75MM COMPREHENSIVE TITANIUM SEGMENTAL REVISION SCREW","SUP-ITM-10122548","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5350.80","4013.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4197.70","78.45","","2085.51","998.68","6202.11","56","2675.4","4197.7","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","AETNA [1001]","HB CH AETNA HMO / PPO","2365.52","58.3","","1634.24","1004.95","1718.99","42","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2961.98","73","","2123.89","1900.92","2123.89","1 through 10","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2365.52","58.3","","3729.00","1254.19","3729.00","1 through 10","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2150.48","53","","939.37","939.37","5593.65","1 through 10","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3448.88","85","","2323.25","1864.50","2882.25","16","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4057.50","100","","2909.44","1772.40","10952.08","45","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4057.50","100","","2323.25","2323.25","2323.25","1 through 10","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4057.50","100","","2882.25","1772.40","10169.17","187","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2961.98","73","","1659.41","1659.41","1659.41","1 through 10","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","both","","","4057.50","3043.12","WELLPOINT [1015]","HB CH WELLPOINT","3161.20","77.91","","2050.91","1468.48","2902.83","52","1803.56","4057.5","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2406.10","59.3","","1548.60","1092.60","3613.79","82","2028.75","3183.11","percent of total billed charges",""
"SHOULDER STEM 7MM HUMERAL CEMENTED","SUP-ITM-10175591","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4057.50","3043.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3183.11","78.45","","2085.51","998.68","6202.11","56","2028.75","3183.11","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"SHOULDER STEM 9MM DIAMETERX180 AEQUALIS CEMENT REVERSED","SUP-ITM-10136090","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","AETNA [1001]","HB CH AETNA HMO / PPO","2273.54","58.3","","1634.24","1004.95","1718.99","42","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2846.80","73","","2123.89","1900.92","2123.89","1 through 10","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.54","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2066.85","53","","939.37","939.37","5593.65","1 through 10","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3314.76","85","","2323.25","1864.50","2882.25","16","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3899.72","100","","2909.44","1772.40","10952.08","45","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3899.72","100","","2323.25","2323.25","2323.25","1 through 10","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3899.72","100","","2882.25","1772.40","10169.17","187","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2846.80","73","","1659.41","1659.41","1659.41","1 through 10","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","both","","","3899.72","2924.79","WELLPOINT [1015]","HB CH WELLPOINT","3038.27","77.91","","2050.91","1468.48","2902.83","52","1733.43","3899.72","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3899.72","2924.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.53","59.3","","1548.60","1092.60","3613.79","82","1949.86","3059.33","percent of total billed charges",""
"SHOULDER STEM SIZE 6 REVERS REVISION REVERSE 02","SUP-ITM-10135885","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3899.72","2924.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.33","78.45","","2085.51","998.68","6202.11","56","1949.86","3059.33","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","AETNA [1001]","HB CH AETNA HMO / PPO","2248.88","58.3","","1634.24","1004.95","1718.99","42","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2815.92","73","","2123.89","1900.92","2123.89","1 through 10","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2248.88","58.3","","3729.00","1254.19","3729.00","1 through 10","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2044.43","53","","939.37","939.37","5593.65","1 through 10","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3278.81","85","","2323.25","1864.50","2882.25","16","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3857.42","100","","2909.44","1772.40","10952.08","45","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3857.42","100","","2323.25","2323.25","2323.25","1 through 10","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3857.42","100","","2882.25","1772.40","10169.17","187","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2815.92","73","","1659.41","1659.41","1659.41","1 through 10","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","both","","","3857.42","2893.06","WELLPOINT [1015]","HB CH WELLPOINT","3005.32","77.91","","2050.91","1468.48","2902.83","52","1714.62","3857.42","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3857.42","2893.06","CIGNA [1006]","HB CH CIGNA HMO / PPO","2287.45","59.3","","1548.60","1092.60","3613.79","82","1928.71","3026.15","percent of total billed charges",""
"SHOULDER STEM SZ 6 UNIVERS REVERS APEX","SUP-ITM-10275275","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3857.42","2893.06","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3026.15","78.45","","2085.51","998.68","6202.11","56","1928.71","3026.15","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","AETNA [1001]","HB CH AETNA HMO / PPO","5247.00","58.3","","1634.24","1004.95","1718.99","42","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","6570.00","73","","2123.89","1900.92","2123.89","1 through 10","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5247.00","58.3","","3729.00","1254.19","3729.00","1 through 10","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4770.00","53","","939.37","939.37","5593.65","1 through 10","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","7650.00","85","","2323.25","1864.50","2882.25","16","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","9000.00","100","","2909.44","1772.40","10952.08","45","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","9000.00","100","","2323.25","2323.25","2323.25","1 through 10","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","9000.00","100","","2882.25","1772.40","10169.17","187","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6570.00","73","","1659.41","1659.41","1659.41","1 through 10","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","both","","","9000.00","6750.00","WELLPOINT [1015]","HB CH WELLPOINT","7011.90","77.91","","2050.91","1468.48","2902.83","52","4000.5","9000","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","5337.00","59.3","","1548.60","1092.60","3613.79","82","4500","7060.5","percent of total billed charges",""
"SHOULDER TRUNION 41MM ECLIPSE TPS CAP SLOTTED","SUP-ITM-10274227","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","9000.00","6750.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7060.50","78.45","","2085.51","998.68","6202.11","56","4500","7060.5","percent of total billed charges",""
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","511","MS-DRG","","","","","","","","inpatient","","","49929.32","37446.99","MEDICARE [2001]","HB BWF MEDICARE","19485.26","","Case rate ($19,485.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $19,516.45, add-ons for qualifying new technology services are included. If operating cost exceeds $65,040.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,030.84, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.5. The base transfer operating payment is the transfer adjustment factor * $17,675.95 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $19,177.21 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,470.05. The transfer capital threshold is the transfer adjustment factor * $1,470.05. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19752.28","19752.28","19752.28","1 through 10","19095.55","20069.82","other","Inpatient Replacement Plans DRG"
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/McC","512","MS-DRG","","","","","","","","inpatient","","","22635.72","16976.79","MEDICARE [2001]","HB BWF MEDICARE","17038.54","","Case rate ($17,038.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,606.12, add-ons for qualifying new technology services are included. If operating cost exceeds $61,129.85 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,731.08, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $15,529.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,266.88 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,170.30. The transfer capital threshold is the transfer adjustment factor * $1,170.30. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","3398.86","3398.86","3398.86","1 through 10","15269.64","17038.54","other","Inpatient DRG"
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MINOR","315","DRG","","","","","","","","inpatient","","","54165.17","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24746.06","","Standard inlier is a Case rate ($24,746.06). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,282, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,512.60) for the length of stay and the standard reimbursement.","24746.05","24746.05","24746.05","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MINOR","315","DRG","","","","","","","","inpatient","","","54165.17","","MASSHEALTH [3001]","HB BWF MEDICAID","10228.75","","Case rate ($11,309.64). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,739.64, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11764.99","11764.99","11764.99","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","55732.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","36870.56","","Standard inlier is a Case rate ($36,870.56). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,282, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,233.92) for the length of stay and the standard reimbursement.","35195.10","35195.10","35195.10","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","55732.48","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","39606.34","","Standard inlier is a Case rate ($39,606.34). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $49,472, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,621.95) for the length of stay and the standard reimbursement.","39606.33","39606.33","39606.33","1 through 10","7010.54","84695.31","case rate",""
"Shoulder, Upper Arm And Forearm Procedures Except Joint Replacement,MODERATE","315","DRG","","","","","","","","inpatient","","","55732.48","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","14102.51","","Case rate ($15,592.75). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $58,022.75, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15588.92","15588.92","15588.92","1 through 10","7010.54","84695.31","case rate",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","AETNA [1001]","HB CH AETNA HMO / PPO","432.31","58.3","","1830.28","315.58","1830.28","1 through 10","329.61","741.53","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","541.32","73","","4170.85","4170.85","4170.85","1 through 10","329.61","741.53","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","329.61","44.45","","649.55","649.55","649.55","1 through 10","329.61","741.53","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","both","","","741.53","556.15","WELLPOINT [1015]","HB CH WELLPOINT","577.73","77.91","","8998.38","2542.37","8998.38","20","329.61","741.53","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","741.53","556.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","439.73","59.3","","1891.61","1609.14","3664.18","25","370.77","581.73","percent of total billed charges",""
"Shunt Carotid / Neuro T1","PX-27000714","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","741.53","556.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","581.73","78.45","","1470.68","1310.06","2481.69","19","370.77","581.73","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","AETNA [1001]","HB CH AETNA HMO / PPO","2391.55","58.3","","1830.28","315.58","1830.28","1 through 10","1823.4","4102.14","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2994.56","73","","4170.85","4170.85","4170.85","1 through 10","1823.4","4102.14","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1823.40","44.45","","649.55","649.55","649.55","1 through 10","1823.4","4102.14","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","both","","","4102.14","3076.60","WELLPOINT [1015]","HB CH WELLPOINT","3195.98","77.91","","8998.38","2542.37","8998.38","20","1823.4","4102.14","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4102.14","3076.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","2432.57","59.3","","1891.61","1609.14","3664.18","25","2051.07","3218.13","percent of total billed charges",""
"Shunt Carotid / Neuro T2","PX-27000715","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4102.14","3076.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3218.13","78.45","","1470.68","1310.06","2481.69","19","2051.07","3218.13","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","AETNA [1001]","HB CH AETNA HMO / PPO","2629.14","58.3","","1830.28","315.58","1830.28","1 through 10","2004.55","4509.68","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3292.07","73","","4170.85","4170.85","4170.85","1 through 10","2004.55","4509.68","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2004.55","44.45","","649.55","649.55","649.55","1 through 10","2004.55","4509.68","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","both","","","4509.68","3382.26","WELLPOINT [1015]","HB CH WELLPOINT","3513.49","77.91","","8998.38","2542.37","8998.38","20","2004.55","4509.68","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4509.68","3382.26","CIGNA [1006]","HB CH CIGNA HMO / PPO","2674.24","59.3","","1891.61","1609.14","3664.18","25","2254.84","3537.84","percent of total billed charges",""
"Shunt Carotid / Neuro T3","PX-27000716","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4509.68","3382.26","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3537.84","78.45","","1470.68","1310.06","2481.69","19","2254.84","3537.84","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","6045.98","4534.48","AETNA [1001]","HB CH AETNA HMO / PPO","3524.81","58.3","","1830.28","315.58","1830.28","1 through 10","2687.44","6045.98","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","6045.98","4534.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4413.57","73","","4170.85","4170.85","4170.85","1 through 10","2687.44","6045.98","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","6045.98","4534.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2687.44","44.45","","649.55","649.55","649.55","1 through 10","2687.44","6045.98","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","both","","","6045.98","4534.48","WELLPOINT [1015]","HB CH WELLPOINT","4710.42","77.91","","8998.38","2542.37","8998.38","20","2687.44","6045.98","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6045.98","4534.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","3585.27","59.3","","1891.61","1609.14","3664.18","25","3022.99","4743.07","percent of total billed charges",""
"SHUNT VALVE HAKIM PROGRAMMABLE IN LINE","SUP-ITM-10016960","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6045.98","4534.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4743.07","78.45","","1470.68","1310.06","2481.69","19","3022.99","4743.07","percent of total billed charges",""
"Sickle Cell Anemia Crisis,MINOR","662","DRG","","","","","","","","inpatient","","","15489.03","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7135.22","","Case rate ($7,889.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,319.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8444.35","8444.35","8444.35","1 through 10","7135.22","20581.35","case rate",""
"Sigmoidoscopy Aspiration/Biopsy","PX-75000191","CDM","45342","CPT","0750","RC","","","","both","","","2620.00","1965.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($1,108). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","979.79","1919.74","per diem",""
"Sigmoidoscopy Flex W/Submucosal Inj","PX-75000185","CDM","45335","CPT","0750","RC","","","","outpatient","","","1552.00","1164.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1230.03","1230.03","1 through 10","689.86","1217.54","other","ASC "
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1065.39","1065.39","1065.39","1 through 10","685.42","2114.51","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","FALLON HEALTH [1008]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1061.06","1061.06","1061.06","1 through 10","685.42","2114.51","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 259%, 129.5 procedures at 0%.","262.32","262.32","262.32","1 through 10","685.42","2114.51","other","Multiple Surgery"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","both","","","1542.00","1156.50","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","685.42","2114.51","other","OPPS APC"
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1230.03","1230.03","1230.03","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1206.18","1206.18","1206.18","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","914.41","59.3","","878.41","878.41","878.41","1 through 10","744.89","1873.9","percent of total billed charges",""
"Sigmoidoscopy Flexible","PX-75000180","CDM","45330","CPT","0750","RC","","","","outpatient","","","1542.00","1156.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","1750.49","1750.49","1 through 10","744.89","1873.9","other","Multiple Surgery"
"Sigmoidoscopy Flx Tndsc Balo Dilat","PX-75000189","CDM","45340","CPT","0750","RC","","","","both","","","2620.00","1965.00","MEDICARE [2001]","HB BWF MEDICARE","1400.09","","APC Price ($1,400.09). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1400.23","1400.23","1400.23","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy Rem Tumor/Polyp Snare","PX-75000187","CDM","45338","CPT","0750","RC","","","","outpatient","","","2532.00","1899.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1120.45","","Case rate ($1,120.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1620.17","1620.17","1620.17","1 through 10","979.79","1986.35","other","ASC "
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1115.19","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","683.64","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","532.70","459.87","532.70","1 through 10","683.64","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","541.36","1082.71","1 through 10","683.64","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","683.64","1459.48","per diem",""
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","both","","","1538.00","1153.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1061.06","1061.06","1061.06","1 through 10","683.64","1459.48","other","OPPS APC"
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1204.47","615.02","1204.47","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","851.82","","Case rate ($851.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1231.73","615.87","1231.73","1 through 10","744.89","1873.9","other","ASC "
"Sigmoidoscopy W/Biopsy","PX-75000181","CDM","45331","CPT","0750","RC","","","","outpatient","","","1538.00","1153.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","744.89","","Case rate ($744.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","1750.49","875.25","1750.49","1 through 10","744.89","1873.9","other","Multiple Surgery"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2620.00","1965.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","1115.19","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","1114.11","1114.11","1114.11","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2620.00","1965.00","MEDICARE [2001]","HB BWF MEDICARE","1082.71","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1082.71","1082.71","1082.71","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","both","","","2620.00","1965.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1061.06","","APC Price ($1,082.71). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1068.46","1068.46","1068.46","1 through 10","979.79","1919.74","other","OPPS APC"
"Sigmoidoscopy W/Ultrasound","PX-75000190","CDM","45341","CPT","0750","RC","","","","outpatient","","","2620.00","1965.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1553.66","59.3","","1493.13","1493.13","1493.13","1 through 10","979.79","2055.39","percent of total billed charges",""
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With McC","555","MS-DRG","","","","","","","","inpatient","","","40783.24","30587.43","MEDICARE [2001]","HB BWF MEDICARE","13673.26","","Case rate ($13,673.26). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,529.50, add-ons for qualifying new technology services are included. If operating cost exceeds $58,053.23 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,495.23, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.8. The base transfer operating payment is the transfer adjustment factor * $12,399.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,190.27 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $934.46. The transfer capital threshold is the transfer adjustment factor * $934.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","13641.03","1 through 10","12259.47","13673.26","other","Inpatient DRG"
"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC","556","MS-DRG","","","","","","","","inpatient","","","20835.25","15626.44","MEDICARE [2001]","HB BWF MEDICARE","8718.14","","Case rate ($8,718.14). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,999.42, add-ons for qualifying new technology services are included. If operating cost exceeds $53,523.15 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,147.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,791.71 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,660.19 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $587.20. The transfer capital threshold is the transfer adjustment factor * $587.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8315.25","0.03","8370.00","1 through 10","7827.21","8718.14","other","Inpatient DRG"
"Signs And Symptoms With McC","947","MS-DRG","","","","","","","","inpatient","","","21126.96","15845.22","MEDICARE [2001]","HB BWF MEDICARE","193.14","","Case rate ($193.14) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","1011.22","728.09","10620.73","1 through 10","193.14","12719.2318","other","Inpatient Psych"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","22745.26","17058.94","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","187.96","","Case rate ($187.96) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7330.78","7330.78","7330.78","1 through 10","187.96","7856.8105","other","Inpatient Psych"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","22745.26","17058.94","MEDICARE [2001]","HB BWF MEDICARE","187.96","","Case rate ($187.96) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","8097.96","0.03","8151.25","1 through 10","187.96","7856.8105","other","Inpatient Psych"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","22745.26","17058.94","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","187.96","","Case rate ($187.96) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7340.81","7340.81","7340.81","1 through 10","187.96","7856.8105","other","Inpatient Psych"
"Signs And Symptoms Without McC","948","MS-DRG","","","","","","","","inpatient","","","22745.26","17058.94","WELLSENSE [1003]","HB BWF MEDICARE","187.96","","Case rate ($187.96) multiplied by an age adjustment factor and a comorbidity factor, if any. Adds a variable per diem by day. The outlier threshold is defined as $7,601.73 plus the variable per diem by day. If the cost, as defined by total billed amount less exclusions * a cost-to-charge ratio of 0.434, exceeds the outlier threshold, then the stay qualifies for an outlier and adds a reimbursement of the excess amount adjusted by a variable per diem by day. Age adjustment factors: Ages 0-44: 1, 45-54: 1.02, 55-59: 1.05, 60-64: 1.06, 65-69: 1.09, 70-79: 1.11, 80-999: 1.13. Comorbidity adjustment factors: Developmental Disabilities: 1.04; Tracheotomy: 1.09; Renal Failure, Acute: 1.06; Renal Failure, Chronic: 1.08; Oncology Treatment: 1.44; Uncontrolled Diabetes: 1.05; Protein Calorie Malnutrition: 1.17; Eating Disorders: 1.09; Cardiac Conditions: 1.04; Gangrene: 1.12; Chronic Obstructive Pulmonary Disease and Sleep Apnea: 1.09; Artificial Openings - Digestive and Urinary: 1.07; Musculoskeletal and Connective Tissue Diseases, Severe: 1.05; Poisoning: 1.16. Day adjustment factors: Days 1: 1.28, 2: 1.2, 3: 1.15, 4: 1.12, 5: 1.08, 6: 1.06, 7: 1.03, 8: 1.02, 9: 1.01, 10-9999: 1. The ED day 1 adjustment factor is 1.54, and is used as the day adjustment factor for day 1 unless the inpatient psychiatric facility is a separate unit in an acute care hospital, and the patient is transferred from a different unit in that hospital. Outlier day adjustment factors: Days 1-9: 0.8, 10-9999: 0.6.","7364.30","7364.30","7364.30","1 through 10","187.96","7856.8105","other","Inpatient Psych"
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","35270.29","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7924.281","","Fee schedule rate ($16,027.95). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7924.281","18856.08","18856.08","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","35270.29","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9301.14","","Case rate ($10,284.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,714.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,391.63 and the sum of the standard inlier and any outlier amount.","3325.52","3325.52","10281.49","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MAJOR","861","DRG","","","","","","","","inpatient","","","35270.29","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","9301.14","","Case rate ($10,284.01). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,714.01, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $2,391.63 and the sum of the standard inlier and any outlier amount.","10281.49","10281.49","10281.49","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MINOR","861","DRG","","","","","","","","inpatient","","","20442.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","8921.96","","Standard inlier is a Case rate ($8,921.96). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $20,168, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,266.43) for the length of stay and the standard reimbursement.","8921.95","8921.95","8921.95","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","15045.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","14395.21","","Standard inlier is a Case rate ($14,395.21). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $20,168, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,043.46) for the length of stay and the standard reimbursement.","14395.20","14395.20","14395.20","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","15045.56","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15463.32","","Standard inlier is a Case rate ($15,463.32). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,194.95) for the length of stay and the standard reimbursement.","2194.95","2194.95","2194.95","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","15045.56","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","7924.281","","Fee schedule rate ($11,727.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7924.281","11727.16","11727.16","1 through 10","4767.09","26445.98","case rate",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","15045.56","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","9524.63","9524.63","9524.63","1 through 10","4767.09","26445.98","percent of total billed charges",""
"Signs, Symptoms And Other Factors Influencing Health Status,MODERATE","861","DRG","","","","","","","","inpatient","","","15045.56","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6144.79","","Case rate ($6,794.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,224.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6792.45","6792.45","6792.45","1 through 10","4767.09","26445.98","case rate",""
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","7992.33","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","7959.77","7959.77","7959.77","1 through 10","7604.35","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","7759.54","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7600.54","7600.54","7600.54","1 through 10","7604.35","8272.56","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","ELDER SERVICES [1037]","HB BWF MEDICARE","7759.54","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13820.52","13820.52","13820.52","1 through 10","7604.35","8272.56","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","GENERIC MEDICARE REPLACEMENT [1010]","HB BWF MEDICARE","7759.54","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7558.19","7558.19","7558.19","1 through 10","7604.35","8272.56","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","HUMANA [1012]","HB BWF MEDICARE","7759.54","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7611.59","7611.59","7611.59","1 through 10","7604.35","8272.56","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","MEDICARE [2001]","HB BWF MEDICARE","7759.54","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8349.83","6036.05","8404.82","43","7604.35","8272.56","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","7759.54","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7567.16","7567.16","7567.16","1 through 10","7604.35","8272.56","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7604.35","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14534.34","14534.34","14534.34","1 through 10","7604.35","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With Cc","194","MS-DRG","","","","","","","","inpatient","","","21483.68","16112.76","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7604.35","","Case rate ($7,759.54). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,771.63, add-ons for qualifying new technology services are included. If operating cost exceeds $53,295.36 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,130.52, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.8. The base transfer operating payment is the transfer adjustment factor * $6,850.56 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,432.39 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $569.74. The transfer capital threshold is the transfer adjustment factor * $569.74. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7558.19","7537.56","12002.58","1 through 10","7604.35","8272.56","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","12814.78","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","12645.54","12635.51","12645.54","1 through 10","12192.7","13030.7353","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","12441.53","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12063.70","12063.70","12063.70","1 through 10","12192.7","13030.7353","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12192.70","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12171.10","11996.23","58663.54","1 through 10","12192.7","13030.7353","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","FALLON HEALTH [1008]","HB BWF MEDICARE","12441.53","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","11996.20","11996.20","11996.20","1 through 10","12192.7","13030.7353","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","MEDICARE [2001]","HB BWF MEDICARE","12441.53","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13265.32","10011.79","13353.67","75","12192.7","13030.7353","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12192.70","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9037.87","9037.87","9037.87","1 through 10","12192.7","13030.7353","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12192.70","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13524.52","13524.52","13632.01","1 through 10","12192.7","13030.7353","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy With McC","193","MS-DRG","","","","","","","","inpatient","","","30935.00","23201.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","12192.70","","Case rate ($12,441.53). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,461.25, add-ons for qualifying new technology services are included. If operating cost exceeds $57,984.98 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,490.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,173.07 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,122.02 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $929.23. The transfer capital threshold is the transfer adjustment factor * $929.23. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11996.23","11970.08","12035.73","14","12192.7","13030.7353","other","Inpatient DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","18986.35","14239.76","MEDICARE [2001]","HB BWF MEDICARE","6126.12","","Case rate ($6,126.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,135.57, add-ons for qualifying new technology services are included. If operating cost exceeds $51,659.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,005.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,342.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,796.32 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.32. The transfer capital threshold is the transfer adjustment factor * $444.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","6442.95","6442.95","6442.95","1 through 10","6003.6","6309.9","other","Inpatient Replacement Plans DRG"
"Simple Pneumonia And Pleurisy Without Cc/McC","195","MS-DRG","","","","","","","","inpatient","","","18986.35","14239.76","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6003.60","","Case rate ($6,126.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $6,135.57, add-ons for qualifying new technology services are included. If operating cost exceeds $51,659.30 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,005.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.2. The base transfer operating payment is the transfer adjustment factor * $5,342.57 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $5,796.32 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $444.32. The transfer capital threshold is the transfer adjustment factor * $444.32. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","5828.82","5828.82","5828.82","1 through 10","6003.6","6309.9","other","Inpatient DRG"
"Sincalide Injection","PX-63601059","CDM","J2805","HCPCS","0636","RC","","","","outpatient","","","181.00","135.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.48","52.2","","74.55","74.55","74.55","1 through 10","90.5","292.34","percent of total billed charges",""
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","69579.31","52184.48","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","40897.16","","Case rate ($40,897.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $37,418.19, add-ons for qualifying new technology services are included. If operating cost exceeds $82,941.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,403.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $37,715.59 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $37,078.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,842.33. The transfer capital threshold is the transfer adjustment factor * $2,842.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","35330.14","35330.14","35330.14","1 through 10","36610.7","40897.16","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","69579.31","52184.48","MEDICARE [2001]","HB BWF MEDICARE","40897.16","","Case rate ($40,897.16). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $37,418.19, add-ons for qualifying new technology services are included. If operating cost exceeds $82,941.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,403.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $37,715.59 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $37,078.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,842.33. The transfer capital threshold is the transfer adjustment factor * $2,842.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","39151.98","38889.67","39151.98","1 through 10","36610.7","40897.16","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","402","MS-DRG","","","","","","","","inpatient","","","69579.31","52184.48","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","36610.70","","Case rate ($37,357.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $37,418.19, add-ons for qualifying new technology services are included. If operating cost exceeds $82,941.92 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,403.12, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $34,176.29 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $37,078.95 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,842.33. The transfer capital threshold is the transfer adjustment factor * $2,842.33. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","49341.83","49341.83","49341.83","1 through 10","36610.7","40897.16","other","Inpatient DRG"
"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","404","TRIS-DRG","","","","","","","","inpatient","","","66863.74","","TRICARE [160005]","HB BWF TRICARE","","","If the length of stay is greater than 0, the reimbursement is as follows:  If the length of stay is less than or equal to 0, the reimbursement is as follows:  Final payment is multiplied by 95%.","45805.54","45805.54","45805.54","1 through 10","","","other","Inpatient DRGs"
"Single Level Spinal Fusion Except Cervical With McC Or Custom-Made Anatomically Designed Interbody Fusion Device","450","MS-DRG","","","","","","","","inpatient","","","62737.94","47053.45","MEDICARE [2001]","HB BWF MEDICARE","54103.07","","Case rate ($54,103.07). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $49,491.33, add-ons for qualifying new technology services are included. If operating cost exceeds $95,015.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,328.59, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 6.3. The base transfer operating payment is the transfer adjustment factor * $49,996.02 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $49,152.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,767.81. The transfer capital threshold is the transfer adjustment factor * $3,767.81. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","48423.12","54103.07","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","53198.61","39898.96","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","29481.37","","Case rate ($30,083.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,131.52, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,844.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $27,460.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,792.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.76. The transfer capital threshold is the transfer adjustment factor * $2,283.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","27797.89","27797.89","27797.89","1 through 10","29481.37","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","53198.61","39898.96","MEDICARE [2001]","HB BWF MEDICARE","32926.80","","Case rate ($32,926.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,131.52, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,844.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $30,303.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,792.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.76. The transfer capital threshold is the transfer adjustment factor * $2,283.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","30729.77","22032.72","30936.69","11","29481.37","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","53198.61","39898.96","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","32926.80","","Case rate ($32,926.80). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,131.52, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,844.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $30,303.80 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,792.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.76. The transfer capital threshold is the transfer adjustment factor * $2,283.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","29748.28","29748.28","36561.46","1 through 10","29481.37","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","53198.61","39898.96","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","29481.37","","Case rate ($30,083.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,131.52, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,844.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $27,460.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,792.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.76. The transfer capital threshold is the transfer adjustment factor * $2,283.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","27770.37","30318.04","30318.04","1 through 10","29481.37","33160.06","other","Inpatient DRG"
"Single Level Spinal Fusion Except Cervical Without McC","451","MS-DRG","","","","","","","","inpatient","","","53198.61","39898.96","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","29481.37","","Case rate ($30,083.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $30,131.52, add-ons for qualifying new technology services are included. If operating cost exceeds $75,655.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,844.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $27,460.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,792.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,283.76. The transfer capital threshold is the transfer adjustment factor * $2,283.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","27771.88","27771.88","27771.88","1 through 10","29481.37","33160.06","other","Inpatient DRG"
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","AETNA [1001]","HB CH AETNA HMO / PPO","138.17","58.3","","554.95","91.85","1421.75","94","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","2490.03","2490.03","2490.03","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.17","58.3","","750.00","750.00","750.00","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","125.61","53","","1192.50","120.84","4149.90","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","201.45","85","","750.00","75.00","750.00","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.00","100","","657.00","121.50","1971.00","14","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.00","100","","75.00","75.00","75.00","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.00","100","","366.00","144.00","1971.00","45","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.01","73","","667.50","667.50","667.50","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.35","44.45","","123.77","123.77","123.77","1 through 10","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.00","177.75","WELLPOINT [1015]","HB CH WELLPOINT","184.65","77.91","","483.51","229.32","1316.08","96","105.35","237","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","140.54","59.3","","439.50","225.34","1872.27","197","118.5","185.93","percent of total billed charges",""
"SIZER SCREW CAGE ECLIPSE","SUP-ITM-10274265","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.00","177.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","185.93","78.45","","385.32","55.36","1815.62","58","118.5","185.93","percent of total billed charges",""
"Skin Debridement With Cc","571","MS-DRG","","","","","","","","inpatient","","","42097.39","31573.04","MEDICARE [2001]","HB BWF MEDICARE","17382.55","","Case rate ($17,382.55). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,920.61, add-ons for qualifying new technology services are included. If operating cost exceeds $61,444.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,755.19, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5. The base transfer operating payment is the transfer adjustment factor * $15,848.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $15,581.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,194.41. The transfer capital threshold is the transfer adjustment factor * $1,194.41. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16899.50","16899.50","16899.50","1 through 10","15577.35","17382.55","other","Inpatient DRG"
"Skin Debridement With McC","570","MS-DRG","","","","","","","","inpatient","","","72209.98","54157.48","MEDICARE [2001]","HB BWF MEDICARE","30008.42","","Case rate ($30,008.42). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $27,463.46, add-ons for qualifying new technology services are included. If operating cost exceeds $72,987.19 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,640.02, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.8. The base transfer operating payment is the transfer adjustment factor * $27,589.93 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $27,124.22 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,079.24. The transfer capital threshold is the transfer adjustment factor * $2,079.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","26870.94","30008.42","other","Inpatient DRG"
"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/McC","578","MS-DRG","","","","","","","","inpatient","","","44751.30","33563.47","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14827.52","","Case rate ($15,130.12). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,154.23, add-ons for qualifying new technology services are included. If operating cost exceeds $60,677.96 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,696.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.3. The base transfer operating payment is the transfer adjustment factor * $13,655.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,814.98 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,135.66. The transfer capital threshold is the transfer adjustment factor * $1,135.66. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","15277.13","15277.13","15277.13","1 through 10","14827.52","16489.7","other","Inpatient DRG"
"Skin Graft For Musculoskeletal And Connective Tissue Diagnoses,MINOR","312","DRG","","","","","","","","inpatient","","","44751.30","","MASSHEALTH [3001]","HB BWF MEDICAID","17465.63","","Case rate ($19,311.26). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $61,741.26, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","19306.52","19306.52","19306.52","1 through 10","11772.55","42484.69","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MINOR","361","DRG","","","","","","","","inpatient","","","54914.54","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","13100.65","","Case rate ($14,485.02). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,915.02, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $1,777.30 and the sum of the standard inlier and any outlier amount.","14481.47","14481.47","14481.47","1 through 10","3442","124652.08","case rate",""
"Skin Graft For Skin And Subcutaneous Tissue Diagnoses,MODERATE","361","DRG","","","","","","","","inpatient","","","39659.64","","MASSHEALTH [3001]","HB BWF MEDICAID","16683.11","","Case rate ($18,446.05). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $60,876.05, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","3259.12","3259.12","3259.12","1 through 10","3442","124652.08","case rate",""
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","51228.02","38421.01","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","16856.51","","Case rate ($16,856.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,883.44, add-ons for qualifying new technology services are included. If operating cost exceeds $62,407.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,828.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,249.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,544.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,268.22. The transfer capital threshold is the transfer adjustment factor * $1,268.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17727.78","17727.78","17727.78","1 through 10","16519.38","18414.38","other","Inpatient Replacement Plans DRG"
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","623","MS-DRG","","","","","","","","inpatient","","","51228.02","38421.01","MEDICARE [2001]","HB BWF MEDICARE","16856.51","","Case rate ($16,856.51). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,883.44, add-ons for qualifying new technology services are included. If operating cost exceeds $62,407.17 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,828.99, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.2. The base transfer operating payment is the transfer adjustment factor * $15,249.06 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,544.20 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,268.22. The transfer capital threshold is the transfer adjustment factor * $1,268.22. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19142.76","19142.76","19142.76","1 through 10","16519.38","18414.38","other","Inpatient Replacement Plans DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","24442.62","18331.96","MEDICARE [2001]","HB BWF MEDICARE","11262.04","","Case rate ($11,262.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,279.86, add-ons for qualifying new technology services are included. If operating cost exceeds $56,803.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,399.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,084.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,940.62 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.67. The transfer capital threshold is the transfer adjustment factor * $838.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12409.06","12409.06","12409.06","1 through 10","11036.8","12177.37","other","Inpatient Replacement Plans DRG"
"Skin Ulcers With Cc","593","MS-DRG","","","","","","","","inpatient","","","24442.62","18331.96","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","11036.80","","Case rate ($11,262.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $11,279.86, add-ons for qualifying new technology services are included. If operating cost exceeds $56,803.59 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,399.44, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.2. The base transfer operating payment is the transfer adjustment factor * $10,084.15 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $10,940.62 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $838.67. The transfer capital threshold is the transfer adjustment factor * $838.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","11155.86","11155.86","11155.86","1 through 10","11036.8","12177.37","other","Inpatient DRG"
"Skin Ulcers,EXTREME","380","DRG","","","","","","","","inpatient","","","186566.10","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41538.22","","Standard inlier is a Case rate ($41,538.22). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,260, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,896.51) for the length of stay and the standard reimbursement.","39650.65","39650.65","39650.65","1 through 10","6699.98","97489.73","case rate",""
"Skin Ulcers,EXTREME","380","DRG","","","","","","","","inpatient","","","186566.10","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","20715.67","","Case rate ($22,904.73). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $65,334.73, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $5,849.64 and the sum of the standard inlier and any outlier amount.","30239.42","30239.42","30239.42","1 through 10","6699.98","97489.73","case rate",""
"Skin Ulcers,MAJOR","380","DRG","","","","","","","","inpatient","","","32138.65","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","10146.49","","Case rate ($11,218.69). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,648.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","11215.94","11215.94","11215.94","1 through 10","6699.98","97489.73","case rate",""
"Skin Ulcers,MAJOR","380","DRG","","","","","","","","inpatient","","","32138.65","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","10146.49","","Case rate ($11,218.69). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,648.69, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","12742.81","12742.81","12742.81","1 through 10","6699.98","97489.73","case rate",""
"Skin Ulcers,MODERATE","380","DRG","","","","","","","","inpatient","","","8962.04","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6699.98","","Case rate ($7,407.98). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,837.98, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7706.24","7706.24","7706.24","1 through 10","6699.98","97489.73","case rate",""
"Skin/Muc Mem/Subq Tissue Unlstd","PX-76001780","CDM","17999","CPT","0761","RC","","","","outpatient","","","1456.00","1092.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","729.46","50.1","","285.72","285.72","285.72","1 through 10","567.68","1142.23","percent of total billed charges",""
"Skin/Muc Mem/Subq Tissue Unlstd","PX-76001780","CDM","17999","CPT","0761","RC","","","","outpatient","","","1456.00","1092.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","840.11","57.7","","8477.00","8477.00","8477.00","1 through 10","567.68","1142.23","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"SLEEVE FEMORAL 34MM FULLY POROUS UNIVERSAL","SUP-ITM-10029449","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","AETNA [1001]","HB CH AETNA HMO / PPO","43.73","58.3","","1634.24","1004.95","1718.99","42","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","2123.89","1900.92","2123.89","1 through 10","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","43.73","58.3","","3729.00","1254.19","3729.00","1 through 10","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","39.75","53","","939.37","939.37","5593.65","1 through 10","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","63.75","85","","2323.25","1864.50","2882.25","16","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","75.00","100","","2909.44","1772.40","10952.08","45","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","75.00","100","","2323.25","2323.25","2323.25","1 through 10","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","75.00","100","","2882.25","1772.40","10169.17","187","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","54.75","73","","1659.41","1659.41","1659.41","1 through 10","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","both","","","75.00","56.25","WELLPOINT [1015]","HB CH WELLPOINT","58.43","77.91","","2050.91","1468.48","2902.83","52","33.34","75","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","44.48","59.3","","1548.60","1092.60","3613.79","82","37.5","58.84","percent of total billed charges",""
"SLEEVE FEMORAL 3MM HIP UNITRAX TITANIUM ADJUSTABLE C TAPER NECK MINUS","SUP-ITM-10016594","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","75.00","56.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","58.84","78.45","","2085.51","998.68","6202.11","56","37.5","58.84","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1634.24","1004.95","1718.99","42","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2123.89","1900.92","2123.89","1 through 10","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","3729.00","1254.19","3729.00","1 through 10","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","939.37","939.37","5593.65","1 through 10","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","2323.25","1864.50","2882.25","16","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","2909.44","1772.40","10952.08","45","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","2323.25","2323.25","2323.25","1 through 10","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","2882.25","1772.40","10169.17","187","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","1659.41","1659.41","1659.41","1 through 10","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","2050.91","1468.48","2902.83","52","1066.8","2400","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1548.60","1092.60","3613.79","82","1200","1882.8","percent of total billed charges",""
"SLEEVE FEMORAL SZ 12D SM S-ROM ZTT PROXIMAL POROUS COATED TEXTURED","SUP-ITM-10016311","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","2085.51","998.68","6202.11","56","1200","1882.8","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"SLEEVE TIBIAL 26X29X40MM KNEE MBT REVISION TITANIUM POROUS","SUP-ITM-10018522","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","3473.37","2605.03","AETNA [1001]","HB CH AETNA HMO / PPO","2024.97","58.3","","1952.48","1952.48","1952.48","1 through 10","1543.91","3473.37","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","3473.37","2605.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1840.89","53","","1825.07","1825.07","1825.07","1 through 10","1543.91","3473.37","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","both","","","3473.37","2605.03","WELLPOINT [1015]","HB CH WELLPOINT","2706.10","77.91","","2712.12","2712.12","2712.12","1 through 10","1543.91","3473.37","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHERAL OBTRYX II HALO TRANSOBTURATOR","SUP-ITM-10118316","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3473.37","2605.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","2059.71","59.3","","2017.91","2017.91","2017.91","1 through 10","1736.69","2724.86","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHRAL OBTRYX HALO TRANSOBTURATOR","SUP-ITM-10065061","CDM","C1771","HCPCS","0278","RC","","","","both","","","3473.37","2605.03","AETNA [1001]","HB CH AETNA HMO / PPO","2024.97","58.3","","1952.48","1952.48","1952.48","1 through 10","1543.91","3473.37","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHRAL OBTRYX HALO TRANSOBTURATOR","SUP-ITM-10065061","CDM","C1771","HCPCS","0278","RC","","","","both","","","3473.37","2605.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1840.89","53","","1825.07","1825.07","1825.07","1 through 10","1543.91","3473.37","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHRAL OBTRYX HALO TRANSOBTURATOR","SUP-ITM-10065061","CDM","C1771","HCPCS","0278","RC","","","","both","","","3473.37","2605.03","WELLPOINT [1015]","HB CH WELLPOINT","2706.10","77.91","","2712.12","2712.12","2712.12","1 through 10","1543.91","3473.37","percent of total billed charges",""
"SLING INCONTINENCE MIDURETHRAL OBTRYX HALO TRANSOBTURATOR","SUP-ITM-10065061","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3473.37","2605.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","2059.71","59.3","","2017.91","2017.91","2017.91","1 through 10","1736.69","2724.86","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","both","","","138.90","104.17","AETNA [1001]","HB CH AETNA HMO / PPO","80.98","58.3","","84.15","75.01","84.15","1 through 10","61.74","375.76","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","both","","","138.90","104.17","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","80.15","57.7","","89.49","76.73","89.49","1 through 10","61.74","375.76","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","both","","","138.90","104.17","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","84.03","60.5","","93.94","93.94","93.94","1 through 10","61.74","375.76","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","both","","","138.90","104.17","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","73.62","53","","70.12","70.12","70.12","1 through 10","61.74","375.76","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","138.90","104.17","CIGNA [1006]","HB CH CIGNA HMO / PPO","82.37","59.3","","86.97","77.53","86.97","1 through 10","69.45","263.9","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","138.90","104.17","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","80.15","57.7","","89.49","76.73","89.49","1 through 10","69.45","263.9","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","138.90","104.17","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","84.03","60.5","","93.94","93.94","93.94","1 through 10","69.45","263.9","percent of total billed charges",""
"SLING SHOULDER 13 15IN UNIVERSAL LG ULTRA III MESH PADDED DEROTATION STRAP","SUP-ITM-10018171","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","138.90","104.17","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","108.97","78.45","","114.10","114.10","114.10","1 through 10","69.45","263.9","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","3443.53","2582.65","AETNA [1001]","HB CH AETNA HMO / PPO","2007.58","58.3","","1952.48","1952.48","1952.48","1 through 10","1530.65","3443.53","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","3443.53","2582.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1825.07","53","","1825.07","1825.07","1825.07","1 through 10","1530.65","3443.53","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","both","","","3443.53","2582.65","WELLPOINT [1015]","HB CH WELLPOINT","2682.85","77.91","","2712.12","2712.12","2712.12","1 through 10","1530.65","3443.53","percent of total billed charges",""
"SLING SUBURRETHRAL POLYPROPYLENE MESH IMPLANT DELIVERY DEVICE TRANSVAGINAL ADVANTAGE FIT STRESS URINARY INCONT","SUP-ITM-10115692","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3443.53","2582.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","2042.01","59.3","","2017.91","2017.91","2017.91","1 through 10","1721.77","2701.45","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL SUPRAPUBIC MESH ASSEMBLY HALO NEEDLE GUIDE TUBE HANDLE BX/2EA","SUP-ITM-10065059","CDM","C1771","HCPCS","0278","RC","","","","both","","","3280.16","2460.12","AETNA [1001]","HB CH AETNA HMO / PPO","1912.33","58.3","","1952.48","1952.48","1952.48","1 through 10","1458.03","3280.16","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL SUPRAPUBIC MESH ASSEMBLY HALO NEEDLE GUIDE TUBE HANDLE BX/2EA","SUP-ITM-10065059","CDM","C1771","HCPCS","0278","RC","","","","both","","","3280.16","2460.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1738.48","53","","1825.07","1825.07","1825.07","1 through 10","1458.03","3280.16","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL SUPRAPUBIC MESH ASSEMBLY HALO NEEDLE GUIDE TUBE HANDLE BX/2EA","SUP-ITM-10065059","CDM","C1771","HCPCS","0278","RC","","","","both","","","3280.16","2460.12","WELLPOINT [1015]","HB CH WELLPOINT","2555.57","77.91","","2712.12","2712.12","2712.12","1 through 10","1458.03","3280.16","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL SUPRAPUBIC MESH ASSEMBLY HALO NEEDLE GUIDE TUBE HANDLE BX/2EA","SUP-ITM-10065059","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3280.16","2460.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1945.13","59.3","","2017.91","2017.91","2017.91","1 through 10","1640.08","2573.29","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL TRANSVAGINAL ADVANTAGE","SUP-ITM-10031037","CDM","C1771","HCPCS","0278","RC","","","","both","","","3311.11","2483.33","AETNA [1001]","HB CH AETNA HMO / PPO","1930.38","58.3","","1952.48","1952.48","1952.48","1 through 10","1471.79","3311.11","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL TRANSVAGINAL ADVANTAGE","SUP-ITM-10031037","CDM","C1771","HCPCS","0278","RC","","","","both","","","3311.11","2483.33","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1754.89","53","","1825.07","1825.07","1825.07","1 through 10","1471.79","3311.11","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL TRANSVAGINAL ADVANTAGE","SUP-ITM-10031037","CDM","C1771","HCPCS","0278","RC","","","","both","","","3311.11","2483.33","WELLPOINT [1015]","HB CH WELLPOINT","2579.69","77.91","","2712.12","2712.12","2712.12","1 through 10","1471.79","3311.11","percent of total billed charges",""
"SLING SYSTEM MID URETHRAL TRANSVAGINAL ADVANTAGE","SUP-ITM-10031037","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3311.11","2483.33","CIGNA [1006]","HB CH CIGNA HMO / PPO","1963.49","59.3","","2017.91","2017.91","2017.91","1 through 10","1655.56","2597.57","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Alpha Sub-Unit 83520","PX-30003301","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Anti Centromere 83520","PX-30003315","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Anti Glomerular Bsmnt Mem83520","PX-30003306","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Anti Mullerian Hormone,S 83520","PX-30003313","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Anti-Striated Muscle Ab 83520","PX-30003316","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Digitoxin 83520","PX-30003300","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","both","","","392.00","294.00","AETNA [1001]","HB CH AETNA HMO / PPO","228.54","58.3","","216.03","216.03","216.03","1 through 10","41.98","286.16","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","232.46","59.3","","536.52","223.27","536.52","1 through 10","44.17","307.52","percent of total billed charges",""
"Slm Epstein Barr Pcr Quant 87799","PX-30003321","CDM","87799","CPT","0300","RC","","","","outpatient","","","392.00","294.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","307.52","78.45","","292.91","292.91","292.91","1 through 10","44.17","307.52","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Gm1 Autoantibody Test 83520","PX-30003307","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Hu Antibody 83520","PX-30003308","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Igfbp3 83520","PX-30003310","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Il6, Serum 83520","PX-30003303","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","both","","","167.00","125.25","AETNA [1001]","HB CH AETNA HMO / PPO","97.36","58.3","","121.91","121.91","121.91","1 through 10","18.27","121.91","percent of total billed charges",""
"Slm Infliximab Level 80299","PX-30003297","CDM","80299","CPT","0300","RC","","","","outpatient","","","167.00","125.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.01","78.45","","165.29","165.29","165.29","1 through 10","14.12","131.01","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Inhibin B, Immunoassay 83520","PX-30003302","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Mag Ab Reflex 83520","PX-30003314","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Naso Pharyngeal Airway","PX-41000029","CDM","94799","CPT","0410","RC","","","","both","","","548.00","411.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","418.00","418.00","418.00","1 through 10","176.52","521.15","other","OPPS APC"
"Slm Naso Pharyngeal Airway","PX-41000029","CDM","94799","CPT","0410","RC","","","","outpatient","","","548.00","411.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","268.90","49.07","","224.50","224.50","224.50","1 through 10","191.73","429.91","percent of total billed charges",""
"Slm Naso Pharyngeal Airway","PX-41000029","CDM","94799","CPT","0410","RC","","","","outpatient","","","548.00","411.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","274.55","50.1","","418.00","224.81","418.00","1 through 10","191.73","429.91","percent of total billed charges",""
"Slm Naso Pharyngeal Airway","PX-41000029","CDM","94799","CPT","0410","RC","","","","outpatient","","","548.00","411.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","316.20","57.7","","418.00","418.00","418.00","1 through 10","191.73","429.91","percent of total billed charges",""
"Slm Naso Pharyngeal Airway","PX-41000029","CDM","94799","CPT","0410","RC","","","","outpatient","","","548.00","411.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","331.54","60.5","","418.00","418.00","418.00","1 through 10","191.73","429.91","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Rhmtid Fctr Igg,Iga,Igm 83520","PX-30003317","CDM","83520","CPT","0302","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Saccharomyces Cerevisae Iga","PX-30003312","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Sol Liver Antigen Igg Ab 83520","PX-30003311","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Tegretol Epoxide 2 80299","PX-30003296","CDM","80299","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","161.33","percent of total billed charges",""
"Slm Tegretol Epoxide 2 80299","PX-30003296","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","14.12","173.37","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Slm Tryptase, Serum 83520","PX-30003309","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Slm Voriconazole, Serum 80299","PX-30003298","CDM","80299","CPT","0300","RC","","","","both","","","196.00","147.00","AETNA [1001]","HB CH AETNA HMO / PPO","114.27","58.3","","121.91","121.91","121.91","1 through 10","18.27","143.08","percent of total billed charges",""
"Slm Voriconazole, Serum 80299","PX-30003298","CDM","80299","CPT","0300","RC","","","","outpatient","","","196.00","147.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","153.76","78.45","","165.29","165.29","165.29","1 through 10","14.12","153.76","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","both","","","50.00","37.50","AETNA [1001]","HB CH AETNA HMO / PPO","29.15","58.3","","27.78","27.78","27.78","1 through 10","5.28","36.5","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","50.00","37.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","29.65","59.3","","56.06","56.06","56.06","1 through 10","5.55","39.23","percent of total billed charges",""
"Smear Acid Fast/Fluorescent Stain","PX-30001193","CDM","87206","CPT","0306","RC","","","","outpatient","","","50.00","37.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","39.23","78.45","","22.32","22.32","22.32","1 through 10","5.55","39.23","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","41.00","30.75","AETNA [1001]","HB CH AETNA HMO / PPO","23.90","58.3","","22.68","22.68","22.68","21","4.18","29.93","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","both","","","41.00","30.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","21.73","53","","22.26","22.26","22.26","1 through 10","4.18","29.93","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","41.00","30.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","24.31","59.3","","23.44","23.44","80.28","34","4.4","32.16","percent of total billed charges",""
"Smear Gram or Geimsa Stain","PX-30001192","CDM","87205","CPT","0306","RC","","","","outpatient","","","41.00","30.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","32.16","78.45","","30.75","18.22","30.75","25","4.4","32.16","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","101.00","75.75","AETNA [1001]","HB CH AETNA HMO / PPO","58.88","58.3","","55.57","55.57","55.57","1 through 10","8.72","73.73","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","both","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","44.89","44.45","","75.34","75.34","75.34","1 through 10","8.72","73.73","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","101.00","75.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","59.89","59.3","","57.43","57.43","57.43","1 through 10","9.17","79.23","percent of total billed charges",""
"Smear Ova & Parasite Concent/Ident","PX-30001182","CDM","87177","CPT","0306","RC","","","","outpatient","","","101.00","75.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","79.23","78.45","","44.65","44.65","75.34","1 through 10","9.17","79.23","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","both","","","45.00","33.75","AETNA [1001]","HB CH AETNA HMO / PPO","26.24","58.3","","24.95","24.95","24.95","1 through 10","4.96","32.85","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","45.00","33.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.69","59.3","","25.78","25.78","25.78","1 through 10","5.03","35.3","percent of total billed charges",""
"Sodium Urine","PX-30000675","CDM","84300","CPT","0301","RC","","","","outpatient","","","45.00","33.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","35.30","78.45","","1.62","1.62","1.62","1 through 10","5.03","35.3","percent of total billed charges",""
"Soft Tissue Procedures With Cc","501","MS-DRG","","","","","","","","inpatient","","","35863.06","26897.29","MEDICARE [2001]","HB BWF MEDICARE","17973.70","","Case rate ($17,973.70). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $16,461.05, add-ons for qualifying new technology services are included. If operating cost exceeds $61,984.78 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,796.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 4)) / 2. The base transfer operating payment is the transfer adjustment factor * $16,398.61 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,121.81 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,235.84. The transfer capital threshold is the transfer adjustment factor * $1,235.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17662.57","17662.57","17877.59","1 through 10","16106.12","17973.7","other","Inpatient DRG"
"Soft Tissue Procedures With McC","500","MS-DRG","","","","","","","","inpatient","","","71657.75","53743.31","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","28889.45","","Case rate ($29,479.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $29,526.52, add-ons for qualifying new technology services are included. If operating cost exceeds $75,050.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,798.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 7.6. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 7.6)) / 2. The base transfer operating payment is the transfer adjustment factor * $26,902.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $29,187.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,237.39. The transfer capital threshold is the transfer adjustment factor * $2,237.39. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","28461.59","28461.59","28461.59","1 through 10","28889.45","32265.05","other","Inpatient DRG"
"Soft Tissue Procedures Without Cc/McC","502","MS-DRG","","","","","","","","inpatient","","","39791.75","29843.81","MEDICARE [2001]","HB BWF MEDICARE","12731.58","","Case rate ($12,731.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,751.77, add-ons for qualifying new technology services are included. If operating cost exceeds $58,275.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,512.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,440.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,412.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.50. The transfer capital threshold is the transfer adjustment factor * $951.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8678.54","8678.54","8678.54","1 through 10","12476.95","13815.66","other","Inpatient Replacement Plans DRG"
"Soft Tissue Procedures Without Cc/McC","502","MS-DRG","","","","","","","","inpatient","","","39791.75","29843.81","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12476.95","","Case rate ($12,731.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,751.77, add-ons for qualifying new technology services are included. If operating cost exceeds $58,275.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,512.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. For special-pay transfer cases, the transfer adjustment factor is instead defined as (1 + ((length of stay + 1) / 2.4)) / 2. The base transfer operating payment is the transfer adjustment factor * $11,440.83 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,412.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $951.50. The transfer capital threshold is the transfer adjustment factor * $951.50. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12738.67","12738.67","12738.67","1 through 10","12476.95","13815.66","other","Inpatient DRG"
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Soluble Il 2r Alpha","PX-30002062","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","AETNA [1001]","HB CH AETNA HMO / PPO","2020.10","58.3","","1634.24","1004.95","1718.99","42","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","2123.89","1900.92","2123.89","1 through 10","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2020.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1836.45","53","","939.37","939.37","5593.65","1 through 10","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2945.25","85","","2323.25","1864.50","2882.25","16","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3465.00","100","","2909.44","1772.40","10952.08","45","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3465.00","100","","2323.25","2323.25","2323.25","1 through 10","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3465.00","100","","2882.25","1772.40","10169.17","187","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2529.45","73","","1659.41","1659.41","1659.41","1 through 10","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","both","","","3465.00","2598.75","WELLPOINT [1015]","HB CH WELLPOINT","2699.58","77.91","","2050.91","1468.48","2902.83","52","1540.19","3465","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2054.75","59.3","","1548.60","1092.60","3613.79","82","1732.5","2718.29","percent of total billed charges",""
"SOLUTION CEMENTED COMPONENT FEMORAL KNEE NEXGEN ZIMALOY PRECOATED CRUCIATE RETAINING RT SIZE D","SUP-ITM-10001837","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3465.00","2598.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2718.29","78.45","","2085.51","998.68","6202.11","56","1732.5","2718.29","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","AETNA [1001]","HB CH AETNA HMO / PPO","3817.37","58.3","","1634.24","1004.95","1718.99","42","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4779.89","73","","2123.89","1900.92","2123.89","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3817.37","58.3","","3729.00","1254.19","3729.00","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3470.33","53","","939.37","939.37","5593.65","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5565.63","85","","2323.25","1864.50","2882.25","16","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6547.80","100","","2909.44","1772.40","10952.08","45","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6547.80","100","","2323.25","2323.25","2323.25","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6547.80","100","","2882.25","1772.40","10169.17","187","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4779.89","73","","1659.41","1659.41","1659.41","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","WELLPOINT [1015]","HB CH WELLPOINT","5101.39","77.91","","2050.91","1468.48","2902.83","52","2910.5","6547.8","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","3882.85","59.3","","1548.60","1092.60","3613.79","82","3273.9","5136.75","percent of total billed charges",""
"SOLUTION COMPONENT SIZE 3 FEMORAL KNEE GSF PATELLOFEMORAL JOINT PRECOAT CEMENTED RIGHT","SUP-ITM-10100714","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5136.75","78.45","","2085.51","998.68","6202.11","56","3273.9","5136.75","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","AETNA [1001]","HB CH AETNA HMO / PPO","3817.37","58.3","","1634.24","1004.95","1718.99","42","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4779.89","73","","2123.89","1900.92","2123.89","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3817.37","58.3","","3729.00","1254.19","3729.00","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3470.33","53","","939.37","939.37","5593.65","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5565.63","85","","2323.25","1864.50","2882.25","16","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6547.80","100","","2909.44","1772.40","10952.08","45","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6547.80","100","","2323.25","2323.25","2323.25","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6547.80","100","","2882.25","1772.40","10169.17","187","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4779.89","73","","1659.41","1659.41","1659.41","1 through 10","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","both","","","6547.80","4910.85","WELLPOINT [1015]","HB CH WELLPOINT","5101.39","77.91","","2050.91","1468.48","2902.83","52","2910.5","6547.8","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","CIGNA [1006]","HB CH CIGNA HMO / PPO","3882.85","59.3","","1548.60","1092.60","3613.79","82","3273.9","5136.75","percent of total billed charges",""
"SOLUTION GENDER SIZE 4 COMPONENT FEMORAL KNEE CEMENTED PRECOAT LEFT","SUP-ITM-10107400","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6547.80","4910.85","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5136.75","78.45","","2085.51","998.68","6202.11","56","3273.9","5136.75","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","197.00","147.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.82","59.3","","112.51","112.51","112.51","1 through 10","17.43","154.55","percent of total billed charges",""
"Somatomedin","PX-30000677","CDM","84305","CPT","0301","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","147.61","147.61","1 through 10","17.43","154.55","percent of total billed charges",""
"Somatosensory Study, Up & Low Limbs","PX-92000080","CDM","95938","CPT","0922","RC","","","","both","","","1686.00","1264.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","893.58","53","","868.67","868.67","868.67","1 through 10","598.61","1771","percent of total billed charges",""
"Somatosensory Study, Up & Low Limbs","PX-92000080","CDM","95938","CPT","0922","RC","","","","both","","","1686.00","1264.50","WELLPOINT [1015]","HB CH WELLPOINT","1313.56","77.91","","1274.88","1274.88","1274.88","1 through 10","598.61","1771","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","both","","","160.00","160.00","AETNA [1001]","HB CH AETNA HMO / PPO","93.28","58.3","","42.81","0.57","85.05","1 through 10","50.28","162.53","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","94.88","59.3","","449.00","87.90","449.00","1 through 10","58.56","125.52","percent of total billed charges",""
"Sp Covid19 Elective Testing (Global Charge)","PX-30003712","CDM","87635","CPT","0999","RC","","","","outpatient","","","160.00","160.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","125.52","78.45","","68.34","68.34","115.32","1 through 10","58.56","125.52","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","both","","","112.00","112.00","AETNA [1001]","HB CH AETNA HMO / PPO","65.30","58.3","","42.81","0.57","85.05","1 through 10","49.78","162.53","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","66.42","59.3","","449.00","87.90","449.00","1 through 10","40.99","87.86","percent of total billed charges",""
"Sp Covid19 Elective Testing (Lab Test Only)","PX-30003713","CDM","87635","CPT","0999","RC","","","","outpatient","","","112.00","112.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","87.86","78.45","","68.34","68.34","115.32","1 through 10","40.99","87.86","percent of total billed charges",""
"SPACER CERVICAL 7MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10132466","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1830.28","315.58","1830.28","1 through 10","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 7MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10132466","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","4170.85","4170.85","4170.85","1 through 10","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 7MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10132466","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","649.55","649.55","649.55","1 through 10","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 7MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10132466","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","8998.38","2542.37","8998.38","20","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 7MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10132466","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1891.61","1609.14","3664.18","25","1875","2941.88","percent of total billed charges",""
"SPACER CERVICAL 7MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10132466","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1470.68","1310.06","2481.69","19","1875","2941.88","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1830.28","315.58","1830.28","1 through 10","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","4170.85","4170.85","4170.85","1 through 10","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1666.88","44.45","","649.55","649.55","649.55","1 through 10","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","8998.38","2542.37","8998.38","20","1666.88","3750","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1891.61","1609.14","3664.18","25","1875","2941.88","percent of total billed charges",""
"SPACER CERVICAL 9MM ZERO P PEEK OPTIMA PARALLEL PREASSEMBLED LORDOTIC","SUP-ITM-10133184","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","1470.68","1310.06","2481.69","19","1875","2941.88","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","AETNA [1001]","HB CH AETNA HMO / PPO","857.01","58.3","","1634.24","1004.95","1718.99","42","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","2123.89","1900.92","2123.89","1 through 10","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","857.01","58.3","","3729.00","1254.19","3729.00","1 through 10","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","779.10","53","","939.37","939.37","5593.65","1 through 10","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1249.50","85","","2323.25","1864.50","2882.25","16","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1470.00","100","","2909.44","1772.40","10952.08","45","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1470.00","100","","2323.25","2323.25","2323.25","1 through 10","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1470.00","100","","2882.25","1772.40","10169.17","187","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1073.10","73","","1659.41","1659.41","1659.41","1 through 10","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","both","","","1470.00","1102.50","WELLPOINT [1015]","HB CH WELLPOINT","1145.28","77.91","","2050.91","1468.48","2902.83","52","653.42","1470","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","871.71","59.3","","1548.60","1092.60","3613.79","82","735","1153.22","percent of total billed charges",""
"SPACER HUMERAL 9MM 33 PLUS","SUP-ITM-10327709","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1470.00","1102.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1153.22","78.45","","2085.51","998.68","6202.11","56","735","1153.22","percent of total billed charges",""
"SPACER LUMBAR 10X28X9MM OPAL PEEK FIXATION REVOLVE","SUP-ITM-10033282","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1830.28","315.58","1830.28","1 through 10","1778","4000","percent of total billed charges",""
"SPACER LUMBAR 10X28X9MM OPAL PEEK FIXATION REVOLVE","SUP-ITM-10033282","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","4170.85","4170.85","4170.85","1 through 10","1778","4000","percent of total billed charges",""
"SPACER LUMBAR 10X28X9MM OPAL PEEK FIXATION REVOLVE","SUP-ITM-10033282","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","649.55","649.55","649.55","1 through 10","1778","4000","percent of total billed charges",""
"SPACER LUMBAR 10X28X9MM OPAL PEEK FIXATION REVOLVE","SUP-ITM-10033282","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","8998.38","2542.37","8998.38","20","1778","4000","percent of total billed charges",""
"SPACER LUMBAR 10X28X9MM OPAL PEEK FIXATION REVOLVE","SUP-ITM-10033282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1891.61","1609.14","3664.18","25","2000","3138","percent of total billed charges",""
"SPACER LUMBAR 10X28X9MM OPAL PEEK FIXATION REVOLVE","SUP-ITM-10033282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1470.68","1310.06","2481.69","19","2000","3138","percent of total billed charges",""
"SPACER SPINE 7MM 4DEG CIF UI L","SUP-ITM-10243853","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","1830.28","315.58","1830.28","1 through 10","1133.48","2550","percent of total billed charges",""
"SPACER SPINE 7MM 4DEG CIF UI L","SUP-ITM-10243853","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","4170.85","4170.85","4170.85","1 through 10","1133.48","2550","percent of total billed charges",""
"SPACER SPINE 7MM 4DEG CIF UI L","SUP-ITM-10243853","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","649.55","649.55","649.55","1 through 10","1133.48","2550","percent of total billed charges",""
"SPACER SPINE 7MM 4DEG CIF UI L","SUP-ITM-10243853","CDM","C1889","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","8998.38","2542.37","8998.38","20","1133.48","2550","percent of total billed charges",""
"SPACER SPINE 7MM 4DEG CIF UI L","SUP-ITM-10243853","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","1891.61","1609.14","3664.18","25","1275","2000.48","percent of total billed charges",""
"SPACER SPINE 7MM 4DEG CIF UI L","SUP-ITM-10243853","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","1470.68","1310.06","2481.69","19","1275","2000.48","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","both","","","58.00","43.50","AETNA [1001]","HB CH AETNA HMO / PPO","33.81","58.3","","63.50","31.75","63.50","1 through 10","5.87","42.34","percent of total billed charges",""
"Spec Stain Incls Bodies/Parasites","PX-30001194","CDM","87207","CPT","0306","RC","","","","outpatient","","","58.00","43.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","45.50","78.45","","25.51","25.51","25.51","1 through 10","6.19","47.09","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","both","","","351.00","263.25","WELLPOINT [1015]","HB CH WELLPOINT","273.46","77.91","","1291.57","268.57","1291.57","1 through 10","60.28","273.46","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","351.00","263.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","208.14","59.3","","199.83","199.83","799.30","1 through 10","90.37","275.36","percent of total billed charges",""
"Special Stain I","PX-31000154","CDM","88312","CPT","0312","RC","","","","outpatient","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","275.36","78.45","","155.36","155.36","262.16","21","90.37","275.36","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","both","","","205.00","153.75","MEDICARE [2001]","HB BWF MEDICARE","153.08","","APC Price ($153.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","153.08","153.08","153.08","1 through 10","82.25","170.56","other","OPPS APC"
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","205.00","153.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","121.57","59.3","","116.61","116.61","116.62","13","56.93","160.82","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","205.00","153.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","160.82","78.45","","458.49","458.49","458.49","1 through 10","56.93","160.82","percent of total billed charges",""
"Special Stain II Iron","PX-31000156","CDM","88313","CPT","0312","RC","","","","outpatient","","","205.00","153.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","160.82","78.45","","152.99","90.66","152.99","14","56.93","160.82","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","both","","","377.00","282.75","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","199.81","731.58","other","OPPS APC"
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","377.00","282.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","184.99","49.07","","2115.00","2115.00","2115.00","1 through 10","167.58","567.68","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","377.00","282.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","188.88","50.1","","331.25","331.25","331.25","1 through 10","167.58","567.68","percent of total billed charges",""
"Sphenopalantine Ganglion Q-Tip Nerve Block","PX-76002294","CDM","64999","CPT","0761","RC","","","","outpatient","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","295.76","78.45","","282.15","282.15","282.15","1 through 10","167.58","567.68","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","1830.28","315.58","1830.28","1 through 10","593.41","1335","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","4170.85","4170.85","4170.85","1 through 10","593.41","1335","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","649.55","649.55","649.55","1 through 10","593.41","1335","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","8998.38","2542.37","8998.38","20","593.41","1335","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1891.61","1609.14","3664.18","25","667.5","1047.31","percent of total billed charges",""
"SPINAL CONNECTOR MED FIXATION ARRAY CROSSLINK","SUP-ITM-10018005","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1470.68","1310.06","2481.69","19","667.5","1047.31","percent of total billed charges",""
"Spinal Disorders And Injuries With Cc/McC","052","MS-DRG","","","","","","","","inpatient","","","34760.57","26070.43","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","17016.72","","Case rate ($17,016.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $17,043.90, add-ons for qualifying new technology services are included. If operating cost exceeds $62,567.63 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,841.30, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.1. The base transfer operating payment is the transfer adjustment factor * $15,396.97 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $16,704.67 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,280.52. The transfer capital threshold is the transfer adjustment factor * $1,280.52. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","18243.57","18243.57","18243.57","1 through 10","16676.39","18592.99","other","Inpatient Replacement Plans DRG"
"Spinal Disorders And Injuries,MINOR","040","DRG","","","","","","","","inpatient","","","10054.64","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","12953.83","","Fee schedule rate ($12,953.83). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","9781.33","9781.33","9781.33","1 through 10","2255","44088.38","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","49660.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41962.33","","Standard inlier is a Case rate ($41,962.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,956.72) for the length of stay and the standard reimbursement.","41962.32","41962.32","41962.32","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MINOR","321","DRG","","","","","","","","inpatient","","","49660.07","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","45075.91","","Standard inlier is a Case rate ($45,075.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,398.33) for the length of stay and the standard reimbursement.","43031.01","43031.01","43031.01","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","41962.33","","Standard inlier is a Case rate ($41,962.33). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,956.72) for the length of stay and the standard reimbursement.","50900.49","50900.49","50900.49","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","45075.91","","Standard inlier is a Case rate ($45,075.91). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $54,697, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($6,398.33) for the length of stay and the standard reimbursement.","54677.28","54677.28","54677.28","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","32584.3308","","Fee schedule rate ($44,516.68). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","32584.3308","44516.68","44516.68","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","34213.3806","","Fee schedule rate ($46,742.28). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","34213.3806","46742.28","46742.28","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","","53","","1018.23","1018.23","1018.23","1 through 10","16952.47","73451.83","percent of total billed charges",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","23682.25","","Fee schedule rate ($23,682.25). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($24,044), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","23682.25","23682.25","23682.25","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","50477.56","","Fee schedule rate ($50,477.56). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","50477.56","50477.56","50477.56","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion And Other Back And Neck Procedures Except For Disc Procedures,MODERATE","321","DRG","","","","","","","","inpatient","","","51515.01","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","17846.04","","Case rate ($19,731.87). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $62,161.87, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","22723.58","22723.58","22723.58","1 through 10","16952.47","73451.83","case rate",""
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With Cc","457","MS-DRG","","","","","","","","inpatient","","","70587.02","52940.26","MEDICARE [2001]","HB BWF MEDICARE","60493.68","","Case rate ($60,493.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $55,333.77, add-ons for qualifying new technology services are included. If operating cost exceeds $100,857.50 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,776.45, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.8. The base transfer operating payment is the transfer adjustment factor * $55,938.77 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $54,994.53 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $4,215.67. The transfer capital threshold is the transfer adjustment factor * $4,215.67. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","56935.83","56935.83","57320.68","1 through 10","54139.39","60493.68","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","60814.28","45610.71","MEDICARE [2001]","HB BWF MEDICARE","38758.32","","Case rate ($38,758.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $38,820.94, add-ons for qualifying new technology services are included. If operating cost exceeds $84,344.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,510.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,469.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $38,481.69 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,949.86. The transfer capital threshold is the transfer adjustment factor * $2,949.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","42897.49","42897.49","43187.04","1 through 10","37983.15","42831.74","other","Inpatient Replacement Plans DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","60814.28","45610.71","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","37983.15","","Case rate ($38,758.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $38,820.94, add-ons for qualifying new technology services are included. If operating cost exceeds $84,344.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,510.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,469.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $38,481.69 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,949.86. The transfer capital threshold is the transfer adjustment factor * $2,949.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","38766.25","38766.25","38766.25","1 through 10","37983.15","42831.74","other","Inpatient DRG"
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions Without Cc/McC","458","MS-DRG","","","","","","","","inpatient","","","60814.28","45610.71","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","37983.15","","Case rate ($38,758.32). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $38,820.94, add-ons for qualifying new technology services are included. If operating cost exceeds $84,344.67 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $5,510.64, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $35,469.21 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $38,481.69 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,949.86. The transfer capital threshold is the transfer adjustment factor * $2,949.86. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","38657.42","38657.42","38657.42","1 through 10","37983.15","42831.74","other","Inpatient DRG"
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","both","","","1760.00","1320.00","MEDICARE [2001]","HB BWF MEDICARE","350.56","","APC Price ($350.56). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","350.56","323.26","350.56","1 through 10","333.03","1673.76","other","OPPS APC"
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","863.63","49.07","","2115.00","2115.00","2115.00","1 through 10","567.68","1380.72","percent of total billed charges",""
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","881.76","50.1","","331.25","331.25","331.25","1 through 10","567.68","1380.72","percent of total billed charges",""
"Spinal Hardware Block Injection","PX-76002996","CDM","64999","CPT","0761","RC","","","","outpatient","","","1760.00","1320.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1380.72","78.45","","282.15","282.15","282.15","1 through 10","567.68","1380.72","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","554.95","91.85","1421.75","94","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","2490.03","2490.03","2490.03","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","750.00","750.00","750.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","1192.50","120.84","4149.90","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3570.00","85","","750.00","75.00","750.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4200.00","100","","657.00","121.50","1971.00","14","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4200.00","100","","75.00","75.00","75.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4200.00","100","","366.00","144.00","1971.00","45","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","667.50","667.50","667.50","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","123.77","123.77","123.77","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","483.51","229.32","1316.08","96","1866.9","4200","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","439.50","225.34","1872.27","197","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 10MM 2 HOLE LOW PROFILE TIMBERLINE","SUP-ITM-10140299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","385.32","55.36","1815.62","58","2100","3294.9","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","AETNA [1001]","HB CH AETNA HMO / PPO","1031.91","58.3","","554.95","91.85","1421.75","94","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","2490.03","2490.03","2490.03","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1031.91","58.3","","750.00","750.00","750.00","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","938.10","53","","1192.50","120.84","4149.90","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1504.50","85","","750.00","75.00","750.00","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1770.00","100","","657.00","121.50","1971.00","14","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1770.00","100","","75.00","75.00","75.00","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1770.00","100","","366.00","144.00","1971.00","45","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1292.10","73","","667.50","667.50","667.50","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","786.77","44.45","","123.77","123.77","123.77","1 through 10","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","both","","","1770.00","1327.50","WELLPOINT [1015]","HB CH WELLPOINT","1379.01","77.91","","483.51","229.32","1316.08","96","786.77","1770","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1049.61","59.3","","439.50","225.34","1872.27","197","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 30MM CERVICAL 2 LEVEL MAXAN TITANIUM","SUP-ITM-10108078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1770.00","1327.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1388.57","78.45","","385.32","55.36","1815.62","58","885","1388.57","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","554.95","91.85","1421.75","94","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","2490.03","2490.03","2490.03","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","750.00","750.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","1192.50","120.84","4149.90","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1721.25","85","","750.00","75.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2025.00","100","","657.00","121.50","1971.00","14","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2025.00","100","","75.00","75.00","75.00","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2025.00","100","","366.00","144.00","1971.00","45","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","667.50","667.50","667.50","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","123.77","123.77","123.77","1 through 10","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","483.51","229.32","1316.08","96","900.11","2025","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","439.50","225.34","1872.27","197","1012.5","1588.61","percent of total billed charges",""
"SPINAL PLATE 42MM CERVICAL 3 LEVEL MAXAN TITANIUM","SUP-ITM-10108086","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","385.32","55.36","1815.62","58","1012.5","1588.61","percent of total billed charges",""
"Spinal Procedures,MAJOR","023","DRG","","","","","","","","inpatient","","","47645.95","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","93275.03","","Standard inlier is a Case rate ($93,275.03). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $100,728, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($13,240.00) for the length of stay and the standard reimbursement.","89035.25","89035.25","89035.25","1 through 10","15357.01","121376.09","case rate",""
"Spinal Procedures,MINOR","023","DRG","","","","","","","","inpatient","","","53473.05","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","38508.79","","Fee schedule rate ($38,508.79). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","38508.79","38508.79","38508.79","1 through 10","15357.01","121376.09","case rate",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","AETNA [1001]","HB CH AETNA HMO / PPO","1136.85","58.3","","554.95","91.85","1421.75","94","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","2490.03","2490.03","2490.03","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1136.85","58.3","","750.00","750.00","750.00","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1033.50","53","","1192.50","120.84","4149.90","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1657.50","85","","750.00","75.00","750.00","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1950.00","100","","657.00","121.50","1971.00","14","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1950.00","100","","75.00","75.00","75.00","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1950.00","100","","366.00","144.00","1971.00","45","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1423.50","73","","667.50","667.50","667.50","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","866.78","44.45","","123.77","123.77","123.77","1 through 10","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","both","","","1950.00","1462.50","WELLPOINT [1015]","HB CH WELLPOINT","1519.25","77.91","","483.51","229.32","1316.08","96","866.78","1950","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1156.35","59.3","","439.50","225.34","1872.27","197","975","1529.78","percent of total billed charges",""
"SPINAL SHANK 6.5X45MM THREAD ATS","SUP-ITM-10307409","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1950.00","1462.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1529.78","78.45","","385.32","55.36","1815.62","58","975","1529.78","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1830.28","315.58","1830.28","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","4170.85","4170.85","4170.85","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","649.55","649.55","649.55","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","8998.38","2542.37","8998.38","20","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1891.61","1609.14","3664.18","25","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 10MM CERVICAL GRAFT BIOLOGIC ALLOGRAFT OSTEOSTIM","SUP-ITM-10048669","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1470.68","1310.06","2481.69","19","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1830.28","315.58","1830.28","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","4170.85","4170.85","4170.85","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","649.55","649.55","649.55","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","8998.38","2542.37","8998.38","20","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1891.61","1609.14","3664.18","25","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 11X14X6MM CERVICAL DEVICE FUSION INTERBODY VISTA PEEK OPTIMA LEFT1 ANGLED","SUP-ITM-10080812","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1470.68","1310.06","2481.69","19","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 30X9X16MM LUMBAR TRANSFORAMINAL ARDIS POLYETHER ETHER KETONE FUSION","SUP-ITM-10082603","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1830.28","315.58","1830.28","1 through 10","1778","4000","percent of total billed charges",""
"SPINAL SPACER 30X9X16MM LUMBAR TRANSFORAMINAL ARDIS POLYETHER ETHER KETONE FUSION","SUP-ITM-10082603","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","4170.85","4170.85","4170.85","1 through 10","1778","4000","percent of total billed charges",""
"SPINAL SPACER 30X9X16MM LUMBAR TRANSFORAMINAL ARDIS POLYETHER ETHER KETONE FUSION","SUP-ITM-10082603","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1778.00","44.45","","649.55","649.55","649.55","1 through 10","1778","4000","percent of total billed charges",""
"SPINAL SPACER 30X9X16MM LUMBAR TRANSFORAMINAL ARDIS POLYETHER ETHER KETONE FUSION","SUP-ITM-10082603","CDM","C1889","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","8998.38","2542.37","8998.38","20","1778","4000","percent of total billed charges",""
"SPINAL SPACER 30X9X16MM LUMBAR TRANSFORAMINAL ARDIS POLYETHER ETHER KETONE FUSION","SUP-ITM-10082603","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1891.61","1609.14","3664.18","25","2000","3138","percent of total billed charges",""
"SPINAL SPACER 30X9X16MM LUMBAR TRANSFORAMINAL ARDIS POLYETHER ETHER KETONE FUSION","SUP-ITM-10082603","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","1470.68","1310.06","2481.69","19","2000","3138","percent of total billed charges",""
"SPINAL SPACER 6MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048665","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1830.28","315.58","1830.28","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 6MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048665","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","4170.85","4170.85","4170.85","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 6MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048665","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","649.55","649.55","649.55","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 6MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048665","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","8998.38","2542.37","8998.38","20","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 6MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1891.61","1609.14","3664.18","25","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 6MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048665","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1470.68","1310.06","2481.69","19","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1830.28","315.58","1830.28","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","4170.85","4170.85","4170.85","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","649.55","649.55","649.55","1 through 10","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","8998.38","2542.37","8998.38","20","933.45","2100","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1891.61","1609.14","3664.18","25","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 7MM CERVICAL OSTEOSTIM CANCELLOUS LORDOTIC","SUP-ITM-10048666","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1470.68","1310.06","2481.69","19","1050","1647.45","percent of total billed charges",""
"SPINAL SPACER 7X27MM 6DEG CURVE ZYSTON PARALLEL","SUP-ITM-10108185","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","1830.28","315.58","1830.28","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL SPACER 7X27MM 6DEG CURVE ZYSTON PARALLEL","SUP-ITM-10108185","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","4170.85","4170.85","4170.85","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL SPACER 7X27MM 6DEG CURVE ZYSTON PARALLEL","SUP-ITM-10108185","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","649.55","649.55","649.55","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINAL SPACER 7X27MM 6DEG CURVE ZYSTON PARALLEL","SUP-ITM-10108185","CDM","C1889","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","8998.38","2542.37","8998.38","20","1866.9","4200","percent of total billed charges",""
"SPINAL SPACER 7X27MM 6DEG CURVE ZYSTON PARALLEL","SUP-ITM-10108185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","1891.61","1609.14","3664.18","25","2100","3294.9","percent of total billed charges",""
"SPINAL SPACER 7X27MM 6DEG CURVE ZYSTON PARALLEL","SUP-ITM-10108185","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","1470.68","1310.06","2481.69","19","2100","3294.9","percent of total billed charges",""
"SPINE CAGE 22 30MM SM 0DEGXMESH EXPANDABLE","SUP-ITM-10159235","CDM","C1889","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","AETNA [1001]","HB CH AETNA HMO / PPO","4605.70","58.3","","1830.28","315.58","1830.28","1 through 10","3511.55","7900","percent of total billed charges",""
"SPINE CAGE 22 30MM SM 0DEGXMESH EXPANDABLE","SUP-ITM-10159235","CDM","C1889","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5767.00","73","","4170.85","4170.85","4170.85","1 through 10","3511.55","7900","percent of total billed charges",""
"SPINE CAGE 22 30MM SM 0DEGXMESH EXPANDABLE","SUP-ITM-10159235","CDM","C1889","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3511.55","44.45","","649.55","649.55","649.55","1 through 10","3511.55","7900","percent of total billed charges",""
"SPINE CAGE 22 30MM SM 0DEGXMESH EXPANDABLE","SUP-ITM-10159235","CDM","C1889","HCPCS","0278","RC","","","","both","","","7900.00","5925.00","WELLPOINT [1015]","HB CH WELLPOINT","6154.89","77.91","","8998.38","2542.37","8998.38","20","3511.55","7900","percent of total billed charges",""
"SPINE CAGE 22 30MM SM 0DEGXMESH EXPANDABLE","SUP-ITM-10159235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4684.70","59.3","","1891.61","1609.14","3664.18","25","3950","6197.55","percent of total billed charges",""
"SPINE CAGE 22 30MM SM 0DEGXMESH EXPANDABLE","SUP-ITM-10159235","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7900.00","5925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6197.55","78.45","","1470.68","1310.06","2481.69","19","3950","6197.55","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","AETNA [1001]","HB CH AETNA HMO / PPO","1224.30","58.3","","1830.28","315.58","1830.28","1 through 10","933.45","2100","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1533.00","73","","4170.85","4170.85","4170.85","1 through 10","933.45","2100","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","933.45","44.45","","649.55","649.55","649.55","1 through 10","933.45","2100","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","both","","","2100.00","1575.00","WELLPOINT [1015]","HB CH WELLPOINT","1636.11","77.91","","8998.38","2542.37","8998.38","20","933.45","2100","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1245.30","59.3","","1891.61","1609.14","3664.18","25","1050","1647.45","percent of total billed charges",""
"SPINE CAGE 4.0MM 7.0DEG BENGAL CERVICAL CARBON FILTER REINFORCED POLYMER STANDARD","SUP-ITM-10029555","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2100.00","1575.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1647.45","78.45","","1470.68","1310.06","2481.69","19","1050","1647.45","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","1830.28","315.58","1830.28","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","4170.85","4170.85","4170.85","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","649.55","649.55","649.55","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","8998.38","2542.37","8998.38","20","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1891.61","1609.14","3664.18","25","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 41 49X5.5MM EXPEDIUM SFX TITANIUM CROSSLINK LATERAL SIZE A5","SUP-ITM-10022296","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1470.68","1310.06","2481.69","19","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","AETNA [1001]","HB CH AETNA HMO / PPO","848.27","58.3","","1830.28","315.58","1830.28","1 through 10","646.75","1455","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1062.15","73","","4170.85","4170.85","4170.85","1 through 10","646.75","1455","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","646.75","44.45","","649.55","649.55","649.55","1 through 10","646.75","1455","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","both","","","1455.00","1091.25","WELLPOINT [1015]","HB CH WELLPOINT","1133.59","77.91","","8998.38","2542.37","8998.38","20","646.75","1455","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","862.82","59.3","","1891.61","1609.14","3664.18","25","727.5","1141.45","percent of total billed charges",""
"SPINE CONNECTOR 5.5 TO 6.35 XMM EXPEDIUM ANGLED TITANIUM OPEN CLOSED","SUP-ITM-10079323","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1455.00","1091.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1141.45","78.45","","1470.68","1310.06","2481.69","19","727.5","1141.45","percent of total billed charges",""
"SPINE CONNECTOR 5.5 XMM EXPEDIUM TITANIUM TOP NOTCH","SUP-ITM-10105842","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","1830.28","315.58","1830.28","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5 XMM EXPEDIUM TITANIUM TOP NOTCH","SUP-ITM-10105842","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","4170.85","4170.85","4170.85","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5 XMM EXPEDIUM TITANIUM TOP NOTCH","SUP-ITM-10105842","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","649.55","649.55","649.55","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5 XMM EXPEDIUM TITANIUM TOP NOTCH","SUP-ITM-10105842","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","8998.38","2542.37","8998.38","20","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5 XMM EXPEDIUM TITANIUM TOP NOTCH","SUP-ITM-10105842","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","1891.61","1609.14","3664.18","25","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 5.5 XMM EXPEDIUM TITANIUM TOP NOTCH","SUP-ITM-10105842","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1470.68","1310.06","2481.69","19","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 5.5MM ROD","SUP-ITM-10105843","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","1830.28","315.58","1830.28","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5MM ROD","SUP-ITM-10105843","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","4170.85","4170.85","4170.85","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5MM ROD","SUP-ITM-10105843","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","649.55","649.55","649.55","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5MM ROD","SUP-ITM-10105843","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","8998.38","2542.37","8998.38","20","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5MM ROD","SUP-ITM-10105843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","1891.61","1609.14","3664.18","25","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 5.5MM ROD","SUP-ITM-10105843","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1470.68","1310.06","2481.69","19","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","1830.28","315.58","1830.28","1 through 10","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","4170.85","4170.85","4170.85","1 through 10","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","649.55","649.55","649.55","1 through 10","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","8998.38","2542.37","8998.38","20","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","1891.61","1609.14","3664.18","25","217.5","341.26","percent of total billed charges",""
"SPINE CONNECTOR 5.5X20.0MM EXPEDIUM TITANIUM ILIAC OPEN LATERAL","SUP-ITM-10045848","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","1470.68","1310.06","2481.69","19","217.5","341.26","percent of total billed charges",""
"SPINE CONNECTOR 5.5X49 66MM EXPEDIUM SFX TITANIUM CROSS ADJUSTABLE LATERAL SIZE A6","SUP-ITM-10031064","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","1830.28","315.58","1830.28","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 5.5X49 66MM EXPEDIUM SFX TITANIUM CROSS ADJUSTABLE LATERAL SIZE A6","SUP-ITM-10031064","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","4170.85","4170.85","4170.85","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 5.5X49 66MM EXPEDIUM SFX TITANIUM CROSS ADJUSTABLE LATERAL SIZE A6","SUP-ITM-10031064","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","649.55","649.55","649.55","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 5.5X49 66MM EXPEDIUM SFX TITANIUM CROSS ADJUSTABLE LATERAL SIZE A6","SUP-ITM-10031064","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","8998.38","2542.37","8998.38","20","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR 5.5X49 66MM EXPEDIUM SFX TITANIUM CROSS ADJUSTABLE LATERAL SIZE A6","SUP-ITM-10031064","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1891.61","1609.14","3664.18","25","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 5.5X49 66MM EXPEDIUM SFX TITANIUM CROSS ADJUSTABLE LATERAL SIZE A6","SUP-ITM-10031064","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1470.68","1310.06","2481.69","19","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","1830.28","315.58","1830.28","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","4170.85","4170.85","4170.85","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","649.55","649.55","649.55","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","8998.38","2542.37","8998.38","20","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","1891.61","1609.14","3664.18","25","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 5.5X5.50MM MONARCH TITANIUM DUAL SIDE BY","SUP-ITM-10045591","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1470.68","1310.06","2481.69","19","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 6.35X5.5MM MONARCH TITANIUM DUAL SIDE","SUP-ITM-10045486","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","1830.28","315.58","1830.28","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 6.35X5.5MM MONARCH TITANIUM DUAL SIDE","SUP-ITM-10045486","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","4170.85","4170.85","4170.85","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 6.35X5.5MM MONARCH TITANIUM DUAL SIDE","SUP-ITM-10045486","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","333.38","44.45","","649.55","649.55","649.55","1 through 10","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 6.35X5.5MM MONARCH TITANIUM DUAL SIDE","SUP-ITM-10045486","CDM","C1889","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","8998.38","2542.37","8998.38","20","333.38","750","percent of total billed charges",""
"SPINE CONNECTOR 6.35X5.5MM MONARCH TITANIUM DUAL SIDE","SUP-ITM-10045486","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","1891.61","1609.14","3664.18","25","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR 6.35X5.5MM MONARCH TITANIUM DUAL SIDE","SUP-ITM-10045486","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","1470.68","1310.06","2481.69","19","375","588.38","percent of total billed charges",""
"SPINE CONNECTOR SM TITANIUM","SUP-ITM-10059525","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","AETNA [1001]","HB CH AETNA HMO / PPO","253.61","58.3","","1830.28","315.58","1830.28","1 through 10","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR SM TITANIUM","SUP-ITM-10059525","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","317.55","73","","4170.85","4170.85","4170.85","1 through 10","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR SM TITANIUM","SUP-ITM-10059525","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","193.36","44.45","","649.55","649.55","649.55","1 through 10","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR SM TITANIUM","SUP-ITM-10059525","CDM","C1889","HCPCS","0278","RC","","","","both","","","435.00","326.25","WELLPOINT [1015]","HB CH WELLPOINT","338.91","77.91","","8998.38","2542.37","8998.38","20","193.36","435","percent of total billed charges",""
"SPINE CONNECTOR SM TITANIUM","SUP-ITM-10059525","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","257.96","59.3","","1891.61","1609.14","3664.18","25","217.5","341.26","percent of total billed charges",""
"SPINE CONNECTOR SM TITANIUM","SUP-ITM-10059525","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","435.00","326.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","341.26","78.45","","1470.68","1310.06","2481.69","19","217.5","341.26","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","1830.28","315.58","1830.28","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","4170.85","4170.85","4170.85","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","649.55","649.55","649.55","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","8998.38","2542.37","8998.38","20","593.41","1335","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1891.61","1609.14","3664.18","25","667.5","1047.31","percent of total billed charges",""
"SPINE CONNECTOR SMALL 0DEG XIA II LOW PROFILE ROD","SUP-ITM-10026099","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1470.68","1310.06","2481.69","19","667.5","1047.31","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.026S","SUP-ITM-10047624","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","AETNA [1001]","HB CH AETNA HMO / PPO","5458.05","58.3","","1830.28","315.58","1830.28","1 through 10","4161.41","9362","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.026S","SUP-ITM-10047624","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6834.26","73","","4170.85","4170.85","4170.85","1 through 10","4161.41","9362","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.026S","SUP-ITM-10047624","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","4161.41","44.45","","649.55","649.55","649.55","1 through 10","4161.41","9362","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.026S","SUP-ITM-10047624","CDM","C1889","HCPCS","0278","RC","","","","both","","","9362.00","7021.50","WELLPOINT [1015]","HB CH WELLPOINT","7293.93","77.91","","8998.38","2542.37","8998.38","20","4161.41","9362","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.026S","SUP-ITM-10047624","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9362.00","7021.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5551.67","59.3","","1891.61","1609.14","3664.18","25","4681","7344.49","percent of total billed charges",""
"SPINE DISC 6MM PRODISC-C COBALT CHROME MOLYBDENUM ULTRA HIGH MOLECULAR WEIGHT POLYETHYLENE TI COATING MED 09.820.026S","SUP-ITM-10047624","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","9362.00","7021.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","7344.49","78.45","","1470.68","1310.06","2481.69","19","4681","7344.49","percent of total billed charges",""
"SPINE HOOK SACRAL XIA 3 RIGHT","SUP-ITM-10107398","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","AETNA [1001]","HB CH AETNA HMO / PPO","778.31","58.3","","1830.28","315.58","1830.28","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE HOOK SACRAL XIA 3 RIGHT","SUP-ITM-10107398","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","974.55","73","","4170.85","4170.85","4170.85","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE HOOK SACRAL XIA 3 RIGHT","SUP-ITM-10107398","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","593.41","44.45","","649.55","649.55","649.55","1 through 10","593.41","1335","percent of total billed charges",""
"SPINE HOOK SACRAL XIA 3 RIGHT","SUP-ITM-10107398","CDM","C1889","HCPCS","0278","RC","","","","both","","","1335.00","1001.25","WELLPOINT [1015]","HB CH WELLPOINT","1040.10","77.91","","8998.38","2542.37","8998.38","20","593.41","1335","percent of total billed charges",""
"SPINE HOOK SACRAL XIA 3 RIGHT","SUP-ITM-10107398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","791.66","59.3","","1891.61","1609.14","3664.18","25","667.5","1047.31","percent of total billed charges",""
"SPINE HOOK SACRAL XIA 3 RIGHT","SUP-ITM-10107398","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1335.00","1001.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1047.31","78.45","","1470.68","1310.06","2481.69","19","667.5","1047.31","percent of total billed charges",""
"SPINE HOOK SM PEDICLE XIA 3 TITANIUM","SUP-ITM-10089721","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","AETNA [1001]","HB CH AETNA HMO / PPO","699.60","58.3","","1830.28","315.58","1830.28","1 through 10","533.4","1200","percent of total billed charges",""
"SPINE HOOK SM PEDICLE XIA 3 TITANIUM","SUP-ITM-10089721","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","876.00","73","","4170.85","4170.85","4170.85","1 through 10","533.4","1200","percent of total billed charges",""
"SPINE HOOK SM PEDICLE XIA 3 TITANIUM","SUP-ITM-10089721","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","533.40","44.45","","649.55","649.55","649.55","1 through 10","533.4","1200","percent of total billed charges",""
"SPINE HOOK SM PEDICLE XIA 3 TITANIUM","SUP-ITM-10089721","CDM","C1889","HCPCS","0278","RC","","","","both","","","1200.00","900.00","WELLPOINT [1015]","HB CH WELLPOINT","934.92","77.91","","8998.38","2542.37","8998.38","20","533.4","1200","percent of total billed charges",""
"SPINE HOOK SM PEDICLE XIA 3 TITANIUM","SUP-ITM-10089721","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","711.60","59.3","","1891.61","1609.14","3664.18","25","600","941.4","percent of total billed charges",""
"SPINE HOOK SM PEDICLE XIA 3 TITANIUM","SUP-ITM-10089721","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1200.00","900.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","941.40","78.45","","1470.68","1310.06","2481.69","19","600","941.4","percent of total billed charges",""
"SPINE INTERBODY 10X28X8 TO 13MM 12DEG PROLIFT EXPANDABLE","SUP-ITM-10283156","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","AETNA [1001]","HB CH AETNA HMO / PPO","3498.00","58.3","","1830.28","315.58","1830.28","1 through 10","2667","6000","percent of total billed charges",""
"SPINE INTERBODY 10X28X8 TO 13MM 12DEG PROLIFT EXPANDABLE","SUP-ITM-10283156","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","4170.85","4170.85","4170.85","1 through 10","2667","6000","percent of total billed charges",""
"SPINE INTERBODY 10X28X8 TO 13MM 12DEG PROLIFT EXPANDABLE","SUP-ITM-10283156","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2667.00","44.45","","649.55","649.55","649.55","1 through 10","2667","6000","percent of total billed charges",""
"SPINE INTERBODY 10X28X8 TO 13MM 12DEG PROLIFT EXPANDABLE","SUP-ITM-10283156","CDM","C1889","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB CH WELLPOINT","4674.60","77.91","","8998.38","2542.37","8998.38","20","2667","6000","percent of total billed charges",""
"SPINE INTERBODY 10X28X8 TO 13MM 12DEG PROLIFT EXPANDABLE","SUP-ITM-10283156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","1891.61","1609.14","3664.18","25","3000","4707","percent of total billed charges",""
"SPINE INTERBODY 10X28X8 TO 13MM 12DEG PROLIFT EXPANDABLE","SUP-ITM-10283156","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4707.00","78.45","","1470.68","1310.06","2481.69","19","3000","4707","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","AETNA [1001]","HB CH AETNA HMO / PPO","638.39","58.3","","554.95","91.85","1421.75","94","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","799.35","73","","2490.03","2490.03","2490.03","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","638.39","58.3","","750.00","750.00","750.00","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","580.35","53","","1192.50","120.84","4149.90","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","930.75","85","","750.00","75.00","750.00","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1095.00","100","","657.00","121.50","1971.00","14","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1095.00","100","","75.00","75.00","75.00","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1095.00","100","","366.00","144.00","1971.00","45","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","799.35","73","","667.50","667.50","667.50","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","486.73","44.45","","123.77","123.77","123.77","1 through 10","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","both","","","1095.00","821.25","WELLPOINT [1015]","HB CH WELLPOINT","853.11","77.91","","483.51","229.32","1316.08","96","486.73","1095","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","649.34","59.3","","439.50","225.34","1872.27","197","547.5","859.03","percent of total billed charges",""
"SPINE PLATE 2 HOLE TIMBERLINE COVER LOW PROFILE","SUP-ITM-10140288","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1095.00","821.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","859.03","78.45","","385.32","55.36","1815.62","58","547.5","859.03","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","AETNA [1001]","HB CH AETNA HMO / PPO","1486.65","58.3","","554.95","91.85","1421.75","94","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","2490.03","2490.03","2490.03","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1486.65","58.3","","750.00","750.00","750.00","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1351.50","53","","1192.50","120.84","4149.90","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2167.50","85","","750.00","75.00","750.00","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2550.00","100","","657.00","121.50","1971.00","14","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2550.00","100","","75.00","75.00","75.00","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2550.00","100","","366.00","144.00","1971.00","45","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1861.50","73","","667.50","667.50","667.50","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1133.48","44.45","","123.77","123.77","123.77","1 through 10","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","both","","","2550.00","1912.50","WELLPOINT [1015]","HB CH WELLPOINT","1986.71","77.91","","483.51","229.32","1316.08","96","1133.48","2550","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1512.15","59.3","","439.50","225.34","1872.27","197","1275","2000.48","percent of total billed charges",""
"SPINE PLATE 31MM SMALL BONE MOUNTAINEER TITANIUM OCCIPITAL","SUP-ITM-10017659","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2550.00","1912.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2000.48","78.45","","385.32","55.36","1815.62","58","1275","2000.48","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","AETNA [1001]","HB CH AETNA HMO / PPO","3498.00","58.3","","554.95","91.85","1421.75","94","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","2490.03","2490.03","2490.03","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3498.00","58.3","","750.00","750.00","750.00","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3180.00","53","","1192.50","120.84","4149.90","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5100.00","85","","750.00","75.00","750.00","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6000.00","100","","657.00","121.50","1971.00","14","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6000.00","100","","75.00","75.00","75.00","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6000.00","100","","366.00","144.00","1971.00","45","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4380.00","73","","667.50","667.50","667.50","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2667.00","44.45","","123.77","123.77","123.77","1 through 10","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","both","","","6000.00","4500.00","WELLPOINT [1015]","HB CH WELLPOINT","4674.60","77.91","","483.51","229.32","1316.08","96","2667","6000","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3558.00","59.3","","439.50","225.34","1872.27","197","3000","4707","percent of total billed charges",""
"SPINE PLATE 35MM AFFIX II","SUP-ITM-10093871","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6000.00","4500.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4707.00","78.45","","385.32","55.36","1815.62","58","3000","4707","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","AETNA [1001]","HB CH AETNA HMO / PPO","647.13","58.3","","554.95","91.85","1421.75","94","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","2490.03","2490.03","2490.03","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","647.13","58.3","","750.00","750.00","750.00","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","588.30","53","","1192.50","120.84","4149.90","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","943.50","85","","750.00","75.00","750.00","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1110.00","100","","657.00","121.50","1971.00","14","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1110.00","100","","75.00","75.00","75.00","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1110.00","100","","366.00","144.00","1971.00","45","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","810.30","73","","667.50","667.50","667.50","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","493.40","44.45","","123.77","123.77","123.77","1 through 10","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","both","","","1110.00","832.50","WELLPOINT [1015]","HB CH WELLPOINT","864.80","77.91","","483.51","229.32","1316.08","96","493.4","1110","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","658.23","59.3","","439.50","225.34","1872.27","197","555","870.8","percent of total billed charges",""
"SPINE PLATE 8MM 31X2 TI DOUBLE BEND MINI SPACIN","SUP-ITM-10014031","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1110.00","832.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","870.80","78.45","","385.32","55.36","1815.62","58","555","870.8","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","AETNA [1001]","HB CH AETNA HMO / PPO","2448.60","58.3","","554.95","91.85","1421.75","94","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","2490.03","2490.03","2490.03","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2448.60","58.3","","750.00","750.00","750.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2226.00","53","","1192.50","120.84","4149.90","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3570.00","85","","750.00","75.00","750.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4200.00","100","","657.00","121.50","1971.00","14","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4200.00","100","","75.00","75.00","75.00","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4200.00","100","","366.00","144.00","1971.00","45","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3066.00","73","","667.50","667.50","667.50","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1866.90","44.45","","123.77","123.77","123.77","1 through 10","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","both","","","4200.00","3150.00","WELLPOINT [1015]","HB CH WELLPOINT","3272.22","77.91","","483.51","229.32","1316.08","96","1866.9","4200","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2490.60","59.3","","439.50","225.34","1872.27","197","2100","3294.9","percent of total billed charges",""
"SPINE PLATE SM LUMBAR OBLIQUE FUSION 2 HOLE","SUP-ITM-10175600","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4200.00","3150.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3294.90","78.45","","385.32","55.36","1815.62","58","2100","3294.9","percent of total billed charges",""
"SPINE RING 17MMX22 0DEG END SYNMESH PRESS FIT OBLONG ANTEROLATERAL","SUP-ITM-10007261","CDM","C1889","HCPCS","0278","RC","","","","both","","","390.00","292.50","AETNA [1001]","HB CH AETNA HMO / PPO","227.37","58.3","","1830.28","315.58","1830.28","1 through 10","173.36","390","percent of total billed charges",""
"SPINE RING 17MMX22 0DEG END SYNMESH PRESS FIT OBLONG ANTEROLATERAL","SUP-ITM-10007261","CDM","C1889","HCPCS","0278","RC","","","","both","","","390.00","292.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.70","73","","4170.85","4170.85","4170.85","1 through 10","173.36","390","percent of total billed charges",""
"SPINE RING 17MMX22 0DEG END SYNMESH PRESS FIT OBLONG ANTEROLATERAL","SUP-ITM-10007261","CDM","C1889","HCPCS","0278","RC","","","","both","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","173.36","44.45","","649.55","649.55","649.55","1 through 10","173.36","390","percent of total billed charges",""
"SPINE RING 17MMX22 0DEG END SYNMESH PRESS FIT OBLONG ANTEROLATERAL","SUP-ITM-10007261","CDM","C1889","HCPCS","0278","RC","","","","both","","","390.00","292.50","WELLPOINT [1015]","HB CH WELLPOINT","303.85","77.91","","8998.38","2542.37","8998.38","20","173.36","390","percent of total billed charges",""
"SPINE RING 17MMX22 0DEG END SYNMESH PRESS FIT OBLONG ANTEROLATERAL","SUP-ITM-10007261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.27","59.3","","1891.61","1609.14","3664.18","25","195","305.96","percent of total billed charges",""
"SPINE RING 17MMX22 0DEG END SYNMESH PRESS FIT OBLONG ANTEROLATERAL","SUP-ITM-10007261","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.96","78.45","","1470.68","1310.06","2481.69","19","195","305.96","percent of total billed charges",""
"SPINE ROD 3 6MMX120 SHORT XIA VITALLIUM PREBENT PRECUT 1 HEX","SUP-ITM-10129701","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","AETNA [1001]","HB CH AETNA HMO / PPO","843.02","58.3","","1830.28","315.58","1830.28","1 through 10","642.75","1446","percent of total billed charges",""
"SPINE ROD 3 6MMX120 SHORT XIA VITALLIUM PREBENT PRECUT 1 HEX","SUP-ITM-10129701","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1055.58","73","","4170.85","4170.85","4170.85","1 through 10","642.75","1446","percent of total billed charges",""
"SPINE ROD 3 6MMX120 SHORT XIA VITALLIUM PREBENT PRECUT 1 HEX","SUP-ITM-10129701","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","642.75","44.45","","649.55","649.55","649.55","1 through 10","642.75","1446","percent of total billed charges",""
"SPINE ROD 3 6MMX120 SHORT XIA VITALLIUM PREBENT PRECUT 1 HEX","SUP-ITM-10129701","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","WELLPOINT [1015]","HB CH WELLPOINT","1126.58","77.91","","8998.38","2542.37","8998.38","20","642.75","1446","percent of total billed charges",""
"SPINE ROD 3 6MMX120 SHORT XIA VITALLIUM PREBENT PRECUT 1 HEX","SUP-ITM-10129701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1446.00","1084.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","857.48","59.3","","1891.61","1609.14","3664.18","25","723","1134.39","percent of total billed charges",""
"SPINE ROD 3 6MMX120 SHORT XIA VITALLIUM PREBENT PRECUT 1 HEX","SUP-ITM-10129701","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1446.00","1084.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1134.39","78.45","","1470.68","1310.06","2481.69","19","723","1134.39","percent of total billed charges",""
"SPINE ROD 3 6MMX30 XIA VITALLIUM PREBENT PRECUT","SUP-ITM-10100046","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","AETNA [1001]","HB CH AETNA HMO / PPO","276.34","58.3","","1830.28","315.58","1830.28","1 through 10","210.69","474","percent of total billed charges",""
"SPINE ROD 3 6MMX30 XIA VITALLIUM PREBENT PRECUT","SUP-ITM-10100046","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","346.02","73","","4170.85","4170.85","4170.85","1 through 10","210.69","474","percent of total billed charges",""
"SPINE ROD 3 6MMX30 XIA VITALLIUM PREBENT PRECUT","SUP-ITM-10100046","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","210.69","44.45","","649.55","649.55","649.55","1 through 10","210.69","474","percent of total billed charges",""
"SPINE ROD 3 6MMX30 XIA VITALLIUM PREBENT PRECUT","SUP-ITM-10100046","CDM","C1889","HCPCS","0278","RC","","","","both","","","474.00","355.50","WELLPOINT [1015]","HB CH WELLPOINT","369.29","77.91","","8998.38","2542.37","8998.38","20","210.69","474","percent of total billed charges",""
"SPINE ROD 3 6MMX30 XIA VITALLIUM PREBENT PRECUT","SUP-ITM-10100046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","474.00","355.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","281.08","59.3","","1891.61","1609.14","3664.18","25","237","371.85","percent of total billed charges",""
"SPINE ROD 3 6MMX30 XIA VITALLIUM PREBENT PRECUT","SUP-ITM-10100046","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","474.00","355.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","371.85","78.45","","1470.68","1310.06","2481.69","19","237","371.85","percent of total billed charges",""
"SPINE ROD 3.5X120 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046433","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","AETNA [1001]","HB CH AETNA HMO / PPO","682.11","58.3","","1830.28","315.58","1830.28","1 through 10","520.07","1170","percent of total billed charges",""
"SPINE ROD 3.5X120 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046433","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","854.10","73","","4170.85","4170.85","4170.85","1 through 10","520.07","1170","percent of total billed charges",""
"SPINE ROD 3.5X120 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046433","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","520.07","44.45","","649.55","649.55","649.55","1 through 10","520.07","1170","percent of total billed charges",""
"SPINE ROD 3.5X120 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046433","CDM","C1889","HCPCS","0278","RC","","","","both","","","1170.00","877.50","WELLPOINT [1015]","HB CH WELLPOINT","911.55","77.91","","8998.38","2542.37","8998.38","20","520.07","1170","percent of total billed charges",""
"SPINE ROD 3.5X120 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","693.81","59.3","","1891.61","1609.14","3664.18","25","585","917.87","percent of total billed charges",""
"SPINE ROD 3.5X120 TO 72MM MOUNTAINEER TITANIUM LOW PROFILE ADJUSTABLE OCCIPITAL","SUP-ITM-10046433","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1170.00","877.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","917.87","78.45","","1470.68","1310.06","2481.69","19","585","917.87","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","1830.28","315.58","1830.28","1 through 10","200.03","450","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","4170.85","4170.85","4170.85","1 through 10","200.03","450","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","649.55","649.55","649.55","1 through 10","200.03","450","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","8998.38","2542.37","8998.38","20","200.03","450","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","1891.61","1609.14","3664.18","25","225","353.03","percent of total billed charges",""
"SPINE ROD 300X5.5MM EXPEDIUM TITANIUM PRECUT HEX END STRAIGHT","SUP-ITM-10018312","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1470.68","1310.06","2481.69","19","225","353.03","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","1830.28","315.58","1830.28","1 through 10","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","4170.85","4170.85","4170.85","1 through 10","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","649.55","649.55","649.55","1 through 10","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","8998.38","2542.37","8998.38","20","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","1891.61","1609.14","3664.18","25","360","564.84","percent of total billed charges",""
"SPINE ROD 5.5X120.0MM VIPER2 MINIMALLY INVASIVE LORDOTIC","SUP-ITM-10046241","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","1470.68","1310.06","2481.69","19","360","564.84","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","1830.28","315.58","1830.28","1 through 10","266.7","600","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","4170.85","4170.85","4170.85","1 through 10","266.7","600","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","649.55","649.55","649.55","1 through 10","266.7","600","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","8998.38","2542.37","8998.38","20","266.7","600","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","1891.61","1609.14","3664.18","25","300","470.7","percent of total billed charges",""
"SPINE ROD 5.5X480MM BONE LUMBAR PRECUT STRAIGHT TITANIUM","SUP-ITM-10018599","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1470.68","1310.06","2481.69","19","300","470.7","percent of total billed charges",""
"SPINE ROD 5.5X60.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046233","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","1830.28","315.58","1830.28","1 through 10","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X60.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046233","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","4170.85","4170.85","4170.85","1 through 10","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X60.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046233","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","649.55","649.55","649.55","1 through 10","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X60.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046233","CDM","C1889","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","8998.38","2542.37","8998.38","20","320.04","720","percent of total billed charges",""
"SPINE ROD 5.5X60.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","1891.61","1609.14","3664.18","25","360","564.84","percent of total billed charges",""
"SPINE ROD 5.5X60.0MM VIPER 2 TITANIUM CURVED LORDOSED","SUP-ITM-10046233","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","1470.68","1310.06","2481.69","19","360","564.84","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","AETNA [1001]","HB CH AETNA HMO / PPO","384.78","58.3","","1830.28","315.58","1830.28","1 through 10","293.37","660","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","481.80","73","","4170.85","4170.85","4170.85","1 through 10","293.37","660","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","293.37","44.45","","649.55","649.55","649.55","1 through 10","293.37","660","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","both","","","660.00","495.00","WELLPOINT [1015]","HB CH WELLPOINT","514.21","77.91","","8998.38","2542.37","8998.38","20","293.37","660","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","391.38","59.3","","1891.61","1609.14","3664.18","25","330","517.77","percent of total billed charges",""
"SPINE ROD 5.5X65.0MM VIPER 2 TITANIUM LORDOSED CURVED","SUP-ITM-10046234","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","660.00","495.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","517.77","78.45","","1470.68","1310.06","2481.69","19","330","517.77","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","AETNA [1001]","HB CH AETNA HMO / PPO","262.35","58.3","","1830.28","315.58","1830.28","1 through 10","200.03","450","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","328.50","73","","4170.85","4170.85","4170.85","1 through 10","200.03","450","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","200.03","44.45","","649.55","649.55","649.55","1 through 10","200.03","450","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","both","","","450.00","337.50","WELLPOINT [1015]","HB CH WELLPOINT","350.60","77.91","","8998.38","2542.37","8998.38","20","200.03","450","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","266.85","59.3","","1891.61","1609.14","3664.18","25","225","353.03","percent of total billed charges",""
"SPINE ROD 6.0X35.0MM TI ANT/POST SMOOTH CURVED RAD XIA III","SUP-ITM-10089785","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","450.00","337.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","353.03","78.45","","1470.68","1310.06","2481.69","19","225","353.03","percent of total billed charges",""
"SPINE ROD 6.0X600.0MM ANTERIOR/POSTERIOR HEXAGONAL SMOOTH XIA","SUP-ITM-10089745","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","AETNA [1001]","HB CH AETNA HMO / PPO","843.02","58.3","","1830.28","315.58","1830.28","1 through 10","642.75","1446","percent of total billed charges",""
"SPINE ROD 6.0X600.0MM ANTERIOR/POSTERIOR HEXAGONAL SMOOTH XIA","SUP-ITM-10089745","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1055.58","73","","4170.85","4170.85","4170.85","1 through 10","642.75","1446","percent of total billed charges",""
"SPINE ROD 6.0X600.0MM ANTERIOR/POSTERIOR HEXAGONAL SMOOTH XIA","SUP-ITM-10089745","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","642.75","44.45","","649.55","649.55","649.55","1 through 10","642.75","1446","percent of total billed charges",""
"SPINE ROD 6.0X600.0MM ANTERIOR/POSTERIOR HEXAGONAL SMOOTH XIA","SUP-ITM-10089745","CDM","C1889","HCPCS","0278","RC","","","","both","","","1446.00","1084.50","WELLPOINT [1015]","HB CH WELLPOINT","1126.58","77.91","","8998.38","2542.37","8998.38","20","642.75","1446","percent of total billed charges",""
"SPINE ROD 6.0X600.0MM ANTERIOR/POSTERIOR HEXAGONAL SMOOTH XIA","SUP-ITM-10089745","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1446.00","1084.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","857.48","59.3","","1891.61","1609.14","3664.18","25","723","1134.39","percent of total billed charges",""
"SPINE ROD 6.0X600.0MM ANTERIOR/POSTERIOR HEXAGONAL SMOOTH XIA","SUP-ITM-10089745","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","1446.00","1084.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1134.39","78.45","","1470.68","1310.06","2481.69","19","723","1134.39","percent of total billed charges",""
"SPINE ROD 6X600MM TI ANT/POST SMOOTH HEX END L CP XIA II","SUP-ITM-10089744","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","AETNA [1001]","HB CH AETNA HMO / PPO","349.80","58.3","","1830.28","315.58","1830.28","1 through 10","266.7","600","percent of total billed charges",""
"SPINE ROD 6X600MM TI ANT/POST SMOOTH HEX END L CP XIA II","SUP-ITM-10089744","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","438.00","73","","4170.85","4170.85","4170.85","1 through 10","266.7","600","percent of total billed charges",""
"SPINE ROD 6X600MM TI ANT/POST SMOOTH HEX END L CP XIA II","SUP-ITM-10089744","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","266.70","44.45","","649.55","649.55","649.55","1 through 10","266.7","600","percent of total billed charges",""
"SPINE ROD 6X600MM TI ANT/POST SMOOTH HEX END L CP XIA II","SUP-ITM-10089744","CDM","C1889","HCPCS","0278","RC","","","","both","","","600.00","450.00","WELLPOINT [1015]","HB CH WELLPOINT","467.46","77.91","","8998.38","2542.37","8998.38","20","266.7","600","percent of total billed charges",""
"SPINE ROD 6X600MM TI ANT/POST SMOOTH HEX END L CP XIA II","SUP-ITM-10089744","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","355.80","59.3","","1891.61","1609.14","3664.18","25","300","470.7","percent of total billed charges",""
"SPINE ROD 6X600MM TI ANT/POST SMOOTH HEX END L CP XIA II","SUP-ITM-10089744","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","600.00","450.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","470.70","78.45","","1470.68","1310.06","2481.69","19","300","470.7","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","AETNA [1001]","HB CH AETNA HMO / PPO","3614.60","58.3","","554.95","91.85","1421.75","94","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4526.00","73","","2490.03","2490.03","2490.03","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3614.60","58.3","","750.00","750.00","750.00","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3286.00","53","","1192.50","120.84","4149.90","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5270.00","85","","750.00","75.00","750.00","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6200.00","100","","657.00","121.50","1971.00","14","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6200.00","100","","75.00","75.00","75.00","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6200.00","100","","366.00","144.00","1971.00","45","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4526.00","73","","667.50","667.50","667.50","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2755.90","44.45","","123.77","123.77","123.77","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB CH WELLPOINT","4830.42","77.91","","483.51","229.32","1316.08","96","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3676.60","59.3","","439.50","225.34","1872.27","197","3100","4863.9","percent of total billed charges",""
"SPINE ROD 7.0X30MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10175533","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4863.90","78.45","","385.32","55.36","1815.62","58","3100","4863.9","percent of total billed charges",""
"SPINE ROD 7.0X35MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10146828","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","AETNA [1001]","HB CH AETNA HMO / PPO","3614.60","58.3","","1830.28","315.58","1830.28","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X35MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10146828","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4526.00","73","","4170.85","4170.85","4170.85","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X35MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10146828","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2755.90","44.45","","649.55","649.55","649.55","1 through 10","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X35MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10146828","CDM","C1889","HCPCS","0278","RC","","","","both","","","6200.00","4650.00","WELLPOINT [1015]","HB CH WELLPOINT","4830.42","77.91","","8998.38","2542.37","8998.38","20","2755.9","6200","percent of total billed charges",""
"SPINE ROD 7.0X35MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10146828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3676.60","59.3","","1891.61","1609.14","3664.18","25","3100","4863.9","percent of total billed charges",""
"SPINE ROD 7.0X35MM SPINAL IFUSE TITANIUM SACROILIAC FUSION","SUP-ITM-10146828","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6200.00","4650.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4863.90","78.45","","1470.68","1310.06","2481.69","19","3100","4863.9","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","AETNA [1001]","HB CH AETNA HMO / PPO","104.94","58.3","","1634.24","1004.95","1718.99","42","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","2123.89","1900.92","2123.89","1 through 10","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","104.94","58.3","","3729.00","1254.19","3729.00","1 through 10","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","95.40","53","","939.37","939.37","5593.65","1 through 10","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","153.00","85","","2323.25","1864.50","2882.25","16","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","180.00","100","","2909.44","1772.40","10952.08","45","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","180.00","100","","2323.25","2323.25","2323.25","1 through 10","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","180.00","100","","2882.25","1772.40","10169.17","187","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","131.40","73","","1659.41","1659.41","1659.41","1 through 10","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","both","","","180.00","135.00","WELLPOINT [1015]","HB CH WELLPOINT","140.24","77.91","","2050.91","1468.48","2902.83","52","80.01","180","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","106.74","59.3","","1548.60","1092.60","3613.79","82","90","141.21","percent of total billed charges",""
"SPINE ROD SHOULDER RETRIVERSION REVERSE 09","SUP-ITM-10082279","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","180.00","135.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.21","78.45","","2085.51","998.68","6202.11","56","90","141.21","percent of total billed charges",""
"SPINE SET 1.3X4.7MM 40CM EXT STIMLTR CORD IMPL INLINE SCRW PASS TUNNELING OBTRTR TRQ WRENCH BOOT OCTAPOLAR","SUP-ITM-10016454","CDM","C1883","HCPCS","0278","RC","","","","both","","","1785.00","1338.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","946.05","53","","1892.10","1892.10","1892.10","1 through 10","946.05","1785","percent of total billed charges",""
"SPINE SPACER 12X18 45MM XL 10DEG COROENT PEEK STAND ALONE LORDOTIC XLF","SUP-ITM-10057541","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","AETNA [1001]","HB CH AETNA HMO / PPO","4949.67","58.3","","1830.28","315.58","1830.28","1 through 10","3773.81","8490","percent of total billed charges",""
"SPINE SPACER 12X18 45MM XL 10DEG COROENT PEEK STAND ALONE LORDOTIC XLF","SUP-ITM-10057541","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","6197.70","73","","4170.85","4170.85","4170.85","1 through 10","3773.81","8490","percent of total billed charges",""
"SPINE SPACER 12X18 45MM XL 10DEG COROENT PEEK STAND ALONE LORDOTIC XLF","SUP-ITM-10057541","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3773.81","44.45","","649.55","649.55","649.55","1 through 10","3773.81","8490","percent of total billed charges",""
"SPINE SPACER 12X18 45MM XL 10DEG COROENT PEEK STAND ALONE LORDOTIC XLF","SUP-ITM-10057541","CDM","C1889","HCPCS","0278","RC","","","","both","","","8490.00","6367.50","WELLPOINT [1015]","HB CH WELLPOINT","6614.56","77.91","","8998.38","2542.37","8998.38","20","3773.81","8490","percent of total billed charges",""
"SPINE SPACER 12X18 45MM XL 10DEG COROENT PEEK STAND ALONE LORDOTIC XLF","SUP-ITM-10057541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8490.00","6367.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","5034.57","59.3","","1891.61","1609.14","3664.18","25","4245","6660.41","percent of total billed charges",""
"SPINE SPACER 12X18 45MM XL 10DEG COROENT PEEK STAND ALONE LORDOTIC XLF","SUP-ITM-10057541","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","8490.00","6367.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6660.41","78.45","","1470.68","1310.06","2481.69","19","4245","6660.41","percent of total billed charges",""
"SPINE SPACER 4MM ALLOGRAFT ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048803","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","AETNA [1001]","HB CH AETNA HMO / PPO","1530.95","58.3","","1830.28","315.58","1830.28","1 through 10","1167.25","2625.99","percent of total billed charges",""
"SPINE SPACER 4MM ALLOGRAFT ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048803","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1916.97","73","","4170.85","4170.85","4170.85","1 through 10","1167.25","2625.99","percent of total billed charges",""
"SPINE SPACER 4MM ALLOGRAFT ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048803","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1167.25","44.45","","649.55","649.55","649.55","1 through 10","1167.25","2625.99","percent of total billed charges",""
"SPINE SPACER 4MM ALLOGRAFT ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048803","CDM","C1889","HCPCS","0278","RC","","","","both","","","2625.99","1969.49","WELLPOINT [1015]","HB CH WELLPOINT","2045.91","77.91","","8998.38","2542.37","8998.38","20","1167.25","2625.99","percent of total billed charges",""
"SPINE SPACER 4MM ALLOGRAFT ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048803","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","CIGNA [1006]","HB CH CIGNA HMO / PPO","1557.21","59.3","","1891.61","1609.14","3664.18","25","1313","2060.09","percent of total billed charges",""
"SPINE SPACER 4MM ALLOGRAFT ARCH OPEN DOOR LAMINOPLASTY PARALLEL FREEZE DRIED","SUP-ITM-10048803","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2625.99","1969.49","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2060.09","78.45","","1470.68","1310.06","2481.69","19","1313","2060.09","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","7674.14","5755.60","AETNA [1001]","HB CH AETNA HMO / PPO","4474.02","58.3","","1830.28","315.58","1830.28","1 through 10","3411.16","7674.14","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","7674.14","5755.60","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5602.12","73","","4170.85","4170.85","4170.85","1 through 10","3411.16","7674.14","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","7674.14","5755.60","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3411.16","44.45","","649.55","649.55","649.55","1 through 10","3411.16","7674.14","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","both","","","7674.14","5755.60","WELLPOINT [1015]","HB CH WELLPOINT","5978.92","77.91","","8998.38","2542.37","8998.38","20","3411.16","7674.14","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7674.14","5755.60","CIGNA [1006]","HB CH CIGNA HMO / PPO","4550.77","59.3","","1891.61","1609.14","3664.18","25","3837.07","6020.36","percent of total billed charges",""
"SPINE SPACER 7MM HX10 /11 L 30 W T PLIF LUMINARY H W FREEZE DRIED","SUP-ITM-10082839","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","7674.14","5755.60","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6020.36","78.45","","1470.68","1310.06","2481.69","19","3837.07","6020.36","percent of total billed charges",""
"Spirometry/Pft Cplx","PX-46000021","CDM","94070","CPT","0460","RC","","","","both","","","842.00","631.50","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","1 through 10","351.32","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","337.09","363.89","1 through 10","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.89","363.89","363.89","1 through 10","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","369.81","369.81","175","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.81","1 through 10","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.01","362.41","363.89","1 through 10","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","362.41","363.42","43","197.14","981.49","other","OPPS APC"
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","both","","","802.00","601.50","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","356.49","44.45","","355.37","355.37","355.37","1 through 10","197.14","981.49","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","802.00","601.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","475.59","59.3","","457.08","457.08","457.08","1 through 10","401","629.17","percent of total billed charges",""
"Spirometry/Pft Pre & Post Bronch","PX-46000020","CDM","94060","CPT","0460","RC","","","","outpatient","","","802.00","601.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","629.17","78.45","","599.66","599.66","653.48","1 through 10","401","629.17","percent of total billed charges",""
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","MEDICARE [2001]","HB BWF MEDICARE","185.81","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","185.81","185.81","185.81","14","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","182.09","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","182.84","182.84","182.84","1 through 10","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","both","","","464.00","348.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","182.09","","APC Price ($185.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","167.75","167.75","167.75","1 through 10","176.52","528.85","other","OPPS APC"
"Spirometry/Pft Smp","PX-46000014","CDM","94010","CPT","0460","RC","","","","outpatient","","","464.00","348.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.01","78.45","","346.73","346.73","346.73","1 through 10","206.25","364.01","percent of total billed charges",""
"Splenic Procedures,MINOR","650","DRG","","","","","","","","inpatient","","","68817.61","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","16175.90","","Case rate ($17,885.24). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $60,315.24, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","17880.85","17880.85","17880.85","1 through 10","12660.99","42549.18","case rate",""
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/McC","537","MS-DRG","","","","","","","","inpatient","","","35586.74","26690.05","MEDICARE [2001]","HB BWF MEDICARE","9966.00","","Case rate ($9,966). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $9,140.24, add-ons for qualifying new technology services are included. If operating cost exceeds $54,663.97 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,235.43, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.3. The base transfer operating payment is the transfer adjustment factor * $8,952.12 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,801.01 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $674.65. The transfer capital threshold is the transfer adjustment factor * $674.65. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","1054.55","1054.55","9389.23","1 through 10","8943.4","9966","other","Inpatient DRG"
"St Eval Oral/Swallow Function","PX-44000011","CDM","92610","CPT","0444","RC","","","","both","","","417.00","312.75","WELLPOINT [1015]","HB CH WELLPOINT","324.88","77.91","","318.98","318.98","318.98","1 through 10","74.05","410.4","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","465.00","348.75","AETNA [1001]","HB CH AETNA HMO / PPO","271.10","58.3","","256.28","256.28","256.28","1 through 10","97.28","441.75","percent of total billed charges",""
"St Eval Swallow Video/Fluoro","PX-44000012","CDM","92611","CPT","0444","RC","","","","both","","","465.00","348.75","WELLPOINT [1015]","HB CH WELLPOINT","362.28","77.91","","356.00","356.00","356.00","1 through 10","97.28","441.75","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","692.00","519.00","AETNA [1001]","HB CH AETNA HMO / PPO","403.44","58.3","","381.59","381.59","763.18","1 through 10","81.36","505.16","percent of total billed charges",""
"St Treatment Speech/Lang/Comm Ind","PX-44000005","CDM","92507","CPT","0441","RC","","","","both","","","692.00","519.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","81.36","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($83.02). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($63.85). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","81.46","81.36","81.46","1 through 10","81.36","505.16","fee schedule",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1634.24","1004.95","1718.99","42","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","2123.89","1900.92","2123.89","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2635.16","58.3","","3729.00","1254.19","3729.00","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","939.37","939.37","5593.65","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3842.00","85","","2323.25","1864.50","2882.25","16","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4520.00","100","","2909.44","1772.40","10952.08","45","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4520.00","100","","2323.25","2323.25","2323.25","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4520.00","100","","2882.25","1772.40","10169.17","187","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","1659.41","1659.41","1659.41","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","2050.91","1468.48","2902.83","52","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1548.60","1092.60","3613.79","82","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 4 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT 5512-F-401","SUP-ITM-10043005","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","2085.51","998.68","6202.11","56","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1634.24","1004.95","1718.99","42","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","2123.89","1900.92","2123.89","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2635.16","58.3","","3729.00","1254.19","3729.00","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","939.37","939.37","5593.65","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3842.00","85","","2323.25","1864.50","2882.25","16","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4520.00","100","","2909.44","1772.40","10952.08","45","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4520.00","100","","2323.25","2323.25","2323.25","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4520.00","100","","2882.25","1772.40","10169.17","187","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","1659.41","1659.41","1659.41","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","2050.91","1468.48","2902.83","52","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1548.60","1092.60","3613.79","82","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 5 COMPONENT FEMORAL KNEE TRIATHLON COBALT RIGHT","SUP-ITM-10057459","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","2085.51","998.68","6202.11","56","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","AETNA [1001]","HB CH AETNA HMO / PPO","2635.16","58.3","","1634.24","1004.95","1718.99","42","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","2123.89","1900.92","2123.89","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2635.16","58.3","","3729.00","1254.19","3729.00","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2395.60","53","","939.37","939.37","5593.65","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3842.00","85","","2323.25","1864.50","2882.25","16","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4520.00","100","","2909.44","1772.40","10952.08","45","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4520.00","100","","2323.25","2323.25","2323.25","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4520.00","100","","2882.25","1772.40","10169.17","187","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3299.60","73","","1659.41","1659.41","1659.41","1 through 10","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","both","","","4520.00","3390.00","WELLPOINT [1015]","HB CH WELLPOINT","3521.53","77.91","","2050.91","1468.48","2902.83","52","2009.14","4520","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2680.36","59.3","","1548.60","1092.60","3613.79","82","2260","3545.94","percent of total billed charges",""
"STABILIZER TOTAL SIZE 6 COMPONENT FEMORAL KNEE TRIATHLON COBALT LEFT","SUP-ITM-10048725","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4520.00","3390.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3545.94","78.45","","2085.51","998.68","6202.11","56","2260","3545.94","percent of total billed charges",""
"Standardized Cognitive Prformance Testiing, per Hr (Gn)","PX-44000087","CDM","96125","CPT","0440","RC","","","","both","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","108.04","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($110.24). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($84.49). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","109.04","108.04","109.04","1 through 10","108.04","410.4","fee schedule",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","AETNA [1001]","HB CH AETNA HMO / PPO","2909.17","58.3","","554.95","91.85","1421.75","94","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3642.70","73","","2490.03","2490.03","2490.03","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2909.17","58.3","","750.00","750.00","750.00","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2644.70","53","","1192.50","120.84","4149.90","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4241.50","85","","750.00","75.00","750.00","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4990.00","100","","657.00","121.50","1971.00","14","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4990.00","100","","75.00","75.00","75.00","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4990.00","100","","366.00","144.00","1971.00","45","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3642.70","73","","667.50","667.50","667.50","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2218.06","44.45","","123.77","123.77","123.77","1 through 10","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","both","","","4990.00","3742.50","WELLPOINT [1015]","HB CH WELLPOINT","3887.71","77.91","","483.51","229.32","1316.08","96","2218.06","4990","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.00","3742.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2959.07","59.3","","439.50","225.34","1872.27","197","2495","3914.66","percent of total billed charges",""
"STAPLE BONE 15X15MM DYNANITE SUPERMX NITINOL WITH INSTRUMENT","SUP-ITM-10287887","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4990.00","3742.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3914.66","78.45","","385.32","55.36","1815.62","58","2495","3914.66","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","AETNA [1001]","HB CH AETNA HMO / PPO","2442.77","58.3","","554.95","91.85","1421.75","94","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3058.70","73","","2490.03","2490.03","2490.03","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2442.77","58.3","","750.00","750.00","750.00","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2220.70","53","","1192.50","120.84","4149.90","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3561.50","85","","750.00","75.00","750.00","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4190.00","100","","657.00","121.50","1971.00","14","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4190.00","100","","75.00","75.00","75.00","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4190.00","100","","366.00","144.00","1971.00","45","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3058.70","73","","667.50","667.50","667.50","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1862.46","44.45","","123.77","123.77","123.77","1 through 10","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","both","","","4190.00","3142.50","WELLPOINT [1015]","HB CH WELLPOINT","3264.43","77.91","","483.51","229.32","1316.08","96","1862.46","4190","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.00","3142.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2484.67","59.3","","439.50","225.34","1872.27","197","2095","3287.06","percent of total billed charges",""
"STAPLE COMPRESSION 18X18MM DYNANITE SUPERMX","SUP-ITM-10287883","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4190.00","3142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3287.06","78.45","","385.32","55.36","1815.62","58","2095","3287.06","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","AETNA [1001]","HB CH AETNA HMO / PPO","2209.57","58.3","","554.95","91.85","1421.75","94","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2766.70","73","","2490.03","2490.03","2490.03","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2209.57","58.3","","750.00","750.00","750.00","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2008.70","53","","1192.50","120.84","4149.90","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3221.50","85","","750.00","75.00","750.00","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3790.00","100","","657.00","121.50","1971.00","14","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3790.00","100","","75.00","75.00","75.00","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3790.00","100","","366.00","144.00","1971.00","45","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2766.70","73","","667.50","667.50","667.50","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1684.66","44.45","","123.77","123.77","123.77","1 through 10","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","both","","","3790.00","2842.50","WELLPOINT [1015]","HB CH WELLPOINT","2952.79","77.91","","483.51","229.32","1316.08","96","1684.66","3790","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3790.00","2842.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2247.47","59.3","","439.50","225.34","1872.27","197","1895","2973.26","percent of total billed charges",""
"STAPLE DYNANITE 13X10MM NITINOL INSTRUMENT","SUP-ITM-10212191","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3790.00","2842.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2973.26","78.45","","385.32","55.36","1815.62","58","1895","2973.26","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","AETNA [1001]","HB CH AETNA HMO / PPO","2675.97","58.3","","554.95","91.85","1421.75","94","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3350.70","73","","2490.03","2490.03","2490.03","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2675.97","58.3","","750.00","750.00","750.00","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2432.70","53","","1192.50","120.84","4149.90","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3901.50","85","","750.00","75.00","750.00","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4590.00","100","","657.00","121.50","1971.00","14","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4590.00","100","","75.00","75.00","75.00","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4590.00","100","","366.00","144.00","1971.00","45","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3350.70","73","","667.50","667.50","667.50","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2040.26","44.45","","123.77","123.77","123.77","1 through 10","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","both","","","4590.00","3442.50","WELLPOINT [1015]","HB CH WELLPOINT","3576.07","77.91","","483.51","229.32","1316.08","96","2040.26","4590","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4590.00","3442.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2721.87","59.3","","439.50","225.34","1872.27","197","2295","3600.86","percent of total billed charges",""
"STAPLE DYNANITE 15X15MM NITINOL INSTRUMENT","SUP-ITM-10212197","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4590.00","3442.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3600.86","78.45","","385.32","55.36","1815.62","58","2295","3600.86","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","AETNA [1001]","HB CH AETNA HMO / PPO","1915.16","58.3","","554.95","91.85","1421.75","94","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","2490.03","2490.03","2490.03","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1915.16","58.3","","750.00","750.00","750.00","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1741.05","53","","1192.50","120.84","4149.90","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2792.25","85","","750.00","75.00","750.00","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3285.00","100","","657.00","121.50","1971.00","14","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3285.00","100","","75.00","75.00","75.00","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3285.00","100","","366.00","144.00","1971.00","45","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","667.50","667.50","667.50","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.18","44.45","","123.77","123.77","123.77","1 through 10","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","WELLPOINT [1015]","HB CH WELLPOINT","2559.34","77.91","","483.51","229.32","1316.08","96","1460.18","3285","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1948.01","59.3","","439.50","225.34","1872.27","197","1642.5","2577.08","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL","SUP-ITM-10212184","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2577.08","78.45","","385.32","55.36","1815.62","58","1642.5","2577.08","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","AETNA [1001]","HB CH AETNA HMO / PPO","2178.96","58.3","","554.95","91.85","1421.75","94","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","2490.03","2490.03","2490.03","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2178.96","58.3","","750.00","750.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1980.88","53","","1192.50","120.84","4149.90","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3176.88","85","","750.00","75.00","750.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3737.50","100","","657.00","121.50","1971.00","14","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3737.50","100","","75.00","75.00","75.00","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3737.50","100","","366.00","144.00","1971.00","45","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2728.38","73","","667.50","667.50","667.50","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1661.32","44.45","","123.77","123.77","123.77","1 through 10","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3737.50","2803.12","WELLPOINT [1015]","HB CH WELLPOINT","2911.89","77.91","","483.51","229.32","1316.08","96","1661.32","3737.5","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2216.34","59.3","","439.50","225.34","1872.27","197","1868.75","2932.07","percent of total billed charges",""
"STAPLE DYNANITE 9X7MM NITINOL INSTRUMENT","SUP-ITM-10212183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3737.50","2803.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2932.07","78.45","","385.32","55.36","1815.62","58","1868.75","2932.07","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","AETNA [1001]","HB CH AETNA HMO / PPO","1414.94","58.3","","554.95","91.85","1421.75","94","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1771.71","73","","2490.03","2490.03","2490.03","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1414.94","58.3","","750.00","750.00","750.00","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1286.31","53","","1192.50","120.84","4149.90","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2062.95","85","","750.00","75.00","750.00","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2427.00","100","","657.00","121.50","1971.00","14","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2427.00","100","","75.00","75.00","75.00","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2427.00","100","","366.00","144.00","1971.00","45","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1771.71","73","","667.50","667.50","667.50","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1078.80","44.45","","123.77","123.77","123.77","1 through 10","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","both","","","2427.00","1820.25","WELLPOINT [1015]","HB CH WELLPOINT","1890.88","77.91","","483.51","229.32","1316.08","96","1078.8","2427","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2427.00","1820.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1439.21","59.3","","439.50","225.34","1872.27","197","1213.5","1903.98","percent of total billed charges",""
"STAPLE IMPLANT 10X10MM FUSEFORCE NITINOL","SUP-ITM-10193181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2427.00","1820.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1903.98","78.45","","385.32","55.36","1815.62","58","1213.5","1903.98","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","AETNA [1001]","HB CH AETNA HMO / PPO","673.37","58.3","","554.95","91.85","1421.75","94","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","843.15","73","","2490.03","2490.03","2490.03","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","673.37","58.3","","750.00","750.00","750.00","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","612.15","53","","1192.50","120.84","4149.90","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","981.75","85","","750.00","75.00","750.00","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1155.00","100","","657.00","121.50","1971.00","14","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1155.00","100","","75.00","75.00","75.00","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1155.00","100","","366.00","144.00","1971.00","45","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","843.15","73","","667.50","667.50","667.50","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","513.40","44.45","","123.77","123.77","123.77","1 through 10","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","both","","","1155.00","866.25","WELLPOINT [1015]","HB CH WELLPOINT","899.86","77.91","","483.51","229.32","1316.08","96","513.4","1155","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","684.92","59.3","","439.50","225.34","1872.27","197","577.5","906.1","percent of total billed charges",""
"STAPLE PLAPLE 12MM FIXATION BONE QUICKFIX SS LOW PROFILE FOOT ANKLE","SUP-ITM-10152939","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1155.00","866.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","906.10","78.45","","385.32","55.36","1815.62","58","577.5","906.1","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","AETNA [1001]","HB CH AETNA HMO / PPO","192.39","58.3","","554.95","91.85","1421.75","94","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","2490.03","2490.03","2490.03","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","192.39","58.3","","750.00","750.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","174.90","53","","1192.50","120.84","4149.90","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","280.50","85","","750.00","75.00","750.00","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","330.00","100","","657.00","121.50","1971.00","14","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","330.00","100","","75.00","75.00","75.00","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","330.00","100","","366.00","144.00","1971.00","45","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","240.90","73","","667.50","667.50","667.50","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","146.69","44.45","","123.77","123.77","123.77","1 through 10","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","both","","","330.00","247.50","WELLPOINT [1015]","HB CH WELLPOINT","257.10","77.91","","483.51","229.32","1316.08","96","146.69","330","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","439.50","225.34","1872.27","197","165","258.89","percent of total billed charges",""
"STAPLE QUICKFIX 10MM SMALL SS LOW PROFILE","SUP-ITM-10078965","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","385.32","55.36","1815.62","58","165","258.89","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","AETNA [1001]","HB CH AETNA HMO / PPO","1740.26","58.3","","554.95","91.85","1421.75","94","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2179.05","73","","2490.03","2490.03","2490.03","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1740.26","58.3","","750.00","750.00","750.00","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1582.05","53","","1192.50","120.84","4149.90","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2537.25","85","","750.00","75.00","750.00","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2985.00","100","","657.00","121.50","1971.00","14","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2985.00","100","","75.00","75.00","75.00","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2985.00","100","","366.00","144.00","1971.00","45","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2179.05","73","","667.50","667.50","667.50","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1326.83","44.45","","123.77","123.77","123.77","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","WELLPOINT [1015]","HB CH WELLPOINT","2325.61","77.91","","483.51","229.32","1316.08","96","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2985.00","2238.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1770.11","59.3","","439.50","225.34","1872.27","197","1492.5","2341.73","percent of total billed charges",""
"STAPLE STRAIGHT 18X18MM ASSEMBLY","SUP-ITM-10241299","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2985.00","2238.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2341.73","78.45","","385.32","55.36","1815.62","58","1492.5","2341.73","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","AETNA [1001]","HB CH AETNA HMO / PPO","1740.26","58.3","","554.95","91.85","1421.75","94","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2179.05","73","","2490.03","2490.03","2490.03","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1740.26","58.3","","750.00","750.00","750.00","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1582.05","53","","1192.50","120.84","4149.90","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2537.25","85","","750.00","75.00","750.00","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2985.00","100","","657.00","121.50","1971.00","14","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2985.00","100","","75.00","75.00","75.00","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2985.00","100","","366.00","144.00","1971.00","45","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2179.05","73","","667.50","667.50","667.50","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1326.83","44.45","","123.77","123.77","123.77","1 through 10","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","both","","","2985.00","2238.75","WELLPOINT [1015]","HB CH WELLPOINT","2325.61","77.91","","483.51","229.32","1316.08","96","1326.83","2985","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2985.00","2238.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1770.11","59.3","","439.50","225.34","1872.27","197","1492.5","2341.73","percent of total billed charges",""
"STAPLE STRAIGHT 20X20MM ASSEMBLY","SUP-ITM-10241298","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2985.00","2238.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2341.73","78.45","","385.32","55.36","1815.62","58","1492.5","2341.73","percent of total billed charges",""
"Std Cogni Test per Hr by HC Pro","PX-90000043","CDM","96125","CPT","0918","RC","","","","both","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","108.04","","Practice Expense (PE) is calculated as PE = 4 * (Full Fee Schedule Amount - Reduced Fee Schedule Amount). If the service has the largest PE of all therapy procedures for the service date, it is reimbursed at the full fee schedule amount ($110.24). Only one unit of the service will be reimbursed at this amount for that service date. Otherwise, it will be reimbursed at the reduced fee schedule amount ($84.49). Each line will be capped at the line billed amount. Final payment is multiplied by 98%.","109.04","108.04","109.04","1 through 10","108.04","405.69","fee schedule",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","AETNA [1001]","HB CH AETNA HMO / PPO","2623.50","58.3","","1634.24","1004.95","1718.99","42","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","2123.89","1900.92","2123.89","1 through 10","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2623.50","58.3","","3729.00","1254.19","3729.00","1 through 10","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2385.00","53","","939.37","939.37","5593.65","1 through 10","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3825.00","85","","2323.25","1864.50","2882.25","16","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","2909.44","1772.40","10952.08","45","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4500.00","100","","2323.25","2323.25","2323.25","1 through 10","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4500.00","100","","2882.25","1772.40","10169.17","187","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3285.00","73","","1659.41","1659.41","1659.41","1 through 10","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","WELLPOINT [1015]","HB CH WELLPOINT","3505.95","77.91","","2050.91","1468.48","2902.83","52","2000.25","4500","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2668.50","59.3","","1548.60","1092.60","3613.79","82","2250","3530.25","percent of total billed charges",""
"STEM FEMORAL 132DEGREE SIZE 9 ADVANCED SECUR-FIT","SUP-ITM-10208628","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","2085.51","998.68","6202.11","56","2250","3530.25","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","AETNA [1001]","HB CH AETNA HMO / PPO","2332.00","58.3","","1634.24","1004.95","1718.99","42","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","2123.89","1900.92","2123.89","1 through 10","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2332.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2120.00","53","","939.37","939.37","5593.65","1 through 10","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3400.00","85","","2323.25","1864.50","2882.25","16","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2909.44","1772.40","10952.08","45","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4000.00","100","","2323.25","2323.25","2323.25","1 through 10","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4000.00","100","","2882.25","1772.40","10169.17","187","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2920.00","73","","1659.41","1659.41","1659.41","1 through 10","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","WELLPOINT [1015]","HB CH WELLPOINT","3116.40","77.91","","2050.91","1468.48","2902.83","52","1778","4000","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2372.00","59.3","","1548.60","1092.60","3613.79","82","2000","3138","percent of total billed charges",""
"STEM HIP CATALYSTEM SIZE 3 COLLARED STANDARD OFFSET","SUP-ITM-10335454","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4000.00","3000.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3138.00","78.45","","2085.51","998.68","6202.11","56","2000","3138","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","AETNA [1001]","HB CH AETNA HMO / PPO","2587.06","58.3","","1634.24","1004.95","1718.99","42","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3239.38","73","","2123.89","1900.92","2123.89","1 through 10","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2587.06","58.3","","3729.00","1254.19","3729.00","1 through 10","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2351.88","53","","939.37","939.37","5593.65","1 through 10","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3771.88","85","","2323.25","1864.50","2882.25","16","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4437.50","100","","2909.44","1772.40","10952.08","45","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4437.50","100","","2323.25","2323.25","2323.25","1 through 10","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4437.50","100","","2882.25","1772.40","10169.17","187","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3239.38","73","","1659.41","1659.41","1659.41","1 through 10","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","WELLPOINT [1015]","HB CH WELLPOINT","3457.26","77.91","","2050.91","1468.48","2902.83","52","1972.47","4437.5","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2631.44","59.3","","1548.60","1092.60","3613.79","82","2218.75","3481.22","percent of total billed charges",""
"STEM HIP PATIENT SPECIFIC","SUP-ITM-10215649","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3481.22","78.45","","2085.51","998.68","6202.11","56","2218.75","3481.22","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","AETNA [1001]","HB CH AETNA HMO / PPO","3813.99","58.3","","1634.24","1004.95","1718.99","42","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4775.66","73","","2123.89","1900.92","2123.89","1 through 10","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3813.99","58.3","","3729.00","1254.19","3729.00","1 through 10","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3467.26","53","","939.37","939.37","5593.65","1 through 10","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5560.70","85","","2323.25","1864.50","2882.25","16","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6542.00","100","","2909.44","1772.40","10952.08","45","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6542.00","100","","2323.25","2323.25","2323.25","1 through 10","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6542.00","100","","2882.25","1772.40","10169.17","187","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4775.66","73","","1659.41","1659.41","1659.41","1 through 10","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","both","","","6542.00","4906.50","WELLPOINT [1015]","HB CH WELLPOINT","5096.87","77.91","","2050.91","1468.48","2902.83","52","2907.92","6542","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6542.00","4906.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","3879.41","59.3","","1548.60","1092.60","3613.79","82","3271","5132.2","percent of total billed charges",""
"STEM SHOULDER SZ 4/33 UNIVERS REVERS MONOBLOCK","SUP-ITM-10320307","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6542.00","4906.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5132.20","78.45","","2085.51","998.68","6202.11","56","3271","5132.2","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","both","","","6040.00","4530.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6040.00","100","","6010.00","6010.00","6010.00","1 through 10","2684.78","6040","percent of total billed charges",""
"STENT BX2 7MMX29MM 6FR 135CM CATH BX2 HEP REDUCED PROFILE","SUP-ITM-10321073","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","6040.00","4530.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4738.38","78.45","","5181.71","4620.49","5181.71","1 through 10","3020","4738.38","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","both","","","1800.00","1350.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1800.00","100","","6010.00","6010.00","6010.00","1 through 10","800.1","1800","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T1","PX-27000145","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","1800.00","1350.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1412.10","78.45","","5181.71","4620.49","5181.71","1 through 10","900","1412.1","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","both","","","3639.92","2729.94","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3639.92","100","","6010.00","6010.00","6010.00","1 through 10","1617.94","3639.92","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T2","PX-27000146","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3639.92","2729.94","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2855.52","78.45","","5181.71","4620.49","5181.71","1 through 10","1819.96","2855.52","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","both","","","4790.00","3592.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4790.00","100","","6010.00","6010.00","6010.00","1 through 10","2129.16","4790","percent of total billed charges",""
"Stent Coronary W/Delivery Sys T3","PX-27000147","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4790.00","3592.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3757.76","78.45","","5181.71","4620.49","5181.71","1 through 10","2395","3757.76","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1060.02","795.01","AETNA [1001]","HB CH AETNA HMO / PPO","617.99","58.3","","188.13","188.13","188.13","1 through 10","471.18","1060.02","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1060.02","795.01","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1060.02","100","","331.80","331.80","331.80","1 through 10","471.18","1060.02","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","both","","","1060.02","795.01","WELLPOINT [1015]","HB CH WELLPOINT","825.86","77.91","","593.13","261.33","593.13","1 through 10","471.18","1060.02","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1060.02","795.01","CIGNA [1006]","HB CH CIGNA HMO / PPO","628.59","59.3","","194.44","194.43","583.31","13","530.01","831.59","percent of total billed charges",""
"STENT DIVERSION 7FR 90CM X2 URETERAL SINGLE J GUIDEWIRE PTFE .028 120CM SILICONE","SUP-ITM-10000198","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1060.02","795.01","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","831.59","78.45","","255.09","255.09","255.09","1 through 10","530.01","831.59","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","both","","","3555.00","2666.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3555.00","100","","6010.00","6010.00","6010.00","1 through 10","1580.2","3555","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T1","PX-27000148","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","3555.00","2666.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2788.90","78.45","","5181.71","4620.49","5181.71","1 through 10","1777.5","2788.9","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","both","","","4377.85","3283.39","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4377.85","100","","6010.00","6010.00","6010.00","1 through 10","1945.95","4377.85","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T2","PX-27000149","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4377.85","3283.39","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3434.42","78.45","","5181.71","4620.49","5181.71","1 through 10","2188.93","3434.42","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","both","","","5954.85","4466.14","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5954.85","100","","6010.00","6010.00","6010.00","1 through 10","2646.93","5954.85","percent of total billed charges",""
"Stent Drug Eluting W/Delivery Sys T3","PX-27000150","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","5954.85","4466.14","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4671.58","78.45","","5181.71","4620.49","5181.71","1 through 10","2977.43","4671.58","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","both","","","10443.38","7832.53","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","10443.38","100","","6010.00","6010.00","6010.00","1 through 10","4642.08","10443.38","percent of total billed charges",""
"Stent Graft Endovascular T3","PX-27000720","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","10443.38","7832.53","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8192.83","78.45","","5181.71","4620.49","5181.71","1 through 10","5221.69","8192.83","percent of total billed charges",""
"STENT ULTRAFLEX 12MM 40MM 95CM TRACHEOBRONCHIAL NITINOL WIRE UNCOVERED PROXIMAL RELEASE","SUP-ITM-10138835","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","5016.10","3762.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3935.13","78.45","","1574.12","1574.12","1574.12","1 through 10","2508.05","3935.13","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","AETNA [1001]","HB CH AETNA HMO / PPO","352.09","58.3","","188.13","188.13","188.13","1 through 10","268.45","603.93","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","603.93","100","","331.80","331.80","331.80","1 through 10","268.45","603.93","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","both","","","603.93","452.95","WELLPOINT [1015]","HB CH WELLPOINT","470.52","77.91","","593.13","261.33","593.13","1 through 10","268.45","603.93","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","603.93","452.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","358.13","59.3","","194.44","194.43","583.31","13","301.97","473.78","percent of total billed charges",""
"STENT URETERAL 6.0FR 26CM POLARIS PERCUFLEX HYDROPLUS COATED LOOP DUAL DUROMETER","SUP-ITM-10065053","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","603.93","452.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","473.78","78.45","","255.09","255.09","255.09","1 through 10","301.97","473.78","percent of total billed charges",""
"STENT URETERAL 6FR 7X20CM .038 GW PTFE SUTURE PERCUFLEX CATHETER","SUP-ITM-10154752","CDM","C2617","HCPCS","0278","RC","","","","both","","","420.36","315.27","AETNA [1001]","HB CH AETNA HMO / PPO","245.07","58.3","","188.13","188.13","188.13","1 through 10","186.85","420.36","percent of total billed charges",""
"STENT URETERAL 6FR 7X20CM .038 GW PTFE SUTURE PERCUFLEX CATHETER","SUP-ITM-10154752","CDM","C2617","HCPCS","0278","RC","","","","both","","","420.36","315.27","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","420.36","100","","331.80","331.80","331.80","1 through 10","186.85","420.36","percent of total billed charges",""
"STENT URETERAL 6FR 7X20CM .038 GW PTFE SUTURE PERCUFLEX CATHETER","SUP-ITM-10154752","CDM","C2617","HCPCS","0278","RC","","","","both","","","420.36","315.27","WELLPOINT [1015]","HB CH WELLPOINT","327.50","77.91","","593.13","261.33","593.13","1 through 10","186.85","420.36","percent of total billed charges",""
"STENT URETERAL 6FR 7X20CM .038 GW PTFE SUTURE PERCUFLEX CATHETER","SUP-ITM-10154752","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","420.36","315.27","CIGNA [1006]","HB CH CIGNA HMO / PPO","249.27","59.3","","194.44","194.43","583.31","13","210.18","329.77","percent of total billed charges",""
"STENT URETERAL 6FR 7X20CM .038 GW PTFE SUTURE PERCUFLEX CATHETER","SUP-ITM-10154752","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","420.36","315.27","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","329.77","78.45","","255.09","255.09","255.09","1 through 10","210.18","329.77","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","AETNA [1001]","HB CH AETNA HMO / PPO","617.62","58.3","","188.13","188.13","188.13","1 through 10","470.9","1059.39","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1059.39","100","","331.80","331.80","331.80","1 through 10","470.9","1059.39","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","WELLPOINT [1015]","HB CH WELLPOINT","825.37","77.91","","593.13","261.33","593.13","1 through 10","470.9","1059.39","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1059.39","794.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","628.22","59.3","","194.44","194.43","583.31","13","529.7","831.09","percent of total billed charges",""
"STENT URETERAL 6FRX26CM FIRM TRIA","SUP-ITM-10273881","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1059.39","794.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","831.09","78.45","","255.09","255.09","255.09","1 through 10","529.7","831.09","percent of total billed charges",""
"STENT URETERAL 7FR 28CM PERCUFLEX PLUS PTFE COATED","SUP-ITM-10155143","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.65","403.99","AETNA [1001]","HB CH AETNA HMO / PPO","314.03","58.3","","188.13","188.13","188.13","1 through 10","239.43","538.65","percent of total billed charges",""
"STENT URETERAL 7FR 28CM PERCUFLEX PLUS PTFE COATED","SUP-ITM-10155143","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.65","403.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","538.65","100","","331.80","331.80","331.80","1 through 10","239.43","538.65","percent of total billed charges",""
"STENT URETERAL 7FR 28CM PERCUFLEX PLUS PTFE COATED","SUP-ITM-10155143","CDM","C2617","HCPCS","0278","RC","","","","both","","","538.65","403.99","WELLPOINT [1015]","HB CH WELLPOINT","419.66","77.91","","593.13","261.33","593.13","1 through 10","239.43","538.65","percent of total billed charges",""
"STENT URETERAL 7FR 28CM PERCUFLEX PLUS PTFE COATED","SUP-ITM-10155143","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.65","403.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","319.42","59.3","","194.44","194.43","583.31","13","269.33","422.57","percent of total billed charges",""
"STENT URETERAL 7FR 28CM PERCUFLEX PLUS PTFE COATED","SUP-ITM-10155143","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","538.65","403.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","422.57","78.45","","255.09","255.09","255.09","1 through 10","269.33","422.57","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","AETNA [1001]","HB CH AETNA HMO / PPO","617.62","58.3","","188.13","188.13","188.13","1 through 10","470.9","1059.39","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1059.39","100","","331.80","331.80","331.80","1 through 10","470.9","1059.39","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","both","","","1059.39","794.54","WELLPOINT [1015]","HB CH WELLPOINT","825.37","77.91","","593.13","261.33","593.13","1 through 10","470.9","1059.39","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1059.39","794.54","CIGNA [1006]","HB CH CIGNA HMO / PPO","628.22","59.3","","194.44","194.43","583.31","13","529.7","831.09","percent of total billed charges",""
"STENT URETERAL 8FRX22CM FIRM TRIA","SUP-ITM-10273871","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","1059.39","794.54","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","831.09","78.45","","255.09","255.09","255.09","1 through 10","529.7","831.09","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","AETNA [1001]","HB CH AETNA HMO / PPO","294.99","58.3","","188.13","188.13","188.13","1 through 10","224.91","505.98","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","505.98","100","","331.80","331.80","331.80","1 through 10","224.91","505.98","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","both","","","505.98","379.48","WELLPOINT [1015]","HB CH WELLPOINT","394.21","77.91","","593.13","261.33","593.13","1 through 10","224.91","505.98","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","505.98","379.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","300.05","59.3","","194.44","194.43","583.31","13","252.99","396.94","percent of total billed charges",""
"STENT UROLOGICAL 7FR 24CM DOUBLE PIGTAIL TAPER TIP THREADED HYDROPLUS COATED PERCUFLEX RADIOPAQUE Y","SUP-ITM-10014076","CDM","C2617","HCPCS","0278","RC","","","","outpatient","","","505.98","379.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","396.94","78.45","","255.09","255.09","255.09","1 through 10","252.99","396.94","percent of total billed charges",""
"STENT WALLFLEX 10FR 25MM 30MM 60MM 230CM .035IN COLONIC SINGLE USE","SUP-ITM-10021568","CDM","C1876","HCPCS","0278","RC","","","","outpatient","","","4927.62","3695.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3865.72","78.45","","1574.12","1574.12","1574.12","1 through 10","2463.81","3865.72","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","6010.00","6010.00","6010.00","1 through 10","2000.25","4500","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 10CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073341","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","5181.71","4620.49","5181.71","1 through 10","2250","3530.25","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","6010.00","6010.00","6010.00","1 through 10","2000.25","4500","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 18MM 15CM 25MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10073306","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","5181.71","4620.49","5181.71","1 through 10","2250","3530.25","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 12CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10080297","CDM","C1874","HCPCS","0278","RC","","","","both","","","4500.00","3375.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4500.00","100","","6010.00","6010.00","6010.00","1 through 10","2000.25","4500","percent of total billed charges",""
"STENT WALLFLEX 18.5FR 23MM 12CM 28MM .038IN ESOPHAGEAL FLARE SILICONE Y FULLY COVERED","SUP-ITM-10080297","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4500.00","3375.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3530.25","78.45","","5181.71","4620.49","5181.71","1 through 10","2250","3530.25","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4800.00","100","","6010.00","6010.00","6010.00","1 through 10","2133.6","4800","percent of total billed charges",""
"STENT WALLFLEX 8.5FR 10MM 40MM .035IN RX BILIARY SILICONE FULLY COVERED SELF-EXP GUIDEWIRE COMPAT","SUP-ITM-10050455","CDM","C1874","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3765.60","78.45","","5181.71","4620.49","5181.71","1 through 10","2400","3765.6","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","both","","","3608.00","2706.00","WELLPOINT [1015]","HB CH WELLPOINT","2810.99","77.91","","17681.62","17681.62","17681.62","1 through 10","1912.24","3608","percent of total billed charges",""
"STIMULATOR NEURO SURESCAN RECHARGER SYSTEM ANTENNA BELT","SUP-ITM-10124362","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","3608.00","2706.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2139.54","59.3","","74853.32","74853.32","74853.32","1 through 10","1603.76","2830.48","percent of total billed charges",""
"Stomach, Esophageal And Duodenal Procedures With Cc","327","MS-DRG","","","","","","","","inpatient","","","61445.08","46083.81","MEDICARE [2001]","HB BWF MEDICARE","24995.78","","Case rate ($24,995.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $22,880.80, add-ons for qualifying new technology services are included. If operating cost exceeds $68,404.53 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,288.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $22,928.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $22,541.57 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,727.95. The transfer capital threshold is the transfer adjustment factor * $1,727.95. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","24232.07","11294.41","24394.89","1 through 10","22387.24","24995.78","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","72016.13","54012.10","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","50651.04","","Case rate ($50,651.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $46,335.40, add-ons for qualifying new technology services are included. If operating cost exceeds $91,859.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,086.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $46,785.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $45,996.16 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,525.89. The transfer capital threshold is the transfer adjustment factor * $3,525.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","45665.21","45665.21","45665.21","1 through 10","45335.35","50651.04","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures With McC","326","MS-DRG","","","","","","","","inpatient","","","72016.13","54012.10","MEDICARE [2001]","HB BWF MEDICARE","50651.04","","Case rate ($50,651.04). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $46,335.40, add-ons for qualifying new technology services are included. If operating cost exceeds $91,859.13 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $6,086.68, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 8.9. The base transfer operating payment is the transfer adjustment factor * $46,785.90 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $45,996.16 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $3,525.89. The transfer capital threshold is the transfer adjustment factor * $3,525.89. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16719.12","16719.12","55437.03","1 through 10","45335.35","50651.04","other","Inpatient DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","47659.34","35744.50","MEDICARE [2001]","HB BWF MEDICARE","15092.36","","Case rate ($15,092.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,116.41, add-ons for qualifying new technology services are included. If operating cost exceeds $60,640.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,693.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,620.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,777.17 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.76. The transfer capital threshold is the transfer adjustment factor * $1,132.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","16096.08","16096.08","16096.08","1 through 10","14790.51","16447.61","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","47659.34","35744.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","15092.36","","Case rate ($15,092.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,116.41, add-ons for qualifying new technology services are included. If operating cost exceeds $60,640.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,693.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,620.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,777.17 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.76. The transfer capital threshold is the transfer adjustment factor * $1,132.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14462.55","14462.55","14462.55","1 through 10","14790.51","16447.61","other","Inpatient Replacement Plans DRG"
"Stomach, Esophageal And Duodenal Procedures Without Cc/McC","328","MS-DRG","","","","","","","","inpatient","","","47659.34","35744.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","14790.51","","Case rate ($15,092.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $15,116.41, add-ons for qualifying new technology services are included. If operating cost exceeds $60,640.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,693.54, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $13,620.36 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,777.17 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,132.76. The transfer capital threshold is the transfer adjustment factor * $1,132.76. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14415.49","14415.49","14415.49","1 through 10","14790.51","16447.61","other","Inpatient DRG"
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","AETNA [1001]","HB CH AETNA HMO / PPO","988.19","58.3","","585.96","347.85","5016.82","1 through 10","753.43","1695","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1440.75","85","","1295.16","1295.16","1295.16","1 through 10","753.43","1695","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1695.00","100","","2700.00","1008.69","2700.00","1 through 10","753.43","1695","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1695.00","100","","2520.00","797.10","5898.60","1 through 10","753.43","1695","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.43","44.45","","1953.42","1953.42","1953.42","1 through 10","753.43","1695","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","WELLPOINT [1015]","HB CH WELLPOINT","1320.57","77.91","","1490.36","627.80","7327.37","1 through 10","753.43","1695","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.14","59.3","","536.35","188.54","1772.63","17","847.5","1329.73","percent of total billed charges",""
"STRAP POCKET 1.7IN SM GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100597","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1329.73","78.45","","562.30","246.20","3344.28","1 through 10","847.5","1329.73","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","AETNA [1001]","HB CH AETNA HMO / PPO","1189.32","58.3","","585.96","347.85","5016.82","1 through 10","906.78","2040","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1734.00","85","","1295.16","1295.16","1295.16","1 through 10","906.78","2040","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2040.00","100","","2700.00","1008.69","2700.00","1 through 10","906.78","2040","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2040.00","100","","2520.00","797.10","5898.60","1 through 10","906.78","2040","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","906.78","44.45","","1953.42","1953.42","1953.42","1 through 10","906.78","2040","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","both","","","2040.00","1530.00","WELLPOINT [1015]","HB CH WELLPOINT","1589.36","77.91","","1490.36","627.80","7327.37","1 through 10","906.78","2040","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1209.72","59.3","","536.35","188.54","1772.63","17","1020","1600.38","percent of total billed charges",""
"STRAP POCKET 2.5IN MED GRAFT MESH VENTRALEX ST POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CS/1EA","SUP-ITM-10100598","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2040.00","1530.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1600.38","78.45","","562.30","246.20","3344.28","1 through 10","1020","1600.38","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","2610.00","1957.50","AETNA [1001]","HB CH AETNA HMO / PPO","1521.63","58.3","","585.96","347.85","5016.82","1 through 10","1160.15","2610","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","2610.00","1957.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2218.50","85","","1295.16","1295.16","1295.16","1 through 10","1160.15","2610","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","2610.00","1957.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2610.00","100","","2700.00","1008.69","2700.00","1 through 10","1160.15","2610","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","2610.00","1957.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2610.00","100","","2520.00","797.10","5898.60","1 through 10","1160.15","2610","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","2610.00","1957.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1160.15","44.45","","1953.42","1953.42","1953.42","1 through 10","1160.15","2610","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","both","","","2610.00","1957.50","WELLPOINT [1015]","HB CH WELLPOINT","2033.45","77.91","","1490.36","627.80","7327.37","1 through 10","1160.15","2610","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2610.00","1957.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1547.73","59.3","","536.35","188.54","1772.63","17","1305","2047.55","percent of total billed charges",""
"STRAP POCKET 3.2I N LARGE GRAFT MESH VENTRALEX POLYPROPYLENE PGA PATCH HERNIA FIBER HYDROGEL BIORESORBABLE CIRCLE CA/1EA","SUP-ITM-10100569","CDM","C1781","HCPCS","0278","RC","","","","outpatient","","","2610.00","1957.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2047.55","78.45","","562.30","246.20","3344.28","1 through 10","1305","2047.55","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","AETNA [1001]","HB CH AETNA HMO / PPO","89.99","58.3","","84.15","75.01","84.15","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","89.06","57.7","","89.49","76.73","89.49","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","93.38","60.5","","93.94","93.94","93.94","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.81","53","","70.12","70.12","70.12","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.53","59.3","","86.97","77.53","86.97","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","89.06","57.7","","89.49","76.73","89.49","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","93.38","60.5","","93.94","93.94","93.94","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 11 13IN MEDIUM IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10015870","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.09","78.45","","114.10","114.10","114.10","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","AETNA [1001]","HB CH AETNA HMO / PPO","89.99","58.3","","84.15","75.01","84.15","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","89.06","57.7","","89.49","76.73","89.49","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","93.38","60.5","","93.94","93.94","93.94","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","both","","","154.35","115.76","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.81","53","","70.12","70.12","70.12","1 through 10","68.61","375.76","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.53","59.3","","86.97","77.53","86.97","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","89.06","57.7","","89.49","76.73","89.49","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","93.38","60.5","","93.94","93.94","93.94","1 through 10","77.18","263.9","percent of total billed charges",""
"STRAP WAIST 13 15IN LG IMMOBILIZER SHOULDER ABDUCTION PILLOW PADDED SLING THUMB LOOP UNIVERSAL","SUP-ITM-10007778","CDM","L3670","HCPCS","0274","RC","","","","outpatient","","","154.35","115.76","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.09","78.45","","114.10","114.10","114.10","1 through 10","77.18","263.9","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","both","","","178.00","133.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","94.34","53","","91.69","91.69","91.69","1 through 10","14.69","129.94","percent of total billed charges",""
"Streptococcus Pneumoniae Igg Antibodies, 23 Serotypes, Serum","PX-30003557","CDM","86317","CPT","0302","RC","","","","outpatient","","","178.00","133.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","105.55","59.3","","101.38","101.38","101.38","1 through 10","15.46","139.64","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","272.74","906.00","1 through 10","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","104","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.81","362.41","362.81","1 through 10","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","57.04","57.04","362.81","1 through 10","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","414.27","44.45","","412.77","412.77","412.77","1 through 10","351.32","981.49","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","both","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","362.41","","APC Price ($369.81). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","337.09","363.42","30","351.32","981.49","other","OPPS APC"
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","932.00","699.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","552.68","59.3","","530.92","530.92","530.92","27","416.64","993.25","percent of total billed charges",""
"Stress Test Tracing Only","PX-48000173","CDM","93017","CPT","0482","RC","","","","outpatient","","","932.00","699.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","731.15","78.45","","696.53","412.77","696.53","26","416.64","993.25","percent of total billed charges",""
"SUBTALAR WEDGE 16MM DISTRACTION PRESERVE ARTHRODESIS","SUP-ITM-10203858","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","AETNA [1001]","HB CH AETNA HMO / PPO","2690.55","58.3","","1830.28","315.58","1830.28","1 through 10","2051.37","4615","percent of total billed charges",""
"SUBTALAR WEDGE 16MM DISTRACTION PRESERVE ARTHRODESIS","SUP-ITM-10203858","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3368.95","73","","4170.85","4170.85","4170.85","1 through 10","2051.37","4615","percent of total billed charges",""
"SUBTALAR WEDGE 16MM DISTRACTION PRESERVE ARTHRODESIS","SUP-ITM-10203858","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2051.37","44.45","","649.55","649.55","649.55","1 through 10","2051.37","4615","percent of total billed charges",""
"SUBTALAR WEDGE 16MM DISTRACTION PRESERVE ARTHRODESIS","SUP-ITM-10203858","CDM","C1889","HCPCS","0278","RC","","","","both","","","4615.00","3461.25","WELLPOINT [1015]","HB CH WELLPOINT","3595.55","77.91","","8998.38","2542.37","8998.38","20","2051.37","4615","percent of total billed charges",""
"SUBTALAR WEDGE 16MM DISTRACTION PRESERVE ARTHRODESIS","SUP-ITM-10203858","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4615.00","3461.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2736.70","59.3","","1891.61","1609.14","3664.18","25","2307.5","3620.47","percent of total billed charges",""
"SUBTALAR WEDGE 16MM DISTRACTION PRESERVE ARTHRODESIS","SUP-ITM-10203858","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4615.00","3461.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3620.47","78.45","","1470.68","1310.06","2481.69","19","2307.5","3620.47","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","AETNA [1001]","HB CH AETNA HMO / PPO","2696.38","58.3","","4687.96","4687.96","4687.96","1 through 10","1984.13","3888.77","percent of total billed charges",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,797). Procedure 2, Per diem ($1,898.50). Procedures 3 - 9999, Per diem ($949.25).","3797.00","3797.00","3797.00","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","3899.16","3818.15","3899.16","1 through 10","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3904.56","3904.56","1 through 10","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Incmpl","PX-72000026","CDM","59812","CPT","0720","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","15747.30","8266.79","15747.30","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","both","","","4625.00","3468.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($3,797). Procedure 2, Per diem ($1,898.50). Procedures 3 - 9999, Per diem ($949.25).","3797.00","3797.00","3797.00","1 through 10","1984.13","3888.77","per diem",""
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","2700.25","","Case rate ($2,700.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","3904.56","3823.55","3904.56","1 through 10","2125.14","7939.38","other","ASC "
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2125.14","","Case rate ($2,125.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","5504.11","5504.11","5504.11","1 through 10","2125.14","7939.38","other","Multiple Surgery"
"Surg Tx Abortion Missed 1st Trimest","PX-72000027","CDM","59820","CPT","0361","RC","","","","outpatient","","","4625.00","3468.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3628.31","78.45","","3766.90","3766.90","3766.90","1 through 10","2125.14","7939.38","percent of total billed charges",""
"Surg Tx Abortion Missed 2nd Trimest","PX-72000028","CDM","59821","CPT","0361","RC","","","","both","","","8481.00","6360.75","WELLPOINT [1015]","HB CH WELLPOINT","6607.55","77.91","","8321.78","8321.78","8321.78","1 through 10","2125.14","6607.55","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1258.00","943.50","MEDICARE [2001]","HB BWF MEDICARE","427.19","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","427.19","427.19","427.19","15","405.83","1066.72","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","both","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","418.65","","APC Price ($427.19). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","418.65","418.65","418.65","1 through 10","405.83","1066.72","other","OPPS APC"
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1258.00","943.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","745.99","59.3","","716.68","716.68","716.68","1 through 10","486.06","986.9","percent of total billed charges",""
"Surgical Pathology, Gross and Micro Exam, for Prostate Ndl Biopsy, Any Meth","PX-31000503","CDM","G0416","HCPCS","0310","RC","","","","outpatient","","","1258.00","943.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","986.90","78.45","","940.24","940.24","940.24","1 through 10","486.06","986.9","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6419.00","4814.25","AETNA [1001]","HB CH AETNA HMO / PPO","3742.28","58.3","","2343.98","2343.98","2343.98","1 through 10","2753.75","5001.04","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6419.00","4814.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,027). Procedure 2, Per diem ($1,013.50). Procedures 3 - 9999, Per diem ($506.75).","2027.00","2027.00","2027.00","1 through 10","2753.75","5001.04","per diem",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6419.00","4814.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2151.00","2216.00","1 through 10","2753.75","5001.04","per diem",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","both","","","6419.00","4814.25","WELLPOINT [1015]","HB CH WELLPOINT","5001.04","77.91","","8321.78","8321.78","8321.78","1 through 10","2753.75","5001.04","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3149.80","49.07","","3775.00","3775.00","3775.00","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3215.92","50.1","","3860.43","3780.34","3860.43","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Surgical Tx Anal Fistula Subq","PX-75000219","CDM","46270","CPT","0750","RC","","","","outpatient","","","6419.00","4814.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5035.71","78.45","","8123.14","2719.93","11656.55","1 through 10","2567.6","5035.71","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","91.85","25","8.48","60.59","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","83.00","62.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","49.22","59.3","","47.47","47.47","129.51","16","8.92","65.11","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","83.00","62.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","62.27","62.27","62.27","1 through 10","8.92","65.11","percent of total billed charges",""
"Susceptibility Mic per Plate","PX-30001186","CDM","87186","CPT","0306","RC","","","","outpatient","","","83.00","62.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","65.11","78.45","","62.27","36.90","68.04","17","8.92","65.11","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","AETNA [1001]","HB CH AETNA HMO / PPO","174.90","58.3","","554.95","91.85","1421.75","94","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","2490.03","2490.03","2490.03","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","174.90","58.3","","750.00","750.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","159.00","53","","1192.50","120.84","4149.90","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","255.00","85","","750.00","75.00","750.00","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","300.00","100","","657.00","121.50","1971.00","14","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","300.00","100","","75.00","75.00","75.00","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","300.00","100","","366.00","144.00","1971.00","45","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","219.00","73","","667.50","667.50","667.50","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","133.35","44.45","","123.77","123.77","123.77","1 through 10","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","both","","","300.00","225.00","WELLPOINT [1015]","HB CH WELLPOINT","233.73","77.91","","483.51","229.32","1316.08","96","133.35","300","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","177.90","59.3","","439.50","225.34","1872.27","197","150","235.35","percent of total billed charges",""
"SUTURE BUTTON 12MM RETROCONSTRUCTION TRACTION FIXATION TITANIUM ROUND STERILE","SUP-ITM-10027994","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","300.00","225.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","235.35","78.45","","385.32","55.36","1815.62","58","150","235.35","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","AETNA [1001]","HB CH AETNA HMO / PPO","4.17","58.3","","554.95","91.85","1421.75","94","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5.23","73","","2490.03","2490.03","2490.03","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4.17","58.3","","750.00","750.00","750.00","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3.79","53","","1192.50","120.84","4149.90","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6.09","85","","750.00","75.00","750.00","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","7.16","100","","657.00","121.50","1971.00","14","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7.16","100","","75.00","75.00","75.00","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","7.16","100","","366.00","144.00","1971.00","45","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5.23","73","","667.50","667.50","667.50","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3.18","44.45","","123.77","123.77","123.77","1 through 10","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","both","","","7.16","5.37","WELLPOINT [1015]","HB CH WELLPOINT","5.58","77.91","","483.51","229.32","1316.08","96","3.18","7.16","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7.16","5.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","4.25","59.3","","439.50","225.34","1872.27","197","3.58","5.62","percent of total billed charges",""
"SUTURE MONOCRYL PLUS 4-0 SH 27IN MONOFILAMENT TAPER 1/2 CIRCLE ABSORBABLE UNDYED BX/36EA","SUP-ITM-10020633","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","7.16","5.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5.62","78.45","","385.32","55.36","1815.62","58","3.58","5.62","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","AETNA [1001]","HB CH AETNA HMO / PPO","72.86","58.3","","554.95","91.85","1421.75","94","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","91.24","73","","2490.03","2490.03","2490.03","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","72.86","58.3","","750.00","750.00","750.00","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","66.24","53","","1192.50","120.84","4149.90","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","106.23","85","","750.00","75.00","750.00","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","124.98","100","","657.00","121.50","1971.00","14","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","124.98","100","","75.00","75.00","75.00","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","124.98","100","","366.00","144.00","1971.00","45","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","91.24","73","","667.50","667.50","667.50","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","55.55","44.45","","123.77","123.77","123.77","1 through 10","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","both","","","124.98","93.73","WELLPOINT [1015]","HB CH WELLPOINT","97.37","77.91","","483.51","229.32","1316.08","96","55.55","124.98","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","CIGNA [1006]","HB CH CIGNA HMO / PPO","74.11","59.3","","439.50","225.34","1872.27","197","62.49","98.05","percent of total billed charges",""
"SUTURE ULTRATAPE 2MM 38IN POLYETHYLENE COBRAID STERILE DISPOSABLE BLUE BX/6EA","SUP-ITM-10151415","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","124.98","93.73","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","98.05","78.45","","385.32","55.36","1815.62","58","62.49","98.05","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","554.95","91.85","1421.75","94","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","2490.03","2490.03","2490.03","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","69.96","58.3","","750.00","750.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","63.60","53","","1192.50","120.84","4149.90","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","102.00","85","","750.00","75.00","750.00","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","120.00","100","","657.00","121.50","1971.00","14","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","120.00","100","","75.00","75.00","75.00","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","120.00","100","","366.00","144.00","1971.00","45","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","87.60","73","","667.50","667.50","667.50","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.34","44.45","","123.77","123.77","123.77","1 through 10","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","both","","","120.00","90.00","WELLPOINT [1015]","HB CH WELLPOINT","93.49","77.91","","483.51","229.32","1316.08","96","53.34","120","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.16","59.3","","439.50","225.34","1872.27","197","60","94.14","percent of total billed charges",""
"SUTURE ULTRATAPE 38IN LOW PROFILE NON ABSORBABLE BLUE BX/6EA","SUP-ITM-10151414","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","385.32","55.36","1815.62","58","60","94.14","percent of total billed charges",""
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","8615.39","","Case rate ($8,364.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,409.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","8393.41","8393.41","8393.41","1 through 10","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","9131.74","","Case rate ($9,131.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,176.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8060.58","8060.58","8060.58","1 through 10","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8197.17","","Case rate ($8,364.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,409.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8027.24","8027.24","8082.01","1 through 10","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","ELDER SERVICES [1037]","HB BWF MEDICARE","9131.74","","Case rate ($9,131.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,176.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7993.72","7993.72","7993.72","1 through 10","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","MEDICARE [2001]","HB BWF MEDICARE","9131.74","","Case rate ($9,131.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $8,176.32 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8856.49","0.03","8914.92","35","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8197.17","","Case rate ($8,364.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,409.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","9199.39","9199.39","9199.39","1 through 10","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse","312","MS-DRG","","","","","","","","inpatient","","","30209.73","22657.30","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8197.17","","Case rate ($8,364.46). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,377.55, add-ons for qualifying new technology services are included. If operating cost exceeds $53,901.28 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,176.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,409.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,038.31 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $616.19. The transfer capital threshold is the transfer adjustment factor * $616.19. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8015.64","7993.73","28729.89","1 through 10","8197.17","9131.74","other","Inpatient DRG"
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","52563.29","","MASSHEALTH [3001]","HB BWF MEDICAID","7184.34","","Case rate ($7,943.52). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,373.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7941.57","7941.57","7941.57","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","52563.29","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","7184.34","","Case rate ($7,943.52). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,373.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7941.57","7941.57","7941.57","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MAJOR","204","DRG","","","","","","","","inpatient","","","52563.29","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7184.34","","Case rate ($7,943.52). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,373.52, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7941.57","7941.57","7941.57","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MINOR","204","DRG","","","","","","","","inpatient","","","19584.68","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","14159.79","","Standard inlier is a Case rate ($14,159.79). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $25,170, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,009.92) for the length of stay and the standard reimbursement.","14159.79","14159.79","14159.79","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","21216.85","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8518.3578","","Fee schedule rate ($11,078.36). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8518.3578","10651.48","10651.48","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","21216.85","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","8944.2321","","Fee schedule rate ($11,632.22). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8944.2321","11632.24","11632.24","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","21216.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19709.33","","Fee schedule rate ($19,709.33). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17471.46","17471.46","17471.46","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","21216.85","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","5029.84","","Case rate ($5,561.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,991.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5559.99","3812.16","5559.99","1 through 10","3836.07","53795.89","case rate",""
"Syncope And Collapse,MODERATE","204","DRG","","","","","","","","inpatient","","","21216.85","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","5029.84","","Case rate ($5,561.35). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,991.35, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4240.39","4240.39","4240.39","1 through 10","3836.07","53795.89","case rate",""
"Syphilis Vdrl/Rpr Ql","PX-30000877","CDM","86592","CPT","0302","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","27.68","27.68","27.68","1 through 10","4.4","29.03","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","AETNA [1001]","HB CH AETNA HMO / PPO","2592.02","58.3","","1634.24","1004.95","1718.99","42","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3245.58","73","","2123.89","1900.92","2123.89","1 through 10","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2592.02","58.3","","3729.00","1254.19","3729.00","1 through 10","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2356.38","53","","939.37","939.37","5593.65","1 through 10","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3779.10","85","","2323.25","1864.50","2882.25","16","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4446.00","100","","2909.44","1772.40","10952.08","45","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4446.00","100","","2323.25","2323.25","2323.25","1 through 10","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4446.00","100","","2882.25","1772.40","10169.17","187","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3245.58","73","","1659.41","1659.41","1659.41","1 through 10","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","both","","","4446.00","3334.50","WELLPOINT [1015]","HB CH WELLPOINT","3463.88","77.91","","2050.91","1468.48","2902.83","52","1976.25","4446","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4446.00","3334.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2636.48","59.3","","1548.60","1092.60","3613.79","82","2223","3487.89","percent of total billed charges",""
"SYSTEM ANKLE 10MM SZ 2 PLUS TOTAL INFINITY EVERLAST POLYETHYLENE FIXED BEARING","SUP-ITM-10304265","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4446.00","3334.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3487.89","78.45","","2085.51","998.68","6202.11","56","2223","3487.89","percent of total billed charges",""
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","6990.00","5242.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","","54.40","54.4% of billed. Final payment is multiplied by 103%.","1569.00","1569.00","1569.00","1 through 10","2796","6990","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","6990.00","5242.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","","54.40","54.4% of billed.","2992.06","1576.23","2992.06","1 through 10","2796","6990","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","6990.00","5242.50","MEDICARE [2001]","HB BWF MEDICARE","","54.40","54.4% of billed.","1601.86","1517.98","9388.95","22","2796","6990","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","6990.00","5242.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","","54.40","54.4% of billed. Final payment is multiplied by 98%.","2017.77","2017.77","2017.77","1 through 10","2796","6990","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","both","","","6990.00","5242.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","","54.40","54.4% of billed. Final payment is multiplied by 98%.","1569.83","1569.83","1569.83","1 through 10","2796","6990","other","OPPS APC"
"SYSTEM ASPIRATION CVAC BX/2EA","SUP-ITM-10321025","CDM","C1747","HCPCS","0272","RC","","","","outpatient","","","6990.00","5242.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5483.66","78.45","","5373.91","5373.91","5373.91","1 through 10","2796","5483.66","percent of total billed charges",""
"SYSTEM CHARGING NEUROSTIMULATOR PRODIGY - DISCONTINUED PER SUPPLIER","SUP-ITM-10146141","CDM","C1820","HCPCS","0278","RC","","","","both","","","1500.00","1125.00","WELLPOINT [1015]","HB CH WELLPOINT","1168.65","77.91","","17681.62","17681.62","17681.62","1 through 10","795","1500","percent of total billed charges",""
"SYSTEM CHARGING NEUROSTIMULATOR PRODIGY - DISCONTINUED PER SUPPLIER","SUP-ITM-10146141","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","1500.00","1125.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","889.50","59.3","","74853.32","74853.32","74853.32","1 through 10","666.75","1176.75","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","AETNA [1001]","HB CH AETNA HMO / PPO","2587.06","58.3","","554.95","91.85","1421.75","94","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3239.38","73","","2490.03","2490.03","2490.03","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2587.06","58.3","","750.00","750.00","750.00","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2351.88","53","","1192.50","120.84","4149.90","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3771.88","85","","750.00","75.00","750.00","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4437.50","100","","657.00","121.50","1971.00","14","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4437.50","100","","75.00","75.00","75.00","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4437.50","100","","366.00","144.00","1971.00","45","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3239.38","73","","667.50","667.50","667.50","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1972.47","44.45","","123.77","123.77","123.77","1 through 10","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","both","","","4437.50","3328.12","WELLPOINT [1015]","HB CH WELLPOINT","3457.26","77.91","","483.51","229.32","1316.08","96","1972.47","4437.5","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2631.44","59.3","","439.50","225.34","1872.27","197","2218.75","3481.22","percent of total billed charges",""
"SYSTEM EXTERNAL FIXATION JOINT DIGIT WIDGET","SUP-ITM-10024353","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4437.50","3328.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3481.22","78.45","","385.32","55.36","1815.62","58","2218.75","3481.22","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1830.28","315.58","1830.28","1 through 10","400.05","900","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","4170.85","4170.85","4170.85","1 through 10","400.05","900","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","400.05","44.45","","649.55","649.55","649.55","1 through 10","400.05","900","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","8998.38","2542.37","8998.38","20","400.05","900","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1891.61","1609.14","3664.18","25","450","706.05","percent of total billed charges",""
"SYSTEM FILL 21GA 1 3/4IN FOURTE TISSUE EXPANDER","SUP-ITM-10275659","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","1470.68","1310.06","2481.69","19","450","706.05","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","AETNA [1001]","HB CH AETNA HMO / PPO","2326.52","58.3","","554.95","91.85","1421.75","94","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2913.14","73","","2490.03","2490.03","2490.03","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2326.52","58.3","","750.00","750.00","750.00","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2115.02","53","","1192.50","120.84","4149.90","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3392.01","85","","750.00","75.00","750.00","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3990.60","100","","657.00","121.50","1971.00","14","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3990.60","100","","75.00","75.00","75.00","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3990.60","100","","366.00","144.00","1971.00","45","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2913.14","73","","667.50","667.50","667.50","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1773.82","44.45","","123.77","123.77","123.77","1 through 10","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","both","","","3990.60","2992.95","WELLPOINT [1015]","HB CH WELLPOINT","3109.08","77.91","","483.51","229.32","1316.08","96","1773.82","3990.6","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.60","2992.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","2366.43","59.3","","439.50","225.34","1872.27","197","1995.3","3130.63","percent of total billed charges",""
"SYSTEM FIXATION 3X50MM NAIL TRIMMABLE CANNULATED","SUP-ITM-10304322","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3990.60","2992.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3130.63","78.45","","385.32","55.36","1815.62","58","1995.3","3130.63","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","AETNA [1001]","HB CH AETNA HMO / PPO","1967.63","58.3","","1634.24","1004.95","1718.99","42","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2463.75","73","","2123.89","1900.92","2123.89","1 through 10","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1967.63","58.3","","3729.00","1254.19","3729.00","1 through 10","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1788.75","53","","939.37","939.37","5593.65","1 through 10","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2868.75","85","","2323.25","1864.50","2882.25","16","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3375.00","100","","2909.44","1772.40","10952.08","45","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3375.00","100","","2323.25","2323.25","2323.25","1 through 10","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3375.00","100","","2882.25","1772.40","10169.17","187","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2463.75","73","","1659.41","1659.41","1659.41","1 through 10","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","WELLPOINT [1015]","HB CH WELLPOINT","2629.46","77.91","","2050.91","1468.48","2902.83","52","1500.19","3375","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2001.38","59.3","","1548.60","1092.60","3613.79","82","1687.5","2647.69","percent of total billed charges",""
"SYSTEM IMPLANT 2MM 3MM ANTERIOR CRUCIATE LIGAMENT ACUTE FIBERTAPE TIGERTAPE LOOP CANNULATED DRILL SUTURELASSO SD WIRELOOP 2.4","SUP-ITM-10273958","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3375.00","2531.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2647.69","78.45","","2085.51","998.68","6202.11","56","1687.5","2647.69","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","AETNA [1001]","HB CH AETNA HMO / PPO","3277.92","58.3","","554.95","91.85","1421.75","94","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4104.43","73","","2490.03","2490.03","2490.03","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3277.92","58.3","","750.00","750.00","750.00","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2979.93","53","","1192.50","120.84","4149.90","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4779.13","85","","750.00","75.00","750.00","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5622.50","100","","657.00","121.50","1971.00","14","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5622.50","100","","75.00","75.00","75.00","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5622.50","100","","366.00","144.00","1971.00","45","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4104.43","73","","667.50","667.50","667.50","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2499.20","44.45","","123.77","123.77","123.77","1 through 10","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","both","","","5622.50","4216.87","WELLPOINT [1015]","HB CH WELLPOINT","4380.49","77.91","","483.51","229.32","1316.08","96","2499.2","5622.5","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.50","4216.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","3334.14","59.3","","439.50","225.34","1872.27","197","2811.25","4410.85","percent of total billed charges",""
"SYSTEM IMPLANT FIBERTAK SPEEDBRIDGE","SUP-ITM-10325319","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","5622.50","4216.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4410.85","78.45","","385.32","55.36","1815.62","58","2811.25","4410.85","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","AETNA [1001]","HB CH AETNA HMO / PPO","717.09","58.3","","554.95","91.85","1421.75","94","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","897.90","73","","2490.03","2490.03","2490.03","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","717.09","58.3","","750.00","750.00","750.00","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","651.90","53","","1192.50","120.84","4149.90","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1045.50","85","","750.00","75.00","750.00","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1230.00","100","","657.00","121.50","1971.00","14","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1230.00","100","","75.00","75.00","75.00","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1230.00","100","","366.00","144.00","1971.00","45","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","897.90","73","","667.50","667.50","667.50","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","546.74","44.45","","123.77","123.77","123.77","1 through 10","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","both","","","1230.00","922.50","WELLPOINT [1015]","HB CH WELLPOINT","958.29","77.91","","483.51","229.32","1316.08","96","546.74","1230","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1230.00","922.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","729.39","59.3","","439.50","225.34","1872.27","197","615","964.94","percent of total billed charges",""
"SYSTEM MENISCAL REPAIR ULTRA FAST-FIX FIXATION REVERSE CURVED","SUP-ITM-10031427","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1230.00","922.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","964.94","78.45","","385.32","55.36","1815.62","58","615","964.94","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","AETNA [1001]","HB CH AETNA HMO / PPO","1180.58","58.3","","554.95","91.85","1421.75","94","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","2490.03","2490.03","2490.03","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1180.58","58.3","","750.00","750.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1073.25","53","","1192.50","120.84","4149.90","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1721.25","85","","750.00","75.00","750.00","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2025.00","100","","657.00","121.50","1971.00","14","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2025.00","100","","75.00","75.00","75.00","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2025.00","100","","366.00","144.00","1971.00","45","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1478.25","73","","667.50","667.50","667.50","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","900.11","44.45","","123.77","123.77","123.77","1 through 10","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","both","","","2025.00","1518.75","WELLPOINT [1015]","HB CH WELLPOINT","1577.68","77.91","","483.51","229.32","1316.08","96","900.11","2025","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1200.83","59.3","","439.50","225.34","1872.27","197","1012.5","1588.61","percent of total billed charges",""
"SYSTEM PROXIMAL TENODESIS IMPLANT KIT","SUP-ITM-10307336","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2025.00","1518.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1588.61","78.45","","385.32","55.36","1815.62","58","1012.5","1588.61","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","AETNA [1001]","HB CH AETNA HMO / PPO","830.78","58.3","","554.95","91.85","1421.75","94","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","2490.03","2490.03","2490.03","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","830.78","58.3","","750.00","750.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","755.25","53","","1192.50","120.84","4149.90","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1211.25","85","","750.00","75.00","750.00","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1425.00","100","","657.00","121.50","1971.00","14","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1425.00","100","","75.00","75.00","75.00","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1425.00","100","","366.00","144.00","1971.00","45","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1040.25","73","","667.50","667.50","667.50","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","633.41","44.45","","123.77","123.77","123.77","1 through 10","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","both","","","1425.00","1068.75","WELLPOINT [1015]","HB CH WELLPOINT","1110.22","77.91","","483.51","229.32","1316.08","96","633.41","1425","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.03","59.3","","439.50","225.34","1872.27","197","712.5","1117.91","percent of total billed charges",""
"SYSTEM REPAIR 9DEG CURVED DOWN MENISCAL AIR PLUS","SUP-ITM-10282120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1425.00","1068.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1117.91","78.45","","385.32","55.36","1815.62","58","712.5","1117.91","percent of total billed charges",""
"SYSTEM SCS PROSPERA TRIAL 2 LEADS + ACC","SUP-ITM-10321119","CDM","C1897","HCPCS","0278","RC","","","","both","","","3375.00","2531.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3375.00","100","","2502.46","2502.46","2502.46","1 through 10","1788.75","3375","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","AETNA [1001]","HB CH AETNA HMO / PPO","437.25","58.3","","1634.24","1004.95","1718.99","42","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","2123.89","1900.92","2123.89","1 through 10","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","437.25","58.3","","3729.00","1254.19","3729.00","1 through 10","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","397.50","53","","939.37","939.37","5593.65","1 through 10","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","637.50","85","","2323.25","1864.50","2882.25","16","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","750.00","100","","2909.44","1772.40","10952.08","45","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","750.00","100","","2323.25","2323.25","2323.25","1 through 10","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","750.00","100","","2882.25","1772.40","10169.17","187","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","547.50","73","","1659.41","1659.41","1659.41","1 through 10","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","both","","","750.00","562.50","WELLPOINT [1015]","HB CH WELLPOINT","584.33","77.91","","2050.91","1468.48","2902.83","52","333.38","750","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","444.75","59.3","","1548.60","1092.60","3613.79","82","375","588.38","percent of total billed charges",""
"SYSTEM SHOULDER 6.6X30MM CENTRAL SCREW INHANCE","SUP-ITM-10317991","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","750.00","562.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","588.38","78.45","","2085.51","998.68","6202.11","56","375","588.38","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","AETNA [1001]","HB CH AETNA HMO / PPO","2098.80","58.3","","1634.24","1004.95","1718.99","42","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","2123.89","1900.92","2123.89","1 through 10","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2098.80","58.3","","3729.00","1254.19","3729.00","1 through 10","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1908.00","53","","939.37","939.37","5593.65","1 through 10","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3060.00","85","","2323.25","1864.50","2882.25","16","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3600.00","100","","2909.44","1772.40","10952.08","45","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3600.00","100","","2323.25","2323.25","2323.25","1 through 10","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3600.00","100","","2882.25","1772.40","10169.17","187","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2628.00","73","","1659.41","1659.41","1659.41","1 through 10","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","both","","","3600.00","2700.00","WELLPOINT [1015]","HB CH WELLPOINT","2804.76","77.91","","2050.91","1468.48","2902.83","52","1600.2","3600","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2134.80","59.3","","1548.60","1092.60","3613.79","82","1800","2824.2","percent of total billed charges",""
"SYSTEM SHOULDER REVERSE HUMERAL SHEL SM INHANCE","SUP-ITM-10317997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3600.00","2700.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2824.20","78.45","","2085.51","998.68","6202.11","56","1800","2824.2","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","AETNA [1001]","HB CH AETNA HMO / PPO","2798.40","58.3","","1634.24","1004.95","1718.99","42","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3504.00","73","","2123.89","1900.92","2123.89","1 through 10","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2798.40","58.3","","3729.00","1254.19","3729.00","1 through 10","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2544.00","53","","939.37","939.37","5593.65","1 through 10","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4080.00","85","","2323.25","1864.50","2882.25","16","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4800.00","100","","2909.44","1772.40","10952.08","45","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4800.00","100","","2323.25","2323.25","2323.25","1 through 10","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4800.00","100","","2882.25","1772.40","10169.17","187","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3504.00","73","","1659.41","1659.41","1659.41","1 through 10","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","both","","","4800.00","3600.00","WELLPOINT [1015]","HB CH WELLPOINT","3739.68","77.91","","2050.91","1468.48","2902.83","52","2133.6","4800","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2846.40","59.3","","1548.60","1092.60","3613.79","82","2400","3765.6","percent of total billed charges",""
"SYSTEM SHOULDER STANDARD STEM LG INHANCE","SUP-ITM-10317995","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4800.00","3600.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3765.60","78.45","","2085.51","998.68","6202.11","56","2400","3765.6","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4043.51","3032.63","AETNA [1001]","HB CH AETNA HMO / PPO","2357.37","58.3","","1952.48","1952.48","1952.48","1 through 10","1797.34","4043.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4043.51","3032.63","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2143.06","53","","1825.07","1825.07","1825.07","1 through 10","1797.34","4043.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","both","","","4043.51","3032.63","WELLPOINT [1015]","HB CH WELLPOINT","3150.30","77.91","","2712.12","2712.12","2712.12","1 through 10","1797.34","4043.51","percent of total billed charges",""
"SYSTEM SIS SOLYX SINGLE BLUE","SUP-ITM-10240833","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","4043.51","3032.63","CIGNA [1006]","HB CH CIGNA HMO / PPO","2397.80","59.3","","2017.91","2017.91","2017.91","1 through 10","2021.76","3172.13","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","14710.80","11033.10","AETNA [1001]","HB CH AETNA HMO / PPO","8576.40","58.3","","1952.48","1952.48","1952.48","1 through 10","6538.95","14710.8","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","14710.80","11033.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","7796.72","53","","1825.07","1825.07","1825.07","1 through 10","6538.95","14710.8","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","both","","","14710.80","11033.10","WELLPOINT [1015]","HB CH WELLPOINT","11461.18","77.91","","2712.12","2712.12","2712.12","1 through 10","6538.95","14710.8","percent of total billed charges",""
"SYSTEM SLING MALE ADVANCE XP-3 YEAR SHELF LIFE","SUP-ITM-10320566","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","14710.80","11033.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","8723.50","59.3","","2017.91","2017.91","2017.91","1 through 10","7355.4","11540.62","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3280.16","2460.12","AETNA [1001]","HB CH AETNA HMO / PPO","1912.33","58.3","","1952.48","1952.48","1952.48","1 through 10","1458.03","3280.16","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3280.16","2460.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1738.48","53","","1825.07","1825.07","1825.07","1 through 10","1458.03","3280.16","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","both","","","3280.16","2460.12","WELLPOINT [1015]","HB CH WELLPOINT","2555.57","77.91","","2712.12","2712.12","2712.12","1 through 10","1458.03","3280.16","percent of total billed charges",""
"SYSTEM SLING SUPRAPUBIC BLUE LYNX","SUP-ITM-10211686","CDM","C1771","HCPCS","0278","RC","","","","outpatient","","","3280.16","2460.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","1945.13","59.3","","2017.91","2017.91","2017.91","1 through 10","1640.08","2573.29","percent of total billed charges",""
"SYSTEM SPACEOAR 10ML HYDROGEL","SUP-ITM-10188453","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","AETNA [1001]","HB CH AETNA HMO / PPO","3672.90","58.3","","1830.28","315.58","1830.28","1 through 10","2800.35","6300","percent of total billed charges",""
"SYSTEM SPACEOAR 10ML HYDROGEL","SUP-ITM-10188453","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4599.00","73","","4170.85","4170.85","4170.85","1 through 10","2800.35","6300","percent of total billed charges",""
"SYSTEM SPACEOAR 10ML HYDROGEL","SUP-ITM-10188453","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2800.35","44.45","","649.55","649.55","649.55","1 through 10","2800.35","6300","percent of total billed charges",""
"SYSTEM SPACEOAR 10ML HYDROGEL","SUP-ITM-10188453","CDM","C1889","HCPCS","0278","RC","","","","both","","","6300.00","4725.00","WELLPOINT [1015]","HB CH WELLPOINT","4908.33","77.91","","8998.38","2542.37","8998.38","20","2800.35","6300","percent of total billed charges",""
"SYSTEM SPACEOAR 10ML HYDROGEL","SUP-ITM-10188453","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6300.00","4725.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3735.90","59.3","","1891.61","1609.14","3664.18","25","3150","4942.35","percent of total billed charges",""
"SYSTEM SPACEOAR 10ML HYDROGEL","SUP-ITM-10188453","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6300.00","4725.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4942.35","78.45","","1470.68","1310.06","2481.69","19","3150","4942.35","percent of total billed charges",""
"SYSTEM SPACEOAR VUE HYDROGEN DIAGNOSTICS","SUP-ITM-10266264","CDM","C1889","HCPCS","0278","RC","","","","both","","","6930.00","5197.50","AETNA [1001]","HB CH AETNA HMO / PPO","4040.19","58.3","","1830.28","315.58","1830.28","1 through 10","3080.39","6930","percent of total billed charges",""
"SYSTEM SPACEOAR VUE HYDROGEN DIAGNOSTICS","SUP-ITM-10266264","CDM","C1889","HCPCS","0278","RC","","","","both","","","6930.00","5197.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5058.90","73","","4170.85","4170.85","4170.85","1 through 10","3080.39","6930","percent of total billed charges",""
"SYSTEM SPACEOAR VUE HYDROGEN DIAGNOSTICS","SUP-ITM-10266264","CDM","C1889","HCPCS","0278","RC","","","","both","","","6930.00","5197.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3080.39","44.45","","649.55","649.55","649.55","1 through 10","3080.39","6930","percent of total billed charges",""
"SYSTEM SPACEOAR VUE HYDROGEN DIAGNOSTICS","SUP-ITM-10266264","CDM","C1889","HCPCS","0278","RC","","","","both","","","6930.00","5197.50","WELLPOINT [1015]","HB CH WELLPOINT","5399.16","77.91","","8998.38","2542.37","8998.38","20","3080.39","6930","percent of total billed charges",""
"SYSTEM SPACEOAR VUE HYDROGEN DIAGNOSTICS","SUP-ITM-10266264","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6930.00","5197.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4109.49","59.3","","1891.61","1609.14","3664.18","25","3465","5436.59","percent of total billed charges",""
"SYSTEM SPACEOAR VUE HYDROGEN DIAGNOSTICS","SUP-ITM-10266264","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6930.00","5197.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5436.59","78.45","","1470.68","1310.06","2481.69","19","3465","5436.59","percent of total billed charges",""
"SYSTEM SPINAL CORD STIMULATION PROSPERA 2 LEAD + ACC","SUP-ITM-10321115","CDM","C1822","HCPCS","0278","RC","","","","both","","","41000.00","30750.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","21730.00","53","","16922.90","16922.90","16922.90","1 through 10","21730","41000","percent of total billed charges",""
"SYSTEM STIMULATION SENZA HFX-IQ IPG SPINAL CORD","SUP-ITM-10317795","CDM","C1822","HCPCS","0278","RC","","","","both","","","46400.00","34800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","24592.00","53","","16922.90","16922.90","16922.90","1 through 10","24592","46400","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","both","","","54000.00","40500.00","WELLPOINT [1015]","HB CH WELLPOINT","42071.40","77.91","","17681.62","17681.62","17681.62","1 through 10","28620","54000","percent of total billed charges",""
"SYSTEM STIMULATOR EVOKE G4 CLOSED LOOP","SUP-ITM-10328866","CDM","C1820","HCPCS","0278","RC","","","","outpatient","","","54000.00","40500.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","32022.00","59.3","","74853.32","74853.32","74853.32","1 through 10","24003","42363","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","AETNA [1001]","HB CH AETNA HMO / PPO","2324.71","58.3","","554.95","91.85","1421.75","94","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2910.88","73","","2490.03","2490.03","2490.03","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2324.71","58.3","","750.00","750.00","750.00","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2113.38","53","","1192.50","120.84","4149.90","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3389.38","85","","750.00","75.00","750.00","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3987.50","100","","657.00","121.50","1971.00","14","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3987.50","100","","75.00","75.00","75.00","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3987.50","100","","366.00","144.00","1971.00","45","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2910.88","73","","667.50","667.50","667.50","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1772.44","44.45","","123.77","123.77","123.77","1 through 10","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","both","","","3987.50","2990.62","WELLPOINT [1015]","HB CH WELLPOINT","3106.66","77.91","","483.51","229.32","1316.08","96","1772.44","3987.5","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.50","2990.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","2364.59","59.3","","439.50","225.34","1872.27","197","1993.75","3128.19","percent of total billed charges",""
"SYSTEM SUSPENSION FIBERLOCK","SUP-ITM-10307489","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3987.50","2990.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3128.19","78.45","","385.32","55.36","1815.62","58","1993.75","3128.19","percent of total billed charges",""
"SYSTEM TRIALING 60CM EVOKE","SUP-ITM-10317742","CDM","C1897","HCPCS","0278","RC","","","","both","","","4000.00","3000.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4000.00","100","","2502.46","2502.46","2502.46","1 through 10","2120","4000","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","both","","","207.00","155.25","AETNA [1001]","HB CH AETNA HMO / PPO","120.68","58.3","","113.97","113.97","113.97","1 through 10","46.04","277.18","percent of total billed charges",""
"T Cells Cd4 & Cd8 W/Ratio","PX-30000853","CDM","86360","CPT","0302","RC","","","","outpatient","","","207.00","155.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","162.39","78.45","","154.53","154.53","154.53","1 through 10","14.19","176.44","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","both","","","190.00","142.50","AETNA [1001]","HB CH AETNA HMO / PPO","110.77","58.3","","104.90","104.90","104.90","1 through 10","36.98","222.6","percent of total billed charges",""
"T Cells Total","PX-30000852","CDM","86359","CPT","0302","RC","","","","outpatient","","","190.00","142.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","149.06","78.45","","142.23","142.23","142.23","1 through 10","11.81","149.06","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","AETNA [1001]","HB CH AETNA HMO / PPO","550.94","58.3","","1634.24","1004.95","1718.99","42","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","2123.89","1900.92","2123.89","1 through 10","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","550.94","58.3","","3729.00","1254.19","3729.00","1 through 10","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","500.85","53","","939.37","939.37","5593.65","1 through 10","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","803.25","85","","2323.25","1864.50","2882.25","16","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","945.00","100","","2909.44","1772.40","10952.08","45","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","945.00","100","","2323.25","2323.25","2323.25","1 through 10","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","945.00","100","","2882.25","1772.40","10169.17","187","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","689.85","73","","1659.41","1659.41","1659.41","1 through 10","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","both","","","945.00","708.75","WELLPOINT [1015]","HB CH WELLPOINT","736.25","77.91","","2050.91","1468.48","2902.83","52","420.05","945","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","560.39","59.3","","1548.60","1092.60","3613.79","82","472.5","741.35","percent of total billed charges",""
"T DOME HUMERAL ANAOMIC SHOULDER 135L00/135R00 CENRIC","SUP-ITM-10201495","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","945.00","708.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","741.35","78.45","","2085.51","998.68","6202.11","56","472.5","741.35","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","AETNA [1001]","HB CH AETNA HMO / PPO","1915.16","58.3","","554.95","91.85","1421.75","94","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","2490.03","2490.03","2490.03","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1915.16","58.3","","750.00","750.00","750.00","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1741.05","53","","1192.50","120.84","4149.90","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2792.25","85","","750.00","75.00","750.00","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3285.00","100","","657.00","121.50","1971.00","14","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3285.00","100","","75.00","75.00","75.00","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3285.00","100","","366.00","144.00","1971.00","45","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2398.05","73","","667.50","667.50","667.50","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1460.18","44.45","","123.77","123.77","123.77","1 through 10","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","both","","","3285.00","2463.75","WELLPOINT [1015]","HB CH WELLPOINT","2559.34","77.91","","483.51","229.32","1316.08","96","1460.18","3285","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1948.01","59.3","","439.50","225.34","1872.27","197","1642.5","2577.08","percent of total billed charges",""
"T PLATE 3.5MM 4 HOLE CALCANEAL FRACTURE LOW PROFILE","SUP-ITM-10154410","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3285.00","2463.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2577.08","78.45","","385.32","55.36","1815.62","58","1642.5","2577.08","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","AETNA [1001]","HB CH AETNA HMO / PPO","236.12","58.3","","554.95","91.85","1421.75","94","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","295.65","73","","2490.03","2490.03","2490.03","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","236.12","58.3","","750.00","750.00","750.00","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","214.65","53","","1192.50","120.84","4149.90","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","344.25","85","","750.00","75.00","750.00","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","405.00","100","","657.00","121.50","1971.00","14","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","405.00","100","","75.00","75.00","75.00","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","405.00","100","","366.00","144.00","1971.00","45","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","295.65","73","","667.50","667.50","667.50","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","180.02","44.45","","123.77","123.77","123.77","1 through 10","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","both","","","405.00","303.75","WELLPOINT [1015]","HB CH WELLPOINT","315.54","77.91","","483.51","229.32","1316.08","96","180.02","405","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.00","303.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","240.17","59.3","","439.50","225.34","1872.27","197","202.5","317.72","percent of total billed charges",""
"TACK PLATE LARGE BONE BB TAK FUSION ANKLE DISPOABLE","SUP-ITM-10154445","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","405.00","303.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","317.72","78.45","","385.32","55.36","1815.62","58","202.5","317.72","percent of total billed charges",""
"Tacrolimus (Fk-506)","PX-30000036","CDM","80197","CPT","0301","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","73.04","73.04","1 through 10","7.52","76.88","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","AETNA [1001]","HB CH AETNA HMO / PPO","3628.59","58.3","","1634.24","1004.95","1718.99","42","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4543.52","73","","2123.89","1900.92","2123.89","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3628.59","58.3","","3729.00","1254.19","3729.00","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3298.72","53","","939.37","939.37","5593.65","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5290.40","85","","2323.25","1864.50","2882.25","16","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6224.00","100","","2909.44","1772.40","10952.08","45","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6224.00","100","","2323.25","2323.25","2323.25","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6224.00","100","","2882.25","1772.40","10169.17","187","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4543.52","73","","1659.41","1659.41","1659.41","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","WELLPOINT [1015]","HB CH WELLPOINT","4849.12","77.91","","2050.91","1468.48","2902.83","52","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6224.00","4668.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3690.83","59.3","","1548.60","1092.60","3613.79","82","3112","4882.73","percent of total billed charges",""
"TALUS PLATE SZ 2 PEGGED INVISION RIGHT","SUP-ITM-10193326","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6224.00","4668.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4882.73","78.45","","2085.51","998.68","6202.11","56","3112","4882.73","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","AETNA [1001]","HB CH AETNA HMO / PPO","3628.59","58.3","","554.95","91.85","1421.75","94","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4543.52","73","","2490.03","2490.03","2490.03","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3628.59","58.3","","750.00","750.00","750.00","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3298.72","53","","1192.50","120.84","4149.90","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5290.40","85","","750.00","75.00","750.00","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6224.00","100","","657.00","121.50","1971.00","14","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6224.00","100","","75.00","75.00","75.00","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6224.00","100","","366.00","144.00","1971.00","45","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4543.52","73","","667.50","667.50","667.50","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","2766.57","44.45","","123.77","123.77","123.77","1 through 10","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","both","","","6224.00","4668.00","WELLPOINT [1015]","HB CH WELLPOINT","4849.12","77.91","","483.51","229.32","1316.08","96","2766.57","6224","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6224.00","4668.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3690.83","59.3","","439.50","225.34","1872.27","197","3112","4882.73","percent of total billed charges",""
"TALUS PLATE SZ 3 PEGGED INVISION LEFT","SUP-ITM-10193325","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","6224.00","4668.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4882.73","78.45","","385.32","55.36","1815.62","58","3112","4882.73","percent of total billed charges",""
"Tap Block Bilateral by Injection(S)","PX-51000531","CDM","64488","CPT","0761","RC","","","","outpatient","","","401.00","300.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","314.58","78.45","","299.83","299.83","299.83","1 through 10","116.13","314.58","percent of total billed charges",""
"Tap Block Bilateral by Injection(S)","PX-98300804","CDM","64488","CPT","0983","RC","","","","outpatient","","","","","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","","78.45","","299.83","299.83","299.83","1 through 10","171.3","171.3","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","AETNA [1001]","HB CH AETNA HMO / PPO","312.86","58.3","","554.95","91.85","1421.75","94","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","391.75","73","","2490.03","2490.03","2490.03","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","312.86","58.3","","750.00","750.00","750.00","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","284.42","53","","1192.50","120.84","4149.90","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","456.14","85","","750.00","75.00","750.00","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","536.64","100","","657.00","121.50","1971.00","14","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","536.64","100","","75.00","75.00","75.00","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","536.64","100","","366.00","144.00","1971.00","45","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","391.75","73","","667.50","667.50","667.50","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","238.54","44.45","","123.77","123.77","123.77","1 through 10","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","both","","","536.64","402.48","WELLPOINT [1015]","HB CH WELLPOINT","418.10","77.91","","483.51","229.32","1316.08","96","238.54","536.64","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","318.23","59.3","","439.50","225.34","1872.27","197","268.32","420.99","percent of total billed charges",""
"TAP BONE 110X4MM SCREW STAINLESS CANCELLOUS","SUP-ITM-10003698","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","536.64","402.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","420.99","78.45","","385.32","55.36","1815.62","58","268.32","420.99","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","AETNA [1001]","HB CH AETNA HMO / PPO","886.53","58.3","","554.95","91.85","1421.75","94","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1110.07","73","","2490.03","2490.03","2490.03","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","886.53","58.3","","750.00","750.00","750.00","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","805.94","53","","1192.50","120.84","4149.90","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1292.54","85","","750.00","75.00","750.00","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1520.64","100","","657.00","121.50","1971.00","14","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1520.64","100","","75.00","75.00","75.00","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1520.64","100","","366.00","144.00","1971.00","45","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1110.07","73","","667.50","667.50","667.50","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","675.92","44.45","","123.77","123.77","123.77","1 through 10","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","both","","","1520.64","1140.48","WELLPOINT [1015]","HB CH WELLPOINT","1184.73","77.91","","483.51","229.32","1316.08","96","675.92","1520.64","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.64","1140.48","CIGNA [1006]","HB CH CIGNA HMO / PPO","901.74","59.3","","439.50","225.34","1872.27","197","760.32","1192.94","percent of total billed charges",""
"TAP BONE 3.5X146 61MM SCREW SS CANNULATED","SUP-ITM-10001890","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1520.64","1140.48","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1192.94","78.45","","385.32","55.36","1815.62","58","760.32","1192.94","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","AETNA [1001]","HB CH AETNA HMO / PPO","320.66","58.3","","554.95","91.85","1421.75","94","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","401.51","73","","2490.03","2490.03","2490.03","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","320.66","58.3","","750.00","750.00","750.00","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","291.51","53","","1192.50","120.84","4149.90","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","467.52","85","","750.00","75.00","750.00","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","550.02","100","","657.00","121.50","1971.00","14","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","550.02","100","","75.00","75.00","75.00","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","550.02","100","","366.00","144.00","1971.00","45","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","401.51","73","","667.50","667.50","667.50","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","244.48","44.45","","123.77","123.77","123.77","1 through 10","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","both","","","550.02","412.51","WELLPOINT [1015]","HB CH WELLPOINT","428.52","77.91","","483.51","229.32","1316.08","96","244.48","550.02","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","326.16","59.3","","439.50","225.34","1872.27","197","275.01","431.49","percent of total billed charges",""
"TAP BONE 6.5MM CANCELLOUS SOLID","SUP-ITM-10072396","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","550.02","412.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","431.49","78.45","","385.32","55.36","1815.62","58","275.01","431.49","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","AETNA [1001]","HB CH AETNA HMO / PPO","371.10","58.3","","554.95","91.85","1421.75","94","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","464.67","73","","2490.03","2490.03","2490.03","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","371.10","58.3","","750.00","750.00","750.00","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","337.37","53","","1192.50","120.84","4149.90","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","541.06","85","","750.00","75.00","750.00","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","636.54","100","","657.00","121.50","1971.00","14","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","636.54","100","","75.00","75.00","75.00","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","636.54","100","","366.00","144.00","1971.00","45","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","464.67","73","","667.50","667.50","667.50","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","282.94","44.45","","123.77","123.77","123.77","1 through 10","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","both","","","636.54","477.40","WELLPOINT [1015]","HB CH WELLPOINT","495.93","77.91","","483.51","229.32","1316.08","96","282.94","636.54","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","636.54","477.40","CIGNA [1006]","HB CH CIGNA HMO / PPO","377.47","59.3","","439.50","225.34","1872.27","197","318.27","499.37","percent of total billed charges",""
"TAP SCREW 3.5X70MM CORTICAL","SUP-ITM-10030971","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","636.54","477.40","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","499.37","78.45","","385.32","55.36","1815.62","58","318.27","499.37","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","AETNA [1001]","HB CH AETNA HMO / PPO","566.50","58.3","","554.95","91.85","1421.75","94","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","709.34","73","","2490.03","2490.03","2490.03","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","566.50","58.3","","750.00","750.00","750.00","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","515.00","53","","1192.50","120.84","4149.90","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","825.95","85","","750.00","75.00","750.00","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","971.70","100","","657.00","121.50","1971.00","14","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","971.70","100","","75.00","75.00","75.00","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","971.70","100","","366.00","144.00","1971.00","45","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","709.34","73","","667.50","667.50","667.50","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","431.92","44.45","","123.77","123.77","123.77","1 through 10","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","both","","","971.70","728.77","WELLPOINT [1015]","HB CH WELLPOINT","757.05","77.91","","483.51","229.32","1316.08","96","431.92","971.7","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.70","728.77","CIGNA [1006]","HB CH CIGNA HMO / PPO","576.22","59.3","","439.50","225.34","1872.27","197","485.85","762.3","percent of total billed charges",""
"TAP SCREW 4X70MM CORTICAL","SUP-ITM-10028120","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","971.70","728.77","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","762.30","78.45","","385.32","55.36","1815.62","58","485.85","762.3","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","AETNA [1001]","HB CH AETNA HMO / PPO","164.41","58.3","","1634.24","1004.95","1718.99","42","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","205.86","73","","2123.89","1900.92","2123.89","1 through 10","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","164.41","58.3","","3729.00","1254.19","3729.00","1 through 10","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","149.46","53","","939.37","939.37","5593.65","1 through 10","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","239.70","85","","2323.25","1864.50","2882.25","16","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","282.00","100","","2909.44","1772.40","10952.08","45","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","282.00","100","","2323.25","2323.25","2323.25","1 through 10","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","282.00","100","","2882.25","1772.40","10169.17","187","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","205.86","73","","1659.41","1659.41","1659.41","1 through 10","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","both","","","282.00","211.50","WELLPOINT [1015]","HB CH WELLPOINT","219.71","77.91","","2050.91","1468.48","2902.83","52","125.35","282","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","282.00","211.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","167.23","59.3","","1548.60","1092.60","3613.79","82","141","221.23","percent of total billed charges",""
"TAPER 0MM SLEEVE FEMORAL HIP TITANIUM MODULAR 12/14 PLUS","SUP-ITM-10079507","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","282.00","211.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","221.23","78.45","","2085.51","998.68","6202.11","56","141","221.23","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","AETNA [1001]","HB CH AETNA HMO / PPO","524.70","58.3","","1634.24","1004.95","1718.99","42","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","2123.89","1900.92","2123.89","1 through 10","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","524.70","58.3","","3729.00","1254.19","3729.00","1 through 10","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","477.00","53","","939.37","939.37","5593.65","1 through 10","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","765.00","85","","2323.25","1864.50","2882.25","16","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","900.00","100","","2909.44","1772.40","10952.08","45","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","900.00","100","","2323.25","2323.25","2323.25","1 through 10","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","900.00","100","","2882.25","1772.40","10169.17","187","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","657.00","73","","1659.41","1659.41","1659.41","1 through 10","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","both","","","900.00","675.00","WELLPOINT [1015]","HB CH WELLPOINT","701.19","77.91","","2050.91","1468.48","2902.83","52","400.05","900","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","533.70","59.3","","1548.60","1092.60","3613.79","82","450","706.05","percent of total billed charges",""
"TAPER C 7.5X28MM IMPLANT HIP PLUS FEMORAL HD 05","SUP-ITM-10025697","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","900.00","675.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","706.05","78.45","","2085.51","998.68","6202.11","56","450","706.05","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","AETNA [1001]","HB CH AETNA HMO / PPO","2573.36","58.3","","1634.24","1004.95","1718.99","42","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","2123.89","1900.92","2123.89","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2573.36","58.3","","3729.00","1254.19","3729.00","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2339.42","53","","939.37","939.37","5593.65","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3751.90","85","","2323.25","1864.50","2882.25","16","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4414.00","100","","2909.44","1772.40","10952.08","45","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4414.00","100","","2323.25","2323.25","2323.25","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4414.00","100","","2882.25","1772.40","10169.17","187","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","1659.41","1659.41","1659.41","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","WELLPOINT [1015]","HB CH WELLPOINT","3438.95","77.91","","2050.91","1468.48","2902.83","52","1962.02","4414","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2617.50","59.3","","1548.60","1092.60","3613.79","82","2207","3462.78","percent of total billed charges",""
"TAPER MRS 40MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A","SUP-ITM-10005351","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3462.78","78.45","","2085.51","998.68","6202.11","56","2207","3462.78","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","AETNA [1001]","HB CH AETNA HMO / PPO","2573.36","58.3","","1634.24","1004.95","1718.99","42","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","2123.89","1900.92","2123.89","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2573.36","58.3","","3729.00","1254.19","3729.00","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2339.42","53","","939.37","939.37","5593.65","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3751.90","85","","2323.25","1864.50","2882.25","16","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4414.00","100","","2909.44","1772.40","10952.08","45","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4414.00","100","","2323.25","2323.25","2323.25","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4414.00","100","","2882.25","1772.40","10169.17","187","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3222.22","73","","1659.41","1659.41","1659.41","1 through 10","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","both","","","4414.00","3310.50","WELLPOINT [1015]","HB CH WELLPOINT","3438.95","77.91","","2050.91","1468.48","2902.83","52","1962.02","4414","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2617.50","59.3","","1548.60","1092.60","3613.79","82","2207","3462.78","percent of total billed charges",""
"TAPER MRS 80MM IMPLANT ELBOW HUMERAL BODY MALE FEMALE ONC 13A CS/1BX/1EA","SUP-ITM-10010162","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4414.00","3310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3462.78","78.45","","2085.51","998.68","6202.11","56","2207","3462.78","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","AETNA [1001]","HB CH AETNA HMO / PPO","760.82","58.3","","1634.24","1004.95","1718.99","42","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","952.65","73","","2123.89","1900.92","2123.89","1 through 10","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","760.82","58.3","","3729.00","1254.19","3729.00","1 through 10","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","691.65","53","","939.37","939.37","5593.65","1 through 10","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1109.25","85","","2323.25","1864.50","2882.25","16","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1305.00","100","","2909.44","1772.40","10952.08","45","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1305.00","100","","2323.25","2323.25","2323.25","1 through 10","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1305.00","100","","2882.25","1772.40","10169.17","187","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","952.65","73","","1659.41","1659.41","1659.41","1 through 10","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","both","","","1305.00","978.75","WELLPOINT [1015]","HB CH WELLPOINT","1016.73","77.91","","2050.91","1468.48","2902.83","52","580.07","1305","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","773.87","59.3","","1548.60","1092.60","3613.79","82","652.5","1023.77","percent of total billed charges",""
"TAPER TOEMOTION L18X9.5MM 15 COMPONENT ARTICULAR SURFACE TITANIUM ALLOY METATARSAL HEMICAP POST","SUP-ITM-10028014","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1305.00","978.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1023.77","78.45","","2085.51","998.68","6202.11","56","652.5","1023.77","percent of total billed charges",""
"Tattoo Micropigment <6.0 Sq Cm","PX-76000101","CDM","11920","CPT","0761","RC","","","","outpatient","","","1376.00","1032.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","675.20","49.07","","390.41","390.41","390.41","1 through 10","550.4","1079.47","percent of total billed charges",""
"Tattoo Micropigment <6.0 Sq Cm","PX-76000101","CDM","11920","CPT","0761","RC","","","","outpatient","","","1376.00","1032.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1079.47","78.45","","625.35","625.35","625.35","1 through 10","550.4","1079.47","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","both","","","729.00","546.75","AETNA [1001]","HB CH AETNA HMO / PPO","425.01","58.3","","402.00","402.00","402.00","1 through 10","98","532.17","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","729.00","546.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","432.30","59.3","","415.47","415.47","709.00","1 through 10","77.26","571.9","percent of total billed charges",""
"TB Test Cell Imm Ag Meas Gam Interf","PX-30000870","CDM","86481","CPT","0302","RC","","","","outpatient","","","729.00","546.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","571.90","78.45","","545.08","323.02","545.08","22","77.26","571.9","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","both","","","181.00","135.75","AETNA [1001]","HB CH AETNA HMO / PPO","105.52","58.3","","121.91","121.91","121.91","1 through 10","18.27","132.13","percent of total billed charges",""
"TDA NOS Apixaban (eg. ELIQUIS)","PX-30003542","CDM","80299","CPT","0301","RC","","","","outpatient","","","181.00","135.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","141.99","78.45","","165.29","165.29","165.29","1 through 10","14.12","141.99","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","121.91","121.91","121.91","1 through 10","18.27","108.77","percent of total billed charges",""
"Tda Nos Eslicarbazepine (Eg. Aptiom)","PX-30003547","CDM","80299","CPT","0301","RC","","","","outpatient","","","149.00","111.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","116.89","78.45","","165.29","165.29","165.29","1 through 10","14.12","116.89","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","both","","","176.00","132.00","AETNA [1001]","HB CH AETNA HMO / PPO","102.61","58.3","","121.91","121.91","121.91","1 through 10","18.27","128.48","percent of total billed charges",""
"Tda Nos Rivaroxaban","PX-30003518","CDM","80299","CPT","0301","RC","","","","outpatient","","","176.00","132.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.07","78.45","","165.29","165.29","165.29","1 through 10","14.12","138.07","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","both","","","231.00","173.25","AETNA [1001]","HB CH AETNA HMO / PPO","134.67","58.3","","121.91","121.91","121.91","1 through 10","18.27","168.63","percent of total billed charges",""
"Tda Nos Synthetic Glucocorticoid Screen, Urine","PX-30003623","CDM","80299","CPT","0301","RC","","","","outpatient","","","231.00","173.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","181.22","78.45","","165.29","165.29","165.29","1 through 10","14.12","181.22","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","both","","","220.00","165.00","AETNA [1001]","HB CH AETNA HMO / PPO","128.26","58.3","","121.91","121.91","121.91","1 through 10","18.27","160.6","percent of total billed charges",""
"Tda Nos Ustekinumab and Anti-Ustekinumab Antibodies, Serum (Eg. Stelara)","PX-30003558","CDM","80299","CPT","0301","RC","","","","outpatient","","","220.00","165.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","172.59","78.45","","165.29","165.29","165.29","1 through 10","14.12","172.59","percent of total billed charges",""
"TEMPLATE SPINE 13X14X11MM CORNERSTONE 8740344","SUP-ITM-10059683","CDM","C1889","HCPCS","0278","RC","","","","both","","","730.50","547.87","AETNA [1001]","HB CH AETNA HMO / PPO","425.88","58.3","","1830.28","315.58","1830.28","1 through 10","324.71","730.5","percent of total billed charges",""
"TEMPLATE SPINE 13X14X11MM CORNERSTONE 8740344","SUP-ITM-10059683","CDM","C1889","HCPCS","0278","RC","","","","both","","","730.50","547.87","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","533.27","73","","4170.85","4170.85","4170.85","1 through 10","324.71","730.5","percent of total billed charges",""
"TEMPLATE SPINE 13X14X11MM CORNERSTONE 8740344","SUP-ITM-10059683","CDM","C1889","HCPCS","0278","RC","","","","both","","","730.50","547.87","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","324.71","44.45","","649.55","649.55","649.55","1 through 10","324.71","730.5","percent of total billed charges",""
"TEMPLATE SPINE 13X14X11MM CORNERSTONE 8740344","SUP-ITM-10059683","CDM","C1889","HCPCS","0278","RC","","","","both","","","730.50","547.87","WELLPOINT [1015]","HB CH WELLPOINT","569.13","77.91","","8998.38","2542.37","8998.38","20","324.71","730.5","percent of total billed charges",""
"TEMPLATE SPINE 13X14X11MM CORNERSTONE 8740344","SUP-ITM-10059683","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","730.50","547.87","CIGNA [1006]","HB CH CIGNA HMO / PPO","433.19","59.3","","1891.61","1609.14","3664.18","25","365.25","573.08","percent of total billed charges",""
"TEMPLATE SPINE 13X14X11MM CORNERSTONE 8740344","SUP-ITM-10059683","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","730.50","547.87","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","573.08","78.45","","1470.68","1310.06","2481.69","19","365.25","573.08","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","554.95","91.85","1421.75","94","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","2490.03","2490.03","2490.03","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1399.20","58.3","","750.00","750.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1272.00","53","","1192.50","120.84","4149.90","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2040.00","85","","750.00","75.00","750.00","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2400.00","100","","657.00","121.50","1971.00","14","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2400.00","100","","75.00","75.00","75.00","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2400.00","100","","366.00","144.00","1971.00","45","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","667.50","667.50","667.50","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","123.77","123.77","123.77","1 through 10","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","483.51","229.32","1316.08","96","1066.8","2400","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","439.50","225.34","1872.27","197","1200","1882.8","percent of total billed charges",""
"TENDON ANCHORS 8","SUP-ITM-10216999","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","385.32","55.36","1815.62","58","1200","1882.8","percent of total billed charges",""
"Tendon, Muscle And Other Soft Tissue Procedures,MAJOR","317","DRG","","","","","","","","inpatient","","","34425.26","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","20022.25","","Case rate ($22,138.04). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $64,568.04, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $3,274.86 and the sum of the standard inlier and any outlier amount.","3274.05","3274.05","3274.05","1 through 10","2487","82876.75","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","39791.75","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","24490.62","","Standard inlier is a Case rate ($24,490.62). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,037, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,476.34) for the length of stay and the standard reimbursement.","24490.62","24490.62","24490.62","1 through 10","2487","82876.75","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MINOR","317","DRG","","","","","","","","inpatient","","","39791.75","","MASSHEALTH [3001]","HB BWF MEDICAID","10379.54","","Case rate ($11,476.36). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,906.36, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","1697.27","1697.27","1697.27","1 through 10","2487","82876.75","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","36650.42","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","29489.09","","Standard inlier is a Case rate ($29,489.09). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $35,037, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,186.09) for the length of stay and the standard reimbursement.","28014.63","28014.63","28014.63","1 through 10","2487","82876.75","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","36650.42","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17217.4929","","Fee schedule rate ($52,739.99). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17217.4929","30107.52","30107.52","1 through 10","2487","82876.75","case rate",""
"Tendon, Muscle And Other Soft Tissue Procedures,MODERATE","317","DRG","","","","","","","","inpatient","","","36650.42","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","12484.92","","Case rate ($13,804.22). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $56,234.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","13800.84","13800.84","13800.84","1 through 10","2487","82876.75","case rate",""
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","37596.13","28197.10","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","14450.72","","Case rate ($14,029.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,052.14, add-ons for qualifying new technology services are included. If operating cost exceeds $59,575.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,611.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,639.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,712.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.18. The transfer capital threshold is the transfer adjustment factor * $1,051.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","14774.71","14774.71","14774.71","1 through 10","13749.23","15263.03","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","37596.13","28197.10","MEDICARE [2001]","HB BWF MEDICARE","14029.83","","Case rate ($14,029.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,052.14, add-ons for qualifying new technology services are included. If operating cost exceeds $59,575.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,611.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,639.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,712.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.18. The transfer capital threshold is the transfer adjustment factor * $1,051.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13366.10","13366.10","15660.55","1 through 10","13749.23","15263.03","other","Inpatient Replacement Plans DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","37596.13","28197.10","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13749.23","","Case rate ($14,029.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,052.14, add-ons for qualifying new technology services are included. If operating cost exceeds $59,575.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,611.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,639.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,712.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.18. The transfer capital threshold is the transfer adjustment factor * $1,051.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14026.02","14026.02","14026.02","1 through 10","13749.23","15263.03","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis With McC","557","MS-DRG","","","","","","","","inpatient","","","37596.13","28197.10","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13749.23","","Case rate ($14,029.83). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,052.14, add-ons for qualifying new technology services are included. If operating cost exceeds $59,575.87 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,611.96, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.7. The base transfer operating payment is the transfer adjustment factor * $12,639.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,712.90 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,051.18. The transfer capital threshold is the transfer adjustment factor * $1,051.18. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","14095.01","14095.01","14095.01","1 through 10","13749.23","15263.03","other","Inpatient DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","25355.41","19016.56","MEDICARE [2001]","HB BWF MEDICARE","8563.36","","Case rate ($8,563.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,576.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,100.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,192.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,592.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,237.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.46. The transfer capital threshold is the transfer adjustment factor * $631.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8782.40","8506.86","8840.33","1 through 10","8392.09","8820.26","other","Inpatient Replacement Plans DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","25355.41","19016.56","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","8563.36","","Case rate ($8,563.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,576.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,100.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,192.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,592.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,237.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.46. The transfer capital threshold is the transfer adjustment factor * $631.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7927.01","7927.01","7927.01","1 through 10","8392.09","8820.26","other","Inpatient Replacement Plans DRG"
"Tendonitis, Myositis And Bursitis Without McC","558","MS-DRG","","","","","","","","inpatient","","","25355.41","19016.56","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8392.09","","Case rate ($8,563.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,576.76, add-ons for qualifying new technology services are included. If operating cost exceeds $54,100.49 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,192.24, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.1. The base transfer operating payment is the transfer adjustment factor * $7,592.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,237.51 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $631.46. The transfer capital threshold is the transfer adjustment factor * $631.46. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7983.75","7983.75","7983.75","1 through 10","8392.09","8820.26","other","Inpatient DRG"
"Tenex Procedure Hip","PX-36000490","CDM","27299","CPT","0361","RC","","","","both","","","3016.00","2262.00","MEDICARE [2001]","HB BWF MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","257.38","257.38","257.38","1 through 10","270.63","2868.22","other","OPPS APC"
"Tenex Procedure Knee","PX-36000491","CDM","27599","CPT","0361","RC","","","","both","","","7994.00","5995.50","MEDICARE [2001]","HB BWF MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","7602.29","other","OPPS APC"
"Tenex Procedure Knee","PX-36000491","CDM","27599","CPT","0361","RC","","","","both","","","7994.00","5995.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","7602.29","other","OPPS APC"
"Tenotomy Abductor Hip Percutaneous","PX-76002785","CDM","27599","CPT","0761","RC","","","","both","","","3016.00","2262.00","MEDICARE [2001]","HB BWF MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","2868.22","other","OPPS APC"
"Tenotomy Abductor Hip Percutaneous","PX-76002785","CDM","27599","CPT","0761","RC","","","","both","","","3016.00","2262.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","2868.22","other","OPPS APC"
"Tenotomy Abductor Hip Percutaneous","PX-98302351","CDM","27599","CPT","0983","RC","","","","both","","","1948.00","1461.00","MEDICARE [2001]","HB BWF MEDICARE","284.84","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","284.87","284.87","284.87","1 through 10","270.63","1852.55","other","OPPS APC"
"Tenotomy Abductor Hip Percutaneous","PX-98302351","CDM","27599","CPT","0983","RC","","","","both","","","1948.00","1461.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","279.15","","APC Price ($284.84). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","284.87","284.87","284.87","1 through 10","270.63","1852.55","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","154.13","363.89","1 through 10","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","366.63","366.63","366.63","1 through 10","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","363.89","363.89","363.89","1 through 10","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","590.57","73","","574.51","557.72","574.51","1 through 10","351.32","630.29","percent of total billed charges",""
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","HUMANA [1012]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","362.41","362.41","362.41","1 through 10","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","MARTIN'S POINT [160007]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","363.89","363.89","363.89","1 through 10","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","MEDICARE [2001]","HB BWF MEDICARE","369.81","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","369.81","342.57","369.81","121","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","TRICARE [160005]","HB BWF TRICARE","351.32","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","351.32","351.32","351.32","1 through 10","351.32","630.29","other","Tricare OPPS"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.81","362.61","363.01","1 through 10","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","362.41","","APC Price ($369.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","362.92","337.09","363.42","12","351.32","630.29","other","OPPS APC"
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","both","","","809.00","606.75","WELLPOINT [1015]","HB CH WELLPOINT","630.29","77.91","","787.00","619.84","1406.84","12","351.32","630.29","percent of total billed charges",""
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","outpatient","","","809.00","606.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","479.74","59.3","","461.18","461.18","461.18","15","217.8","634.66","percent of total billed charges",""
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","outpatient","","","809.00","606.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","359.60","44.45","","358.56","358.56","358.56","1 through 10","217.8","634.66","percent of total billed charges",""
"Test Ans Func Parasymp&Symp W/5 Mi","PX-92000125","CDM","95924","CPT","0922","RC","","","","outpatient","","","809.00","606.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","634.66","78.45","","605.05","358.56","605.05","21","217.8","634.66","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","297.00","222.75","AETNA [1001]","HB CH AETNA HMO / PPO","173.15","58.3","","163.86","163.86","163.86","13","24.96","216.81","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","both","","","297.00","222.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","216.81","73","","165.31","165.31","165.31","1 through 10","24.96","216.81","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","297.00","222.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","176.12","59.3","","169.35","169.35","169.36","1 through 10","26.26","233","percent of total billed charges",""
"Testosterone Free","PX-30000689","CDM","84402","CPT","0301","RC","","","","outpatient","","","297.00","222.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","233.00","78.45","","222.18","100.18","222.18","1 through 10","26.26","233","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","AETNA [1001]","HB CH AETNA HMO / PPO","123.01","58.3","","116.24","116.24","116.24","26","25.29","154.03","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","154.03","73","","117.26","117.26","117.26","1 through 10","25.29","154.03","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","both","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","93.79","44.45","","93.40","93.40","93.40","1 through 10","25.29","154.03","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","211.00","158.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","125.12","59.3","","120.13","120.13","120.13","17","26.62","165.53","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","211.00","158.25","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","165.53","78.45","","157.61","157.61","157.61","1 through 10","26.62","165.53","percent of total billed charges",""
"Testosterone Total","PX-30000691","CDM","84403","CPT","0301","RC","","","","outpatient","","","211.00","158.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","165.53","78.45","","157.60","93.40","157.60","17","26.62","165.53","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","161.33","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000038","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","14.12","173.37","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000193","CDM","80299","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","161.33","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30000193","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","14.12","173.37","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001448","CDM","80299","CPT","0301","RC","","","","both","","","265.00","198.75","AETNA [1001]","HB CH AETNA HMO / PPO","154.50","58.3","","121.91","121.91","121.91","1 through 10","18.27","193.45","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001448","CDM","80299","CPT","0301","RC","","","","outpatient","","","265.00","198.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.89","78.45","","165.29","165.29","165.29","1 through 10","14.12","207.89","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001474","CDM","80299","CPT","0300","RC","","","","both","","","161.00","120.75","AETNA [1001]","HB CH AETNA HMO / PPO","93.86","58.3","","121.91","121.91","121.91","1 through 10","18.27","117.53","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001474","CDM","80299","CPT","0300","RC","","","","outpatient","","","161.00","120.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","126.30","78.45","","165.29","165.29","165.29","1 through 10","14.12","126.3","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001475","CDM","80299","CPT","0300","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB CH AETNA HMO / PPO","132.34","58.3","","121.91","121.91","121.91","1 through 10","18.27","165.71","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001475","CDM","80299","CPT","0300","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","165.29","165.29","165.29","1 through 10","14.12","178.08","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001476","CDM","80299","CPT","0300","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","121.91","121.91","121.91","1 through 10","18.27","167.9","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001476","CDM","80299","CPT","0300","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","165.29","165.29","165.29","1 through 10","14.12","180.44","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001477","CDM","80299","CPT","0300","RC","","","","both","","","182.00","136.50","AETNA [1001]","HB CH AETNA HMO / PPO","106.11","58.3","","121.91","121.91","121.91","1 through 10","18.27","132.86","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001477","CDM","80299","CPT","0300","RC","","","","outpatient","","","182.00","136.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","142.78","78.45","","165.29","165.29","165.29","1 through 10","14.12","142.78","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001478","CDM","80299","CPT","0300","RC","","","","both","","","230.00","172.50","AETNA [1001]","HB CH AETNA HMO / PPO","134.09","58.3","","121.91","121.91","121.91","1 through 10","18.27","167.9","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001478","CDM","80299","CPT","0300","RC","","","","outpatient","","","230.00","172.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","180.44","78.45","","165.29","165.29","165.29","1 through 10","14.12","180.44","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001479","CDM","80299","CPT","0300","RC","","","","both","","","168.00","126.00","AETNA [1001]","HB CH AETNA HMO / PPO","97.94","58.3","","121.91","121.91","121.91","1 through 10","18.27","122.64","percent of total billed charges",""
"Therapeutic Drug Assay Other","PX-30001479","CDM","80299","CPT","0300","RC","","","","outpatient","","","168.00","126.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","131.80","78.45","","165.29","165.29","165.29","1 through 10","14.12","131.8","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","87.33","79.12","87.33","1 through 10","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","AETNA [1001]","HB CH AETNA HMO / PPO","132.34","58.3","","125.31","125.31","250.62","1 through 10","46.83","232.43","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","1 through 10","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.00","25.00","25.00","1 through 10","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","75.35","83.17","22","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","ELDER SERVICES [1037]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10.79","10.79","10.79","1 through 10","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","MEDICARE [2001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","76.89","253.56","525","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","82.83","82.83","1 through 10","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","TRICARE [160005]","HB BWF TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","80.29","80.29","1 through 10","46.83","232.43","other","Tricare OPPS"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","21.58","82.83","1 through 10","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","both","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","75.66","84.52","67","46.83","232.43","other","OPPS APC"
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","227.00","170.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","134.61","59.3","","129.51","129.51","129.51","1 through 10","98.67","204.65","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","227.00","170.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","134.61","59.3","","129.48","129.48","129.48","1 through 10","98.67","204.65","percent of total billed charges",""
"Therapeutic Prophylactic/Diagnostic Inj Sc/Im - 96372","PX-26000010","CDM","96372","CPT","0260","RC","","","","outpatient","","","227.00","170.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.08","78.45","","169.90","100.69","169.90","12","98.67","204.65","percent of total billed charges",""
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","both","","","1546.00","1159.50","MEDICARE [2001]","HB BWF MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","598.81","1204.49","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-76002662","CDM","62329","CPT","0761","RC","","","","outpatient","","","1546.00","1159.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1479.06","1479.06","1 through 10","598.81","1873.9","other","Multiple Surgery"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","both","","","588.00","441.00","MEDICARE [2001]","HB BWF MEDICARE","822.33","","APC Price ($822.33). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","822.41","822.41","822.41","1 through 10","311.64","847","other","OPPS APC"
"Therapeutic Spinal Pnxr Drainage CSF W/Fluor/CT","PX-98301898","CDM","62329","CPT","0983","RC","","","","outpatient","","","588.00","441.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","598.81","","Case rate ($598.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","1479.06","1479.06","1479.06","1 through 10","261.37","1873.9","other","Multiple Surgery"
"Thiopurine Metabolites, Whole Blood","PX-30003691","CDM","80299","CPT","0300","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","161.33","percent of total billed charges",""
"Thiopurine Metabolites, Whole Blood","PX-30003691","CDM","80299","CPT","0300","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","14.12","173.37","percent of total billed charges",""
"Thoracentesis W/Imaging Guidance","PX-76001812","CDM","32555","CPT","0761","RC","","","","both","","","1567.00","1175.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","719.54","","APC Price ($734.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","719.54","719.54","719.54","1 through 10","620.01","1220.85","other","OPPS APC"
"Thoracic Fascial Plane Block Bi Injection","PX-76002990","CDM","64468","CPT","0761","RC","","","","outpatient","","","420.00","315.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","242.34","57.7","","246.02","246.02","246.02","1 through 10","168","329.49","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X14 20MM BENGAL PEEK MONOLITHIC STACKABLE STANDARD","SUP-ITM-10045549","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","AETNA [1001]","HB CH AETNA HMO / PPO","2565.20","58.3","","1830.28","315.58","1830.28","1 through 10","1955.8","4400","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X14 20MM BENGAL PEEK MONOLITHIC STACKABLE STANDARD","SUP-ITM-10045549","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3212.00","73","","4170.85","4170.85","4170.85","1 through 10","1955.8","4400","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X14 20MM BENGAL PEEK MONOLITHIC STACKABLE STANDARD","SUP-ITM-10045549","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1955.80","44.45","","649.55","649.55","649.55","1 through 10","1955.8","4400","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X14 20MM BENGAL PEEK MONOLITHIC STACKABLE STANDARD","SUP-ITM-10045549","CDM","C1889","HCPCS","0278","RC","","","","both","","","4400.00","3300.00","WELLPOINT [1015]","HB CH WELLPOINT","3428.04","77.91","","8998.38","2542.37","8998.38","20","1955.8","4400","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X14 20MM BENGAL PEEK MONOLITHIC STACKABLE STANDARD","SUP-ITM-10045549","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2609.20","59.3","","1891.61","1609.14","3664.18","25","2200","3451.8","percent of total billed charges",""
"THORACOLUMBAR CAGE 12X14 20MM BENGAL PEEK MONOLITHIC STACKABLE STANDARD","SUP-ITM-10045549","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4400.00","3300.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3451.80","78.45","","1470.68","1310.06","2481.69","19","2200","3451.8","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"THORACOLUMBAR ROD 6.25X40MM PREBENT TITANIUM DUAL BALL SPHERX DBR II","SUP-ITM-10107810","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1830.28","315.58","1830.28","1 through 10","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","4170.85","4170.85","4170.85","1 through 10","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","649.55","649.55","649.55","1 through 10","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","8998.38","2542.37","8998.38","20","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1891.61","1609.14","3664.18","25","1200","1882.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X6MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007191","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1470.68","1310.06","2481.69","19","1200","1882.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X7MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007192","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","AETNA [1001]","HB CH AETNA HMO / PPO","1399.20","58.3","","1830.28","315.58","1830.28","1 through 10","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X7MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007192","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1752.00","73","","4170.85","4170.85","4170.85","1 through 10","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X7MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007192","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1066.80","44.45","","649.55","649.55","649.55","1 through 10","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X7MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007192","CDM","C1889","HCPCS","0278","RC","","","","both","","","2400.00","1800.00","WELLPOINT [1015]","HB CH WELLPOINT","1869.84","77.91","","8998.38","2542.37","8998.38","20","1066.8","2400","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X7MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007192","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1423.20","59.3","","1891.61","1609.14","3664.18","25","1200","1882.8","percent of total billed charges",""
"THORACOLUMBAR SPACER 12X7MM SYNMESH MESH ROUND HEIGHT TI","SUP-ITM-10007192","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","2400.00","1800.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1882.80","78.45","","1470.68","1310.06","2481.69","19","1200","1882.8","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","48.00","36.00","AETNA [1001]","HB CH AETNA HMO / PPO","27.98","58.3","","26.65","26.65","26.68","1 through 10","5.65","35.04","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","both","","","48.00","36.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","25.44","53","","24.91","24.91","24.91","1 through 10","5.65","35.04","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","outpatient","","","48.00","36.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","28.46","59.3","","27.54","27.54","27.54","1 through 10","5.95","37.66","percent of total billed charges",""
"Thrombin Time Plasma","PX-30001126","CDM","85670","CPT","0305","RC","","","","outpatient","","","48.00","36.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","37.66","78.45","","36.13","34.88","36.13","1 through 10","5.95","37.66","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","both","","","133.00","99.75","AETNA [1001]","HB CH AETNA HMO / PPO","77.54","58.3","","73.14","73.14","73.14","1 through 10","15.74","97.09","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","133.00","99.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","78.87","59.3","","75.59","75.59","75.59","1 through 10","16.56","104.34","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","59.12","44.45","","99.17","99.17","99.17","1 through 10","16.56","104.34","percent of total billed charges",""
"Thyroglobulin","PX-30000696","CDM","84432","CPT","0301","RC","","","","outpatient","","","133.00","99.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","104.34","78.45","","99.18","63.15","99.18","1 through 10","16.56","104.34","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0300","RC","","","","inpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","85.43","70.6","","181.44","181.44","181.44","1 through 10","67.76","85.43","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","15.59","93.83","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","90.72","90.72","90.72","1 through 10","15.59","93.83","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","69.15","69.15","69.15","1 through 10","15.29","94.92","percent of total billed charges",""
"Thyroglobulin Antibody","PX-30001013","CDM","86800","CPT","0302","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","90.72","53.76","90.72","1 through 10","15.29","94.92","percent of total billed charges",""
"Thyroid Disorders,MODERATE","427","DRG","","","","","","","","inpatient","","","22002.77","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","6079.67","","Case rate ($6,722.12). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,152.12, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6720.47","6720.47","6720.47","1 through 10","4352.41","49527.55","case rate",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0300","RC","","","","inpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","139.08","70.6","","147.61","147.61","147.61","1 through 10","110.32","139.08","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","AETNA [1001]","HB CH AETNA HMO / PPO","114.85","58.3","","108.86","108.86","108.86","185","16.46","143.81","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","143.81","73","","140.16","140.16","140.16","1 through 10","16.46","143.81","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","104.41","53","","101.76","101.76","101.76","1 through 10","16.46","143.81","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","143.81","73","","108.86","83.37","108.86","1 through 10","16.46","143.81","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","147.61","86.21","147.61","1 through 10","16.46","143.81","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","both","","","197.00","147.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","87.57","44.45","","87.48","87.48","87.48","1 through 10","16.46","143.81","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","116.82","59.3","","112.51","112.51","192.00","182","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","147.61","147.61","1 through 10","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Hormone (Tsh)","PX-30000701","CDM","84443","CPT","0301","RC","","","","outpatient","","","197.00","147.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","154.55","78.45","","147.61","87.48","147.61","149","17.33","154.55","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0300","RC","","","","inpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","298.64","70.6","","315.98","315.98","315.98","1 through 10","298.64","298.64","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","423.00","317.25","AETNA [1001]","HB CH AETNA HMO / PPO","246.61","58.3","","233.04","233.04","233.04","1 through 10","49.84","308.79","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","both","","","423.00","317.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.84","59.3","","240.85","240.85","240.85","1 through 10","49.84","308.79","percent of total billed charges",""
"Thyroid Stimulating Immun Globulin","PX-30000702","CDM","84445","CPT","0301","RC","","","","outpatient","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.84","78.45","","315.98","187.25","315.98","1 through 10","52.45","331.84","percent of total billed charges",""
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","626","MS-DRG","","","","","","","","inpatient","","","50321.38","37741.03","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","14144.92","","Case rate ($14,144.92). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,167.41, add-ons for qualifying new technology services are included. If operating cost exceeds $59,691.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,620.80, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 1.9. The base transfer operating payment is the transfer adjustment factor * $12,745.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,828.18 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,060.02. The transfer capital threshold is the transfer adjustment factor * $1,060.02. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13704.72","13704.72","13704.72","1 through 10","13862.02","14925.4677","other","Inpatient Replacement Plans DRG"
"Thyroid, Parathyroid And Thyroglossal Procedures,MODERATE","404","DRG","","","","","","","","inpatient","","","74301.97","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","32622.11","","Standard inlier is a Case rate ($32,622.11). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $34,460, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,630.84) for the length of stay and the standard reimbursement.","32622.11","32622.11","32622.11","1 through 10","12512.33","70082.33","case rate",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0300","RC","","","","inpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","72.72","70.6","","76.88","76.88","76.88","1 through 10","57.68","72.72","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","AETNA [1001]","HB CH AETNA HMO / PPO","60.05","58.3","","56.70","56.70","56.70","29","8.84","75.19","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","both","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","45.78","44.45","","76.88","76.88","76.88","1 through 10","8.84","75.19","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","103.00","77.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.08","59.3","","58.60","58.60","58.60","45","9.29","80.8","percent of total billed charges",""
"Thyroxine (T-4) Free","PX-30000699","CDM","84439","CPT","0301","RC","","","","outpatient","","","103.00","77.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","80.80","78.45","","76.88","45.56","76.88","54","9.29","80.8","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","AETNA [1001]","HB CH AETNA HMO / PPO","419.76","58.3","","554.95","91.85","1421.75","94","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","2490.03","2490.03","2490.03","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","419.76","58.3","","750.00","750.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","381.60","53","","1192.50","120.84","4149.90","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","612.00","85","","750.00","75.00","750.00","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","720.00","100","","657.00","121.50","1971.00","14","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","720.00","100","","75.00","75.00","75.00","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","720.00","100","","366.00","144.00","1971.00","45","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","525.60","73","","667.50","667.50","667.50","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","320.04","44.45","","123.77","123.77","123.77","1 through 10","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","both","","","720.00","540.00","WELLPOINT [1015]","HB CH WELLPOINT","560.95","77.91","","483.51","229.32","1316.08","96","320.04","720","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.96","59.3","","439.50","225.34","1872.27","197","360","564.84","percent of total billed charges",""
"TI LORDOTIC ROD 5.5MM X 50MM","SUP-ITM-10245315","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","720.00","540.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.84","78.45","","385.32","55.36","1815.62","58","360","564.84","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","AETNA [1001]","HB CH AETNA HMO / PPO","2605.24","58.3","","554.95","91.85","1421.75","94","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3262.14","73","","2490.03","2490.03","2490.03","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2605.24","58.3","","750.00","750.00","750.00","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2368.40","53","","1192.50","120.84","4149.90","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3798.38","85","","750.00","75.00","750.00","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4468.68","100","","657.00","121.50","1971.00","14","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4468.68","100","","75.00","75.00","75.00","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4468.68","100","","366.00","144.00","1971.00","45","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3262.14","73","","667.50","667.50","667.50","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1986.33","44.45","","123.77","123.77","123.77","1 through 10","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","both","","","4468.68","3351.51","WELLPOINT [1015]","HB CH WELLPOINT","3481.55","77.91","","483.51","229.32","1316.08","96","1986.33","4468.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4468.68","3351.51","CIGNA [1006]","HB CH CIGNA HMO / PPO","2649.93","59.3","","439.50","225.34","1872.27","197","2234.34","3505.68","percent of total billed charges",""
"TIBIA PLATE 10 HOLE 172MM AXSOS DISTAL MEDIAL LEG SS LOCKING METAPHYSEAL LEFT","SUP-ITM-10034230","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4468.68","3351.51","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3505.68","78.45","","385.32","55.36","1815.62","58","2234.34","3505.68","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","AETNA [1001]","HB CH AETNA HMO / PPO","2226.62","58.3","","554.95","91.85","1421.75","94","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2788.05","73","","2490.03","2490.03","2490.03","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2226.62","58.3","","750.00","750.00","750.00","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2024.20","53","","1192.50","120.84","4149.90","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3246.35","85","","750.00","75.00","750.00","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3819.24","100","","657.00","121.50","1971.00","14","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3819.24","100","","75.00","75.00","75.00","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3819.24","100","","366.00","144.00","1971.00","45","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2788.05","73","","667.50","667.50","667.50","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1697.65","44.45","","123.77","123.77","123.77","1 through 10","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","both","","","3819.24","2864.43","WELLPOINT [1015]","HB CH WELLPOINT","2975.57","77.91","","483.51","229.32","1316.08","96","1697.65","3819.24","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3819.24","2864.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","2264.81","59.3","","439.50","225.34","1872.27","197","1909.62","2996.19","percent of total billed charges",""
"TIBIA PLATE 142MM 6 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10072300","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3819.24","2864.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2996.19","78.45","","385.32","55.36","1815.62","58","1909.62","2996.19","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","AETNA [1001]","HB CH AETNA HMO / PPO","2166.57","58.3","","554.95","91.85","1421.75","94","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2712.86","73","","2490.03","2490.03","2490.03","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2166.57","58.3","","750.00","750.00","750.00","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1969.61","53","","1192.50","120.84","4149.90","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3158.80","85","","750.00","75.00","750.00","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3716.24","100","","657.00","121.50","1971.00","14","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3716.24","100","","75.00","75.00","75.00","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3716.24","100","","366.00","144.00","1971.00","45","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2712.86","73","","667.50","667.50","667.50","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1651.87","44.45","","123.77","123.77","123.77","1 through 10","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","both","","","3716.24","2787.18","WELLPOINT [1015]","HB CH WELLPOINT","2895.32","77.91","","483.51","229.32","1316.08","96","1651.87","3716.24","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3716.24","2787.18","CIGNA [1006]","HB CH CIGNA HMO / PPO","2203.73","59.3","","439.50","225.34","1872.27","197","1858.12","2915.39","percent of total billed charges",""
"TIBIA PLATE 184MM 9 HOLE LEG A.L.P.S. TITANIUM LOCKING RT MEDIAL DISTAL L","SUP-ITM-10049187","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3716.24","2787.18","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2915.39","78.45","","385.32","55.36","1815.62","58","1858.12","2915.39","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","AETNA [1001]","HB CH AETNA HMO / PPO","1908.38","58.3","","554.95","91.85","1421.75","94","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2389.57","73","","2490.03","2490.03","2490.03","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1908.38","58.3","","750.00","750.00","750.00","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1734.89","53","","1192.50","120.84","4149.90","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2782.37","85","","750.00","75.00","750.00","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3273.38","100","","657.00","121.50","1971.00","14","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3273.38","100","","75.00","75.00","75.00","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3273.38","100","","366.00","144.00","1971.00","45","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2389.57","73","","667.50","667.50","667.50","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1455.02","44.45","","123.77","123.77","123.77","1 through 10","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","both","","","3273.38","2455.03","WELLPOINT [1015]","HB CH WELLPOINT","2550.29","77.91","","483.51","229.32","1316.08","96","1455.02","3273.38","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.38","2455.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","1941.11","59.3","","439.50","225.34","1872.27","197","1636.69","2567.97","percent of total billed charges",""
"TIBIA PLATE 2.7 3.5X142MM 6 HOLE BONE L VA LCP SS VARIABLE ANGLE MEDIAL DISTAL RIGHT","SUP-ITM-10124889","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3273.38","2455.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2567.97","78.45","","385.32","55.36","1815.62","58","1636.69","2567.97","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","AETNA [1001]","HB CH AETNA HMO / PPO","2197.30","58.3","","554.95","91.85","1421.75","94","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2751.33","73","","2490.03","2490.03","2490.03","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2197.30","58.3","","750.00","750.00","750.00","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1997.54","53","","1192.50","120.84","4149.90","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3203.61","85","","750.00","75.00","750.00","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3768.95","100","","657.00","121.50","1971.00","14","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3768.95","100","","75.00","75.00","75.00","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3768.95","100","","366.00","144.00","1971.00","45","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2751.33","73","","667.50","667.50","667.50","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1675.30","44.45","","123.77","123.77","123.77","1 through 10","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","both","","","3768.95","2826.71","WELLPOINT [1015]","HB CH WELLPOINT","2936.39","77.91","","483.51","229.32","1316.08","96","1675.3","3768.95","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.95","2826.71","CIGNA [1006]","HB CH CIGNA HMO / PPO","2234.99","59.3","","439.50","225.34","1872.27","197","1884.48","2956.74","percent of total billed charges",""
"TIBIA PLATE 4.5X322MM 16 HOLE L LCP SS MEDIAL PROXIMAL LEFT","SUP-ITM-10037912","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3768.95","2826.71","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2956.74","78.45","","385.32","55.36","1815.62","58","1884.48","2956.74","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","AETNA [1001]","HB CH AETNA HMO / PPO","909.48","58.3","","554.95","91.85","1421.75","94","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","2490.03","2490.03","2490.03","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","909.48","58.3","","750.00","750.00","750.00","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","826.80","53","","1192.50","120.84","4149.90","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1326.00","85","","750.00","75.00","750.00","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1560.00","100","","657.00","121.50","1971.00","14","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1560.00","100","","75.00","75.00","75.00","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1560.00","100","","366.00","144.00","1971.00","45","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1138.80","73","","667.50","667.50","667.50","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","693.42","44.45","","123.77","123.77","123.77","1 through 10","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","both","","","1560.00","1170.00","WELLPOINT [1015]","HB CH WELLPOINT","1215.40","77.91","","483.51","229.32","1316.08","96","693.42","1560","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","925.08","59.3","","439.50","225.34","1872.27","197","780","1223.82","percent of total billed charges",""
"TIBIA PLATE 5.0MM BONE L OSTEOTOMY OPENING WEDGE","SUP-ITM-10007765","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1560.00","1170.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1223.82","78.45","","385.32","55.36","1815.62","58","780","1223.82","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","554.95","91.85","1421.75","94","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2490.03","2490.03","2490.03","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","750.00","750.00","750.00","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","1192.50","120.84","4149.90","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","750.00","75.00","750.00","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","657.00","121.50","1971.00","14","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","75.00","75.00","75.00","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","366.00","144.00","1971.00","45","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","667.50","667.50","667.50","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1333.50","44.45","","123.77","123.77","123.77","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","483.51","229.32","1316.08","96","1333.5","3000","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","439.50","225.34","1872.27","197","1500","2353.5","percent of total billed charges",""
"TIBIA PLATE 7.5MM BONE CONTOURLOCK HIGH L OSTEOTOMY AP SLOPED WEDGE LEFT","SUP-ITM-10072498","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","385.32","55.36","1815.62","58","1500","2353.5","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","AETNA [1001]","HB CH AETNA HMO / PPO","1554.86","58.3","","1634.24","1004.95","1718.99","42","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1946.91","73","","2123.89","1900.92","2123.89","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1554.86","58.3","","3729.00","1254.19","3729.00","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1413.51","53","","939.37","939.37","5593.65","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2266.95","85","","2323.25","1864.50","2882.25","16","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2667.00","100","","2909.44","1772.40","10952.08","45","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2667.00","100","","2323.25","2323.25","2323.25","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2667.00","100","","2882.25","1772.40","10169.17","187","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1946.91","73","","1659.41","1659.41","1659.41","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","WELLPOINT [1015]","HB CH WELLPOINT","2077.86","77.91","","2050.91","1468.48","2902.83","52","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2667.00","2000.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1581.53","59.3","","1548.60","1092.60","3613.79","82","1333.5","2092.26","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10113676","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2667.00","2000.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2092.26","78.45","","2085.51","998.68","6202.11","56","1333.5","2092.26","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","AETNA [1001]","HB CH AETNA HMO / PPO","1554.86","58.3","","1634.24","1004.95","1718.99","42","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1946.91","73","","2123.89","1900.92","2123.89","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1554.86","58.3","","3729.00","1254.19","3729.00","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1413.51","53","","939.37","939.37","5593.65","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2266.95","85","","2323.25","1864.50","2882.25","16","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2667.00","100","","2909.44","1772.40","10952.08","45","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2667.00","100","","2323.25","2323.25","2323.25","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2667.00","100","","2882.25","1772.40","10169.17","187","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1946.91","73","","1659.41","1659.41","1659.41","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","WELLPOINT [1015]","HB CH WELLPOINT","2077.86","77.91","","2050.91","1468.48","2902.83","52","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2667.00","2000.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1581.53","59.3","","1548.60","1092.60","3613.79","82","1333.5","2092.26","percent of total billed charges",""
"TIBIA TRAY SZ 2 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNI FIXED BEARING RT LT LATERAL","SUP-ITM-10030268","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2667.00","2000.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2092.26","78.45","","2085.51","998.68","6202.11","56","1333.5","2092.26","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","AETNA [1001]","HB CH AETNA HMO / PPO","1554.86","58.3","","1634.24","1004.95","1718.99","42","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1946.91","73","","2123.89","1900.92","2123.89","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1554.86","58.3","","3729.00","1254.19","3729.00","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1413.51","53","","939.37","939.37","5593.65","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2266.95","85","","2323.25","1864.50","2882.25","16","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2667.00","100","","2909.44","1772.40","10952.08","45","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2667.00","100","","2323.25","2323.25","2323.25","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2667.00","100","","2882.25","1772.40","10169.17","187","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1946.91","73","","1659.41","1659.41","1659.41","1 through 10","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","both","","","2667.00","2000.25","WELLPOINT [1015]","HB CH WELLPOINT","2077.86","77.91","","2050.91","1468.48","2902.83","52","1185.48","2667","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2667.00","2000.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1581.53","59.3","","1548.60","1092.60","3613.79","82","1333.5","2092.26","percent of total billed charges",""
"TIBIA TRAY SZ 4 SIGMA TIBIAL PARTIAL HIGH PERFORMANCE UNICONDYLAR FIXED BEARING LT RIGHT LATERAL","SUP-ITM-10031172","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2667.00","2000.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2092.26","78.45","","2085.51","998.68","6202.11","56","1333.5","2092.26","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","AETNA [1001]","HB CH AETNA HMO / PPO","2782.08","58.3","","1634.24","1004.95","1718.99","42","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3483.56","73","","2123.89","1900.92","2123.89","1 through 10","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2782.08","58.3","","3729.00","1254.19","3729.00","1 through 10","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2529.16","53","","939.37","939.37","5593.65","1 through 10","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4056.20","85","","2323.25","1864.50","2882.25","16","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4772.00","100","","2909.44","1772.40","10952.08","45","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4772.00","100","","2323.25","2323.25","2323.25","1 through 10","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4772.00","100","","2882.25","1772.40","10169.17","187","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3483.56","73","","1659.41","1659.41","1659.41","1 through 10","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","both","","","4772.00","3579.00","WELLPOINT [1015]","HB CH WELLPOINT","3717.87","77.91","","2050.91","1468.48","2902.83","52","2121.15","4772","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4772.00","3579.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2829.80","59.3","","1548.60","1092.60","3613.79","82","2386","3743.63","percent of total billed charges",""
"TIBIAL BASEPLATE MD SIZE 2.0 MONOGRAM TITANIUM MODULAR ROTATING HINGE KEEL","SUP-ITM-10007078","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4772.00","3579.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3743.63","78.45","","2085.51","998.68","6202.11","56","2386","3743.63","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1634.24","1004.95","1718.99","42","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","2123.89","1900.92","2123.89","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","3729.00","1254.19","3729.00","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","939.37","939.37","5593.65","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1606.50","85","","2323.25","1864.50","2882.25","16","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1890.00","100","","2909.44","1772.40","10952.08","45","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1890.00","100","","2323.25","2323.25","2323.25","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1890.00","100","","2882.25","1772.40","10169.17","187","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","1659.41","1659.41","1659.41","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","2050.91","1468.48","2902.83","52","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1548.60","1092.60","3613.79","82","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 2 LEFT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281538","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","2085.51","998.68","6202.11","56","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1634.24","1004.95","1718.99","42","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","2123.89","1900.92","2123.89","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","3729.00","1254.19","3729.00","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","939.37","939.37","5593.65","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1606.50","85","","2323.25","1864.50","2882.25","16","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1890.00","100","","2909.44","1772.40","10952.08","45","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1890.00","100","","2323.25","2323.25","2323.25","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1890.00","100","","2882.25","1772.40","10169.17","187","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","1659.41","1659.41","1659.41","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","2050.91","1468.48","2902.83","52","840.11","1890","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1548.60","1092.60","3613.79","82","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 3 RIGHT LATERAL KNEE JOURNEY II UNI","SUP-ITM-10281529","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","2085.51","998.68","6202.11","56","945","1482.71","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","AETNA [1001]","HB CH AETNA HMO / PPO","1626.57","58.3","","1634.24","1004.95","1718.99","42","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2036.70","73","","2123.89","1900.92","2123.89","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1626.57","58.3","","3729.00","1254.19","3729.00","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1478.70","53","","939.37","939.37","5593.65","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2371.50","85","","2323.25","1864.50","2882.25","16","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2790.00","100","","2909.44","1772.40","10952.08","45","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2790.00","100","","2323.25","2323.25","2323.25","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2790.00","100","","2882.25","1772.40","10169.17","187","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2036.70","73","","1659.41","1659.41","1659.41","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","WELLPOINT [1015]","HB CH WELLPOINT","2173.69","77.91","","2050.91","1468.48","2902.83","52","1240.16","2790","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1654.47","59.3","","1548.60","1092.60","3613.79","82","1395","2188.76","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 5 ATTUNE POLYETHYLENE ANTIOXIDANT ROTATING PLATFORM CEMENTED 150610005","SUP-ITM-10135704","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2188.76","78.45","","2085.51","998.68","6202.11","56","1395","2188.76","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","AETNA [1001]","HB CH AETNA HMO / PPO","1944.89","58.3","","1634.24","1004.95","1718.99","42","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","2123.89","1900.92","2123.89","1 through 10","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1944.89","58.3","","3729.00","1254.19","3729.00","1 through 10","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1768.08","53","","939.37","939.37","5593.65","1 through 10","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2835.60","85","","2323.25","1864.50","2882.25","16","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3336.00","100","","2909.44","1772.40","10952.08","45","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3336.00","100","","2323.25","2323.25","2323.25","1 through 10","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3336.00","100","","2882.25","1772.40","10169.17","187","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2435.28","73","","1659.41","1659.41","1659.41","1 through 10","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","both","","","3336.00","2502.00","WELLPOINT [1015]","HB CH WELLPOINT","2599.08","77.91","","2050.91","1468.48","2902.83","52","1482.85","3336","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1978.25","59.3","","1548.60","1092.60","3613.79","82","1668","2617.09","percent of total billed charges",""
"TIBIAL BASEPLATE SZ 9 ATTUNE CEMENTED","SUP-ITM-10285208","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3336.00","2502.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2617.09","78.45","","2085.51","998.68","6202.11","56","1668","2617.09","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","AETNA [1001]","HB CH AETNA HMO / PPO","2273.70","58.3","","1634.24","1004.95","1718.99","42","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","2123.89","1900.92","2123.89","1 through 10","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2273.70","58.3","","3729.00","1254.19","3729.00","1 through 10","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2067.00","53","","939.37","939.37","5593.65","1 through 10","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3315.00","85","","2323.25","1864.50","2882.25","16","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3900.00","100","","2909.44","1772.40","10952.08","45","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3900.00","100","","2323.25","2323.25","2323.25","1 through 10","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3900.00","100","","2882.25","1772.40","10169.17","187","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2847.00","73","","1659.41","1659.41","1659.41","1 through 10","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","both","","","3900.00","2925.00","WELLPOINT [1015]","HB CH WELLPOINT","3038.49","77.91","","2050.91","1468.48","2902.83","52","1733.55","3900","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2312.70","59.3","","1548.60","1092.60","3613.79","82","1950","3059.55","percent of total billed charges",""
"TIBIAL BASEPLATE SZ5 LEFT PRESS FIT EMPOWR","SUP-ITM-10312098","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3900.00","2925.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3059.55","78.45","","2085.51","998.68","6202.11","56","1950","3059.55","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"TIBIAL BEARING 8MM SZ 4 INSERT SIGMA UNI FIXED HIGH PERFORMANCE INSERTS LT RT","SUP-ITM-10042038","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","AETNA [1001]","HB CH AETNA HMO / PPO","1101.87","58.3","","1634.24","1004.95","1718.99","42","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","2123.89","1900.92","2123.89","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1101.87","58.3","","3729.00","1254.19","3729.00","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1001.70","53","","939.37","939.37","5593.65","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1606.50","85","","2323.25","1864.50","2882.25","16","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1890.00","100","","2909.44","1772.40","10952.08","45","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1890.00","100","","2323.25","2323.25","2323.25","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1890.00","100","","2882.25","1772.40","10169.17","187","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1379.70","73","","1659.41","1659.41","1659.41","1 through 10","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","both","","","1890.00","1417.50","WELLPOINT [1015]","HB CH WELLPOINT","1472.50","77.91","","2050.91","1468.48","2902.83","52","840.11","1890","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1120.77","59.3","","1548.60","1092.60","3613.79","82","945","1482.71","percent of total billed charges",""
"TIBIAL BEARING SZ 3 ATTUNE FIXED BASE CEMENTED","SUP-ITM-10197896","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1890.00","1417.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1482.71","78.45","","2085.51","998.68","6202.11","56","945","1482.71","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","AETNA [1001]","HB CH AETNA HMO / PPO","2031.76","58.3","","1634.24","1004.95","1718.99","42","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2544.05","73","","2123.89","1900.92","2123.89","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.76","58.3","","3729.00","1254.19","3729.00","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1847.05","53","","939.37","939.37","5593.65","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2962.25","85","","2323.25","1864.50","2882.25","16","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3485.00","100","","2909.44","1772.40","10952.08","45","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3485.00","100","","2323.25","2323.25","2323.25","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3485.00","100","","2882.25","1772.40","10169.17","187","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2544.05","73","","1659.41","1659.41","1659.41","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","WELLPOINT [1015]","HB CH WELLPOINT","2715.16","77.91","","2050.91","1468.48","2902.83","52","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3485.00","2613.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2066.61","59.3","","1548.60","1092.60","3613.79","82","1742.5","2733.98","percent of total billed charges",""
"TIBIAL INSERT 12MM XXS BEARING LPS COBOLT CHROMIUM POLYETHYLENE HINGED UNIVERSAL","SUP-ITM-10119759","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3485.00","2613.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.98","78.45","","2085.51","998.68","6202.11","56","1742.5","2733.98","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","AETNA [1001]","HB CH AETNA HMO / PPO","2031.76","58.3","","1634.24","1004.95","1718.99","42","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2544.05","73","","2123.89","1900.92","2123.89","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2031.76","58.3","","3729.00","1254.19","3729.00","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1847.05","53","","939.37","939.37","5593.65","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2962.25","85","","2323.25","1864.50","2882.25","16","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3485.00","100","","2909.44","1772.40","10952.08","45","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3485.00","100","","2323.25","2323.25","2323.25","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3485.00","100","","2882.25","1772.40","10169.17","187","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2544.05","73","","1659.41","1659.41","1659.41","1 through 10","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","both","","","3485.00","2613.75","WELLPOINT [1015]","HB CH WELLPOINT","2715.16","77.91","","2050.91","1468.48","2902.83","52","1549.08","3485","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3485.00","2613.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","2066.61","59.3","","1548.60","1092.60","3613.79","82","1742.5","2733.98","percent of total billed charges",""
"TIBIAL INSERT 14MM XS LPS COBALT POLYETHYLENE BEARING HINGED UNIVERSAL","SUP-ITM-10080626","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3485.00","2613.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2733.98","78.45","","2085.51","998.68","6202.11","56","1742.5","2733.98","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 2 SIGMA UNICOMPARTMENTAL FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10113677","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 7MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RIGHT","SUP-ITM-10051897","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","AETNA [1001]","HB CH AETNA HMO / PPO","1934.39","58.3","","1634.24","1004.95","1718.99","42","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2422.14","73","","2123.89","1900.92","2123.89","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1934.39","58.3","","3729.00","1254.19","3729.00","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1758.54","53","","939.37","939.37","5593.65","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2820.30","85","","2323.25","1864.50","2882.25","16","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3318.00","100","","2909.44","1772.40","10952.08","45","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3318.00","100","","2323.25","2323.25","2323.25","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3318.00","100","","2882.25","1772.40","10169.17","187","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2422.14","73","","1659.41","1659.41","1659.41","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","WELLPOINT [1015]","HB CH WELLPOINT","2585.05","77.91","","2050.91","1468.48","2902.83","52","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1967.57","59.3","","1548.60","1092.60","3613.79","82","1659","2602.97","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282713","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2602.97","78.45","","2085.51","998.68","6202.11","56","1659","2602.97","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","AETNA [1001]","HB CH AETNA HMO / PPO","2399.05","58.3","","1634.24","1004.95","1718.99","42","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","2123.89","1900.92","2123.89","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2399.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2180.95","53","","939.37","939.37","5593.65","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3497.75","85","","2323.25","1864.50","2882.25","16","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4115.00","100","","2909.44","1772.40","10952.08","45","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4115.00","100","","2323.25","2323.25","2323.25","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4115.00","100","","2882.25","1772.40","10169.17","187","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","1659.41","1659.41","1659.41","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","WELLPOINT [1015]","HB CH WELLPOINT","3206.00","77.91","","2050.91","1468.48","2902.83","52","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2440.20","59.3","","1548.60","1092.60","3613.79","82","2057.5","3228.22","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 INFINITY EVERLAST POLYETHYLENE","SUP-ITM-10303100","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3228.22","78.45","","2085.51","998.68","6202.11","56","2057.5","3228.22","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","AETNA [1001]","HB CH AETNA HMO / PPO","832.52","58.3","","1634.24","1004.95","1718.99","42","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","2123.89","1900.92","2123.89","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","832.52","58.3","","3729.00","1254.19","3729.00","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","756.84","53","","939.37","939.37","5593.65","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1213.80","85","","2323.25","1864.50","2882.25","16","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1428.00","100","","2909.44","1772.40","10952.08","45","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1428.00","100","","2323.25","2323.25","2323.25","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1428.00","100","","2882.25","1772.40","10169.17","187","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1042.44","73","","1659.41","1659.41","1659.41","1 through 10","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","both","","","1428.00","1071.00","WELLPOINT [1015]","HB CH WELLPOINT","1112.55","77.91","","2050.91","1468.48","2902.83","52","634.75","1428","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","846.80","59.3","","1548.60","1092.60","3613.79","82","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 3 SIGMA UNI FIXED BEARING HIGH PERFORMANCE LT RT","SUP-ITM-10050614","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1428.00","1071.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1120.27","78.45","","2085.51","998.68","6202.11","56","714","1120.27","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","AETNA [1001]","HB CH AETNA HMO / PPO","1934.39","58.3","","1634.24","1004.95","1718.99","42","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2422.14","73","","2123.89","1900.92","2123.89","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1934.39","58.3","","3729.00","1254.19","3729.00","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1758.54","53","","939.37","939.37","5593.65","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2820.30","85","","2323.25","1864.50","2882.25","16","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3318.00","100","","2909.44","1772.40","10952.08","45","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3318.00","100","","2323.25","2323.25","2323.25","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3318.00","100","","2882.25","1772.40","10169.17","187","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2422.14","73","","1659.41","1659.41","1659.41","1 through 10","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3318.00","2488.50","WELLPOINT [1015]","HB CH WELLPOINT","2585.05","77.91","","2050.91","1468.48","2902.83","52","1474.85","3318","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1967.57","59.3","","1548.60","1092.60","3613.79","82","1659","2602.97","percent of total billed charges",""
"TIBIAL INSERT 8MM SZ 5 ATTUNE POSTERIOR STABILIZED ALL POLY","SUP-ITM-10282701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3318.00","2488.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2602.97","78.45","","2085.51","998.68","6202.11","56","1659","2602.97","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","AETNA [1001]","HB CH AETNA HMO / PPO","198.51","58.3","","1634.24","1004.95","1718.99","42","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","248.57","73","","2123.89","1900.92","2123.89","1 through 10","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","198.51","58.3","","3729.00","1254.19","3729.00","1 through 10","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","180.47","53","","939.37","939.37","5593.65","1 through 10","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","289.43","85","","2323.25","1864.50","2882.25","16","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","340.50","100","","2909.44","1772.40","10952.08","45","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","340.50","100","","2323.25","2323.25","2323.25","1 through 10","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","340.50","100","","2882.25","1772.40","10169.17","187","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","248.57","73","","1659.41","1659.41","1659.41","1 through 10","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","both","","","340.50","255.37","WELLPOINT [1015]","HB CH WELLPOINT","265.28","77.91","","2050.91","1468.48","2902.83","52","151.35","340.5","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","340.50","255.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","201.92","59.3","","1548.60","1092.60","3613.79","82","170.25","267.12","percent of total billed charges",""
"TIBIAL INSERT A ITOTAL IDENTITY CR LATERAL IPOLY","SUP-ITM-10283706","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","340.50","255.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","267.12","78.45","","2085.51","998.68","6202.11","56","170.25","267.12","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","AETNA [1001]","HB CH AETNA HMO / PPO","2399.05","58.3","","1634.24","1004.95","1718.99","42","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","2123.89","1900.92","2123.89","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2399.05","58.3","","3729.00","1254.19","3729.00","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2180.95","53","","939.37","939.37","5593.65","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3497.75","85","","2323.25","1864.50","2882.25","16","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4115.00","100","","2909.44","1772.40","10952.08","45","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4115.00","100","","2323.25","2323.25","2323.25","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4115.00","100","","2882.25","1772.40","10169.17","187","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3003.95","73","","1659.41","1659.41","1659.41","1 through 10","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","both","","","4115.00","3086.25","WELLPOINT [1015]","HB CH WELLPOINT","3206.00","77.91","","2050.91","1468.48","2902.83","52","1829.12","4115","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","2440.20","59.3","","1548.60","1092.60","3613.79","82","2057.5","3228.22","percent of total billed charges",""
"TIBIAL INSERT SIZE 1/1PLUS 8MM INFINITY EVERLAST TOTAL ANKLE SYSTEM","SUP-ITM-10311497","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4115.00","3086.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3228.22","78.45","","2085.51","998.68","6202.11","56","2057.5","3228.22","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","AETNA [1001]","HB CH AETNA HMO / PPO","1787.48","58.3","","1634.24","1004.95","1718.99","42","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2238.18","73","","2123.89","1900.92","2123.89","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1787.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1624.98","53","","939.37","939.37","5593.65","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2606.10","85","","2323.25","1864.50","2882.25","16","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3066.00","100","","2909.44","1772.40","10952.08","45","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3066.00","100","","2323.25","2323.25","2323.25","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3066.00","100","","2882.25","1772.40","10169.17","187","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2238.18","73","","1659.41","1659.41","1659.41","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","WELLPOINT [1015]","HB CH WELLPOINT","2388.72","77.91","","2050.91","1468.48","2902.83","52","1362.84","3066","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1818.14","59.3","","1548.60","1092.60","3613.79","82","1533","2405.28","percent of total billed charges",""
"TIBIAL INSERT SIZE 3 IDENTITY IMPRINT CR","SUP-ITM-10283863","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2405.28","78.45","","2085.51","998.68","6202.11","56","1533","2405.28","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","AETNA [1001]","HB CH AETNA HMO / PPO","227.37","58.3","","1634.24","1004.95","1718.99","42","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","284.70","73","","2123.89","1900.92","2123.89","1 through 10","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","227.37","58.3","","3729.00","1254.19","3729.00","1 through 10","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","206.70","53","","939.37","939.37","5593.65","1 through 10","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","331.50","85","","2323.25","1864.50","2882.25","16","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","390.00","100","","2909.44","1772.40","10952.08","45","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","390.00","100","","2323.25","2323.25","2323.25","1 through 10","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","390.00","100","","2882.25","1772.40","10169.17","187","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","284.70","73","","1659.41","1659.41","1659.41","1 through 10","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","both","","","390.00","292.50","WELLPOINT [1015]","HB CH WELLPOINT","303.85","77.91","","2050.91","1468.48","2902.83","52","173.36","390","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","231.27","59.3","","1548.60","1092.60","3613.79","82","195","305.96","percent of total billed charges",""
"TIBIAL INSERT SZ A ITOTAL IDENTITY CR LATERAL A IPOLY XE MEDIAL RT","SUP-ITM-10283733","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","390.00","292.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","305.96","78.45","","2085.51","998.68","6202.11","56","195","305.96","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","AETNA [1001]","HB CH AETNA HMO / PPO","652.38","58.3","","1634.24","1004.95","1718.99","42","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","816.87","73","","2123.89","1900.92","2123.89","1 through 10","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","652.38","58.3","","3729.00","1254.19","3729.00","1 through 10","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","593.07","53","","939.37","939.37","5593.65","1 through 10","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","951.15","85","","2323.25","1864.50","2882.25","16","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1119.00","100","","2909.44","1772.40","10952.08","45","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1119.00","100","","2323.25","2323.25","2323.25","1 through 10","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1119.00","100","","2882.25","1772.40","10169.17","187","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","816.87","73","","1659.41","1659.41","1659.41","1 through 10","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","both","","","1119.00","839.25","WELLPOINT [1015]","HB CH WELLPOINT","871.81","77.91","","2050.91","1468.48","2902.83","52","497.4","1119","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1119.00","839.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","663.57","59.3","","1548.60","1092.60","3613.79","82","559.5","877.86","percent of total billed charges",""
"TIBIAL PEG BROACH ANTERIOR INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239380","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1119.00","839.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","877.86","78.45","","2085.51","998.68","6202.11","56","559.5","877.86","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","AETNA [1001]","HB CH AETNA HMO / PPO","2042.83","58.3","","1634.24","1004.95","1718.99","42","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2557.92","73","","2123.89","1900.92","2123.89","1 through 10","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2042.83","58.3","","3729.00","1254.19","3729.00","1 through 10","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1857.12","53","","939.37","939.37","5593.65","1 through 10","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2978.40","85","","2323.25","1864.50","2882.25","16","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3504.00","100","","2909.44","1772.40","10952.08","45","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3504.00","100","","2323.25","2323.25","2323.25","1 through 10","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3504.00","100","","2882.25","1772.40","10169.17","187","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2557.92","73","","1659.41","1659.41","1659.41","1 through 10","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","both","","","3504.00","2628.00","WELLPOINT [1015]","HB CH WELLPOINT","2729.97","77.91","","2050.91","1468.48","2902.83","52","1557.53","3504","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3504.00","2628.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.87","59.3","","1548.60","1092.60","3613.79","82","1752","2748.89","percent of total billed charges",""
"TIBIAL PEG BROACH INFINITYTM TOTAL ANKLE SYSTEM","SUP-ITM-10239379","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3504.00","2628.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2748.89","78.45","","2085.51","998.68","6202.11","56","1752","2748.89","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","AETNA [1001]","HB CH AETNA HMO / PPO","2246.92","58.3","","554.95","91.85","1421.75","94","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2813.47","73","","2490.03","2490.03","2490.03","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2246.92","58.3","","750.00","750.00","750.00","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2042.66","53","","1192.50","120.84","4149.90","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3275.96","85","","750.00","75.00","750.00","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3854.07","100","","657.00","121.50","1971.00","14","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3854.07","100","","75.00","75.00","75.00","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3854.07","100","","366.00","144.00","1971.00","45","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2813.47","73","","667.50","667.50","667.50","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1713.13","44.45","","123.77","123.77","123.77","1 through 10","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","both","","","3854.07","2890.55","WELLPOINT [1015]","HB CH WELLPOINT","3002.71","77.91","","483.51","229.32","1316.08","96","1713.13","3854.07","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3854.07","2890.55","CIGNA [1006]","HB CH CIGNA HMO / PPO","2285.46","59.3","","439.50","225.34","1872.27","197","1927.04","3023.52","percent of total billed charges",""
"TIBIAL PLATE 140MM 5 HOLE LOCKING COMPRESSION LATERAL LT TITANIUM","SUP-ITM-10040358","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3854.07","2890.55","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3023.52","78.45","","385.32","55.36","1815.62","58","1927.04","3023.52","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","AETNA [1001]","HB CH AETNA HMO / PPO","1911.62","58.3","","554.95","91.85","1421.75","94","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2393.63","73","","2490.03","2490.03","2490.03","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1911.62","58.3","","750.00","750.00","750.00","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1737.84","53","","1192.50","120.84","4149.90","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2787.10","85","","750.00","75.00","750.00","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3278.94","100","","657.00","121.50","1971.00","14","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3278.94","100","","75.00","75.00","75.00","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3278.94","100","","366.00","144.00","1971.00","45","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2393.63","73","","667.50","667.50","667.50","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1457.49","44.45","","123.77","123.77","123.77","1 through 10","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","both","","","3278.94","2459.20","WELLPOINT [1015]","HB CH WELLPOINT","2554.62","77.91","","483.51","229.32","1316.08","96","1457.49","3278.94","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3278.94","2459.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","1944.41","59.3","","439.50","225.34","1872.27","197","1639.47","2572.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X102MM 6 HOLE L LCP SS LOW BEND IMAL RIGHT","SUP-ITM-10091039","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3278.94","2459.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2572.33","78.45","","385.32","55.36","1815.62","58","1639.47","2572.33","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","AETNA [1001]","HB CH AETNA HMO / PPO","1697.42","58.3","","554.95","91.85","1421.75","94","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2125.42","73","","2490.03","2490.03","2490.03","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1697.42","58.3","","750.00","750.00","750.00","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1543.11","53","","1192.50","120.84","4149.90","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2474.80","85","","750.00","75.00","750.00","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2911.53","100","","657.00","121.50","1971.00","14","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2911.53","100","","75.00","75.00","75.00","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2911.53","100","","366.00","144.00","1971.00","45","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2125.42","73","","667.50","667.50","667.50","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1294.18","44.45","","123.77","123.77","123.77","1 through 10","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","both","","","2911.53","2183.65","WELLPOINT [1015]","HB CH WELLPOINT","2268.37","77.91","","483.51","229.32","1316.08","96","1294.18","2911.53","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2911.53","2183.65","CIGNA [1006]","HB CH CIGNA HMO / PPO","1726.54","59.3","","439.50","225.34","1872.27","197","1455.77","2284.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X109.0MM 4 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10095112","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2911.53","2183.65","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2284.10","78.45","","385.32","55.36","1815.62","58","1455.77","2284.1","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","AETNA [1001]","HB CH AETNA HMO / PPO","2252.45","58.3","","554.95","91.85","1421.75","94","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2820.39","73","","2490.03","2490.03","2490.03","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2252.45","58.3","","750.00","750.00","750.00","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2047.68","53","","1192.50","120.84","4149.90","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3284.02","85","","750.00","75.00","750.00","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3863.55","100","","657.00","121.50","1971.00","14","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3863.55","100","","75.00","75.00","75.00","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3863.55","100","","366.00","144.00","1971.00","45","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2820.39","73","","667.50","667.50","667.50","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1717.35","44.45","","123.77","123.77","123.77","1 through 10","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","both","","","3863.55","2897.66","WELLPOINT [1015]","HB CH WELLPOINT","3010.09","77.91","","483.51","229.32","1316.08","96","1717.35","3863.55","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.55","2897.66","CIGNA [1006]","HB CH CIGNA HMO / PPO","2291.09","59.3","","439.50","225.34","1872.27","197","1931.78","3030.95","percent of total billed charges",""
"TIBIAL PLATE 3.5X119MM 6 HOLE PROXIMAL MEDIAL LCP SS LT","SUP-ITM-10021420","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3863.55","2897.66","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3030.95","78.45","","385.32","55.36","1815.62","58","1931.78","3030.95","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","AETNA [1001]","HB CH AETNA HMO / PPO","1716.84","58.3","","554.95","91.85","1421.75","94","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2149.73","73","","2490.03","2490.03","2490.03","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1716.84","58.3","","750.00","750.00","750.00","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1560.76","53","","1192.50","120.84","4149.90","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2503.11","85","","750.00","75.00","750.00","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2944.83","100","","657.00","121.50","1971.00","14","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2944.83","100","","75.00","75.00","75.00","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2944.83","100","","366.00","144.00","1971.00","45","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2149.73","73","","667.50","667.50","667.50","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1308.98","44.45","","123.77","123.77","123.77","1 through 10","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","both","","","2944.83","2208.62","WELLPOINT [1015]","HB CH WELLPOINT","2294.32","77.91","","483.51","229.32","1316.08","96","1308.98","2944.83","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2944.83","2208.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","1746.28","59.3","","439.50","225.34","1872.27","197","1472.42","2310.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X135MM 6 HOLE BONE LCP SS LOW BEND MEDIAL DISTAL LEFT","SUP-ITM-10076213","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2944.83","2208.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2310.22","78.45","","385.32","55.36","1815.62","58","1472.42","2310.22","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","AETNA [1001]","HB CH AETNA HMO / PPO","1932.98","58.3","","554.95","91.85","1421.75","94","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2420.37","73","","2490.03","2490.03","2490.03","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1932.98","58.3","","750.00","750.00","750.00","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1757.25","53","","1192.50","120.84","4149.90","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2818.23","85","","750.00","75.00","750.00","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3315.57","100","","657.00","121.50","1971.00","14","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3315.57","100","","75.00","75.00","75.00","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3315.57","100","","366.00","144.00","1971.00","45","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2420.37","73","","667.50","667.50","667.50","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1473.77","44.45","","123.77","123.77","123.77","1 through 10","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","both","","","3315.57","2486.68","WELLPOINT [1015]","HB CH WELLPOINT","2583.16","77.91","","483.51","229.32","1316.08","96","1473.77","3315.57","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.57","2486.68","CIGNA [1006]","HB CH CIGNA HMO / PPO","1966.13","59.3","","439.50","225.34","1872.27","197","1657.79","2601.06","percent of total billed charges",""
"TIBIAL PLATE 3.5X80MM 5 HOLE ANTEROLATERAL DISTAL LCP LEFT","SUP-ITM-10019988","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3315.57","2486.68","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2601.06","78.45","","385.32","55.36","1815.62","58","1657.79","2601.06","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","AETNA [1001]","HB CH AETNA HMO / PPO","1750.49","58.3","","554.95","91.85","1421.75","94","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2191.86","73","","2490.03","2490.03","2490.03","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1750.49","58.3","","750.00","750.00","750.00","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1591.35","53","","1192.50","120.84","4149.90","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2552.17","85","","750.00","75.00","750.00","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3002.55","100","","657.00","121.50","1971.00","14","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3002.55","100","","75.00","75.00","75.00","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3002.55","100","","366.00","144.00","1971.00","45","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2191.86","73","","667.50","667.50","667.50","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1334.63","44.45","","123.77","123.77","123.77","1 through 10","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","both","","","3002.55","2251.91","WELLPOINT [1015]","HB CH WELLPOINT","2339.29","77.91","","483.51","229.32","1316.08","96","1334.63","3002.55","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3002.55","2251.91","CIGNA [1006]","HB CH CIGNA HMO / PPO","1780.51","59.3","","439.50","225.34","1872.27","197","1501.28","2355.5","percent of total billed charges",""
"TIBIAL PLATE 4 HOLE BONE MEDIAL DISTAL HIGH TOMOFIX TITANIUM","SUP-ITM-10017867","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3002.55","2251.91","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2355.50","78.45","","385.32","55.36","1815.62","58","1501.28","2355.5","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","AETNA [1001]","HB CH AETNA HMO / PPO","2021.25","58.3","","554.95","91.85","1421.75","94","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2530.90","73","","2490.03","2490.03","2490.03","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2021.25","58.3","","750.00","750.00","750.00","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1837.50","53","","1192.50","120.84","4149.90","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2946.93","85","","750.00","75.00","750.00","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3466.98","100","","657.00","121.50","1971.00","14","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3466.98","100","","75.00","75.00","75.00","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3466.98","100","","366.00","144.00","1971.00","45","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2530.90","73","","667.50","667.50","667.50","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1541.07","44.45","","123.77","123.77","123.77","1 through 10","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","both","","","3466.98","2600.23","WELLPOINT [1015]","HB CH WELLPOINT","2701.12","77.91","","483.51","229.32","1316.08","96","1541.07","3466.98","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.98","2600.23","CIGNA [1006]","HB CH CIGNA HMO / PPO","2055.92","59.3","","439.50","225.34","1872.27","197","1733.49","2719.85","percent of total billed charges",""
"TIBIAL PLATE 4.5X118MM 6 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009183","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3466.98","2600.23","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2719.85","78.45","","385.32","55.36","1815.62","58","1733.49","2719.85","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","AETNA [1001]","HB CH AETNA HMO / PPO","1978.28","58.3","","554.95","91.85","1421.75","94","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2477.09","73","","2490.03","2490.03","2490.03","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1978.28","58.3","","750.00","750.00","750.00","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1798.43","53","","1192.50","120.84","4149.90","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2884.28","85","","750.00","75.00","750.00","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3393.27","100","","657.00","121.50","1971.00","14","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3393.27","100","","75.00","75.00","75.00","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3393.27","100","","366.00","144.00","1971.00","45","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2477.09","73","","667.50","667.50","667.50","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1508.31","44.45","","123.77","123.77","123.77","1 through 10","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","both","","","3393.27","2544.95","WELLPOINT [1015]","HB CH WELLPOINT","2643.70","77.91","","483.51","229.32","1316.08","96","1508.31","3393.27","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.27","2544.95","CIGNA [1006]","HB CH CIGNA HMO / PPO","2012.21","59.3","","439.50","225.34","1872.27","197","1696.64","2662.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X140MM 5 HOLE IMAL LISS TITANIUM LEFT","SUP-ITM-10007496","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3393.27","2544.95","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2662.02","78.45","","385.32","55.36","1815.62","58","1696.64","2662.02","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","AETNA [1001]","HB CH AETNA HMO / PPO","1996.27","58.3","","554.95","91.85","1421.75","94","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2499.62","73","","2490.03","2490.03","2490.03","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1996.27","58.3","","750.00","750.00","750.00","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1814.79","53","","1192.50","120.84","4149.90","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2910.52","85","","750.00","75.00","750.00","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3424.14","100","","657.00","121.50","1971.00","14","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3424.14","100","","75.00","75.00","75.00","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3424.14","100","","366.00","144.00","1971.00","45","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2499.62","73","","667.50","667.50","667.50","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1522.03","44.45","","123.77","123.77","123.77","1 through 10","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","both","","","3424.14","2568.10","WELLPOINT [1015]","HB CH WELLPOINT","2667.75","77.91","","483.51","229.32","1316.08","96","1522.03","3424.14","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3424.14","2568.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2030.52","59.3","","439.50","225.34","1872.27","197","1712.07","2686.24","percent of total billed charges",""
"TIBIAL PLATE 4.5X82MM 4 HOLE PROXIMAL LOCKING LCP SS RIGHT","SUP-ITM-10009181","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3424.14","2568.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2686.24","78.45","","385.32","55.36","1815.62","58","1712.07","2686.24","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","AETNA [1001]","HB CH AETNA HMO / PPO","1276.77","58.3","","554.95","91.85","1421.75","94","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","2490.03","2490.03","2490.03","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1276.77","58.3","","750.00","750.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1160.70","53","","1192.50","120.84","4149.90","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1861.50","85","","750.00","75.00","750.00","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2190.00","100","","657.00","121.50","1971.00","14","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2190.00","100","","75.00","75.00","75.00","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2190.00","100","","366.00","144.00","1971.00","45","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1598.70","73","","667.50","667.50","667.50","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","973.46","44.45","","123.77","123.77","123.77","1 through 10","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","both","","","2190.00","1642.50","WELLPOINT [1015]","HB CH WELLPOINT","1706.23","77.91","","483.51","229.32","1316.08","96","973.46","2190","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1298.67","59.3","","439.50","225.34","1872.27","197","1095","1718.06","percent of total billed charges",""
"TIBIAL PLATE 5.0MM OSTEOTOMY OPENING TITANIUM ANTERIOR POSTERIOR SLOPED","SUP-ITM-10027997","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2190.00","1642.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1718.06","78.45","","385.32","55.36","1815.62","58","1095","1718.06","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","AETNA [1001]","HB CH AETNA HMO / PPO","3635.01","58.3","","1634.24","1004.95","1718.99","42","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4551.55","73","","2123.89","1900.92","2123.89","1 through 10","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3635.01","58.3","","3729.00","1254.19","3729.00","1 through 10","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3304.55","53","","939.37","939.37","5593.65","1 through 10","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5299.75","85","","2323.25","1864.50","2882.25","16","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6235.00","100","","2909.44","1772.40","10952.08","45","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6235.00","100","","2323.25","2323.25","2323.25","1 through 10","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6235.00","100","","2882.25","1772.40","10169.17","187","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4551.55","73","","1659.41","1659.41","1659.41","1 through 10","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","both","","","6235.00","4676.25","WELLPOINT [1015]","HB CH WELLPOINT","4857.69","77.91","","2050.91","1468.48","2902.83","52","2771.46","6235","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6235.00","4676.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","3697.36","59.3","","1548.60","1092.60","3613.79","82","3117.5","4891.36","percent of total billed charges",""
"TIBIAL STEM 9MM 155 EXTENDER STABILIZING PRIMARY Y","SUP-ITM-10035490","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6235.00","4676.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4891.36","78.45","","2085.51","998.68","6202.11","56","3117.5","4891.36","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","AETNA [1001]","HB CH AETNA HMO / PPO","1787.48","58.3","","1634.24","1004.95","1718.99","42","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2238.18","73","","2123.89","1900.92","2123.89","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1787.48","58.3","","3729.00","1254.19","3729.00","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1624.98","53","","939.37","939.37","5593.65","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2606.10","85","","2323.25","1864.50","2882.25","16","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3066.00","100","","2909.44","1772.40","10952.08","45","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3066.00","100","","2323.25","2323.25","2323.25","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3066.00","100","","2882.25","1772.40","10169.17","187","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2238.18","73","","1659.41","1659.41","1659.41","1 through 10","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","both","","","3066.00","2299.50","WELLPOINT [1015]","HB CH WELLPOINT","2388.72","77.91","","2050.91","1468.48","2902.83","52","1362.84","3066","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1818.14","59.3","","1548.60","1092.60","3613.79","82","1533","2405.28","percent of total billed charges",""
"TIBIAL TRAY ITOTAL IDENTITY PS TI","SUP-ITM-10281671","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3066.00","2299.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2405.28","78.45","","2085.51","998.68","6202.11","56","1533","2405.28","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","AETNA [1001]","HB CH AETNA HMO / PPO","1626.57","58.3","","1634.24","1004.95","1718.99","42","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2036.70","73","","2123.89","1900.92","2123.89","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1626.57","58.3","","3729.00","1254.19","3729.00","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1478.70","53","","939.37","939.37","5593.65","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2371.50","85","","2323.25","1864.50","2882.25","16","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2790.00","100","","2909.44","1772.40","10952.08","45","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2790.00","100","","2323.25","2323.25","2323.25","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2790.00","100","","2882.25","1772.40","10169.17","187","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2036.70","73","","1659.41","1659.41","1659.41","1 through 10","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","both","","","2790.00","2092.50","WELLPOINT [1015]","HB CH WELLPOINT","2173.69","77.91","","2050.91","1468.48","2902.83","52","1240.16","2790","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1654.47","59.3","","1548.60","1092.60","3613.79","82","1395","2188.76","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT CEMENTED","SUP-ITM-10119241","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2790.00","2092.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2188.76","78.45","","2085.51","998.68","6202.11","56","1395","2188.76","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","AETNA [1001]","HB CH AETNA HMO / PPO","1749.00","58.3","","1634.24","1004.95","1718.99","42","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","2123.89","1900.92","2123.89","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1749.00","58.3","","3729.00","1254.19","3729.00","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1590.00","53","","939.37","939.37","5593.65","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2550.00","85","","2323.25","1864.50","2882.25","16","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3000.00","100","","2909.44","1772.40","10952.08","45","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3000.00","100","","2323.25","2323.25","2323.25","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3000.00","100","","2882.25","1772.40","10169.17","187","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2190.00","73","","1659.41","1659.41","1659.41","1 through 10","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","both","","","3000.00","2250.00","WELLPOINT [1015]","HB CH WELLPOINT","2337.30","77.91","","2050.91","1468.48","2902.83","52","1333.5","3000","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1779.00","59.3","","1548.60","1092.60","3613.79","82","1500","2353.5","percent of total billed charges",""
"TIBIAL TRAY SZ 1 KNEE LCS COMPLETE MBT POROCOAT","SUP-ITM-10119250","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3000.00","2250.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2353.50","78.45","","2085.51","998.68","6202.11","56","1500","2353.5","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","AETNA [1001]","HB CH AETNA HMO / PPO","988.19","58.3","","554.95","91.85","1421.75","94","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1237.35","73","","2490.03","2490.03","2490.03","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","988.19","58.3","","750.00","750.00","750.00","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","898.35","53","","1192.50","120.84","4149.90","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1440.75","85","","750.00","75.00","750.00","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1695.00","100","","657.00","121.50","1971.00","14","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1695.00","100","","75.00","75.00","75.00","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1695.00","100","","366.00","144.00","1971.00","45","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1237.35","73","","667.50","667.50","667.50","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","753.43","44.45","","123.77","123.77","123.77","1 through 10","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","both","","","1695.00","1271.25","WELLPOINT [1015]","HB CH WELLPOINT","1320.57","77.91","","483.51","229.32","1316.08","96","753.43","1695","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1005.14","59.3","","439.50","225.34","1872.27","197","847.5","1329.73","percent of total billed charges",""
"TIGHTROPE II RT W/FIBERTAPE INTERNAL","SUP-ITM-10310309","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1695.00","1271.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1329.73","78.45","","385.32","55.36","1815.62","58","847.5","1329.73","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","AETNA [1001]","HB CH AETNA HMO / PPO","813.29","58.3","","554.95","91.85","1421.75","94","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1018.35","73","","2490.03","2490.03","2490.03","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","813.29","58.3","","750.00","750.00","750.00","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","739.35","53","","1192.50","120.84","4149.90","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1185.75","85","","750.00","75.00","750.00","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1395.00","100","","657.00","121.50","1971.00","14","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1395.00","100","","75.00","75.00","75.00","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1395.00","100","","366.00","144.00","1971.00","45","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1018.35","73","","667.50","667.50","667.50","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","620.08","44.45","","123.77","123.77","123.77","1 through 10","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","both","","","1395.00","1046.25","WELLPOINT [1015]","HB CH WELLPOINT","1086.84","77.91","","483.51","229.32","1316.08","96","620.08","1395","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","827.24","59.3","","439.50","225.34","1872.27","197","697.5","1094.38","percent of total billed charges",""
"TIGHTROPE II RT WITH DEPLOYING SUTURE","SUP-ITM-10320766","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1395.00","1046.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1094.38","78.45","","385.32","55.36","1815.62","58","697.5","1094.38","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","23608.00","17706.00","AETNA [1001]","HB CH AETNA HMO / PPO","13763.46","58.3","","1830.28","315.58","1830.28","1 through 10","10493.76","23608","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","23608.00","17706.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","17233.84","73","","4170.85","4170.85","4170.85","1 through 10","10493.76","23608","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","23608.00","17706.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","10493.76","44.45","","649.55","649.55","649.55","1 through 10","10493.76","23608","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","both","","","23608.00","17706.00","WELLPOINT [1015]","HB CH WELLPOINT","18392.99","77.91","","8998.38","2542.37","8998.38","20","10493.76","23608","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","23608.00","17706.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","13999.54","59.3","","1891.61","1609.14","3664.18","25","11804","18520.48","percent of total billed charges",""
"TISSUE ALLOGRAFT RIGHT MEDIAL FEMORAL CONDYLE","SUP-ITM-10118282","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","23608.00","17706.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18520.48","78.45","","1470.68","1310.06","2481.69","19","11804","18520.48","percent of total billed charges",""
"Tissue Connective Non-Human T1","PX-27000076","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","1334.48","1000.86","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1046.90","78.45","","555.84","555.84","555.84","1 through 10","667.24","1046.9","percent of total billed charges",""
"Tissue Connective Non-Human T2","PX-27000077","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","3768.09","2826.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2956.07","78.45","","555.84","555.84","555.84","1 through 10","1884.05","2956.07","percent of total billed charges",""
"Tissue Connective Non-Human T3","PX-27000078","CDM","C1763","HCPCS","0278","RC","","","","outpatient","","","6431.45","4823.59","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5045.47","78.45","","555.84","555.84","555.84","1 through 10","3215.73","5045.47","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","AETNA [1001]","HB CH AETNA HMO / PPO","2080.77","58.3","","1830.28","315.58","1830.28","1 through 10","1586.46","3569.08","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2605.43","73","","4170.85","4170.85","4170.85","1 through 10","1586.46","3569.08","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1586.46","44.45","","649.55","649.55","649.55","1 through 10","1586.46","3569.08","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","both","","","3569.08","2676.81","WELLPOINT [1015]","HB CH WELLPOINT","2780.67","77.91","","8998.38","2542.37","8998.38","20","1586.46","3569.08","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3569.08","2676.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","2116.46","59.3","","1891.61","1609.14","3664.18","25","1784.54","2799.94","percent of total billed charges",""
"TISSUE GRAFT 160X25MM TENDON ACHILLES FROZEN BLOCK BONE LENGTH GREATER THAN OR EQUAL","SUP-ITM-10010257","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3569.08","2676.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2799.94","78.45","","1470.68","1310.06","2481.69","19","1784.54","2799.94","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","AETNA [1001]","HB CH AETNA HMO / PPO","2264.71","58.3","","1830.28","315.58","1830.28","1 through 10","1726.7","3884.58","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2835.74","73","","4170.85","4170.85","4170.85","1 through 10","1726.7","3884.58","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1726.70","44.45","","649.55","649.55","649.55","1 through 10","1726.7","3884.58","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","both","","","3884.58","2913.43","WELLPOINT [1015]","HB CH WELLPOINT","3026.48","77.91","","8998.38","2542.37","8998.38","20","1726.7","3884.58","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3884.58","2913.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","2303.56","59.3","","1891.61","1609.14","3664.18","25","1942.29","3047.45","percent of total billed charges",""
"TISSUE GRAFT GTE 230X4.0MM TENDON FLEXI ALLO SEMI TENDINOSUS GRACILIS FROZEN","SUP-ITM-10010302","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3884.58","2913.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3047.45","78.45","","1470.68","1310.06","2481.69","19","1942.29","3047.45","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","AETNA [1001]","HB CH AETNA HMO / PPO","2274.50","58.3","","1830.28","315.58","1830.28","1 through 10","1734.16","3901.38","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2848.01","73","","4170.85","4170.85","4170.85","1 through 10","1734.16","3901.38","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1734.16","44.45","","649.55","649.55","649.55","1 through 10","1734.16","3901.38","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","both","","","3901.38","2926.03","WELLPOINT [1015]","HB CH WELLPOINT","3039.57","77.91","","8998.38","2542.37","8998.38","20","1734.16","3901.38","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3901.38","2926.03","CIGNA [1006]","HB CH CIGNA HMO / PPO","2313.52","59.3","","1891.61","1609.14","3664.18","25","1950.69","3060.63","percent of total billed charges",""
"TISSUE GRAFT GTE 230X7.5MM FLEXI ALLO TENDON ANTERIOR TIBIALIS FROZEN","SUP-ITM-10010255","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","3901.38","2926.03","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3060.63","78.45","","1470.68","1310.06","2481.69","19","1950.69","3060.63","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","AETNA [1001]","HB CH AETNA HMO / PPO","2500.53","58.3","","1830.28","315.58","1830.28","1 through 10","1906.5","4289.08","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3131.03","73","","4170.85","4170.85","4170.85","1 through 10","1906.5","4289.08","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1906.50","44.45","","649.55","649.55","649.55","1 through 10","1906.5","4289.08","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","both","","","4289.08","3216.81","WELLPOINT [1015]","HB CH WELLPOINT","3341.62","77.91","","8998.38","2542.37","8998.38","20","1906.5","4289.08","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4289.08","3216.81","CIGNA [1006]","HB CH CIGNA HMO / PPO","2543.42","59.3","","1891.61","1609.14","3664.18","25","2144.54","3364.78","percent of total billed charges",""
"TISSUE HUMAN 10MM ALLOGRAFT DISSECTED PATELLAR LIGAMENT FROZEN INSERTION WIDTH","SUP-ITM-10010259","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","4289.08","3216.81","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3364.78","78.45","","1470.68","1310.06","2481.69","19","2144.54","3364.78","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","AETNA [1001]","HB CH AETNA HMO / PPO","458.24","58.3","","554.95","91.85","1421.75","94","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","573.78","73","","2490.03","2490.03","2490.03","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","458.24","58.3","","750.00","750.00","750.00","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","416.58","53","","1192.50","120.84","4149.90","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","668.10","85","","750.00","75.00","750.00","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","786.00","100","","657.00","121.50","1971.00","14","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","786.00","100","","75.00","75.00","75.00","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","786.00","100","","366.00","144.00","1971.00","45","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","573.78","73","","667.50","667.50","667.50","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","349.38","44.45","","123.77","123.77","123.77","1 through 10","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","both","","","786.00","589.50","WELLPOINT [1015]","HB CH WELLPOINT","612.37","77.91","","483.51","229.32","1316.08","96","349.38","786","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.00","589.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","466.10","59.3","","439.50","225.34","1872.27","197","393","616.62","percent of total billed charges",""
"TISSUE SOFT 14.0MM WASHER TITANIUM LOW PROFILE SPIKED ROUND","SUP-ITM-10015945","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","786.00","589.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","616.62","78.45","","385.32","55.36","1815.62","58","393","616.62","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","both","","","98.00","73.50","AETNA [1001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","1 through 10","11.3","93.2","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","both","","","98.00","73.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","62.13","63.4","","62.99","62.99","62.99","1 through 10","11.3","93.2","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","both","","","98.00","73.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","57.13","58.3","","53.87","53.87","53.87","1 through 10","11.3","93.2","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","both","","","98.00","73.50","WELLPOINT [1015]","HB CH WELLPOINT","76.35","77.91","","74.82","74.82","74.82","1 through 10","11.3","93.2","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","56.55","57.7","","57.29","55.10","57.29","22","23.48","76.88","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","outpatient","","","98.00","73.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","59.29","60.5","","60.14","57.86","95.00","1 through 10","23.48","76.88","percent of total billed charges",""
"Tissue Transglutaminase Ea Immunoglobulin Class","PX-30003771","CDM","86364","CPT","0302","RC","","","","outpatient","","","98.00","73.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","76.88","78.45","","73.04","43.28","73.04","12","23.48","76.88","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","AETNA [1001]","HB CH AETNA HMO / PPO","2330.54","58.3","","1634.24","1004.95","1718.99","42","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2918.18","73","","2123.89","1900.92","2123.89","1 through 10","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2330.54","58.3","","3729.00","1254.19","3729.00","1 through 10","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2118.68","53","","939.37","939.37","5593.65","1 through 10","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3397.88","85","","2323.25","1864.50","2882.25","16","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3997.50","100","","2909.44","1772.40","10952.08","45","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3997.50","100","","2323.25","2323.25","2323.25","1 through 10","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3997.50","100","","2882.25","1772.40","10169.17","187","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2918.18","73","","1659.41","1659.41","1659.41","1 through 10","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","both","","","3997.50","2998.12","WELLPOINT [1015]","HB CH WELLPOINT","3114.45","77.91","","2050.91","1468.48","2902.83","52","1776.89","3997.5","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3997.50","2998.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2370.52","59.3","","1548.60","1092.60","3613.79","82","1998.75","3136.04","percent of total billed charges",""
"TOE IMPLANT LG METAL HEMI","SUP-ITM-10193701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3997.50","2998.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3136.04","78.45","","2085.51","998.68","6202.11","56","1998.75","3136.04","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","AETNA [1001]","HB CH AETNA HMO / PPO","2126.78","58.3","","554.95","91.85","1421.75","94","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2663.04","73","","2490.03","2490.03","2490.03","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2126.78","58.3","","750.00","750.00","750.00","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1933.44","53","","1192.50","120.84","4149.90","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3100.80","85","","750.00","75.00","750.00","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3648.00","100","","657.00","121.50","1971.00","14","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3648.00","100","","75.00","75.00","75.00","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3648.00","100","","366.00","144.00","1971.00","45","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2663.04","73","","667.50","667.50","667.50","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1621.54","44.45","","123.77","123.77","123.77","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","WELLPOINT [1015]","HB CH WELLPOINT","2842.16","77.91","","483.51","229.32","1316.08","96","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3648.00","2736.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2163.26","59.3","","439.50","225.34","1872.27","197","1824","2861.86","percent of total billed charges",""
"TOE WEDGE 18X10MM FOOT BIOFOAM EVANS IMPLANT","SUP-ITM-10057075","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3648.00","2736.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2861.86","78.45","","385.32","55.36","1815.62","58","1824","2861.86","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","AETNA [1001]","HB CH AETNA HMO / PPO","2126.78","58.3","","554.95","91.85","1421.75","94","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2663.04","73","","2490.03","2490.03","2490.03","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2126.78","58.3","","750.00","750.00","750.00","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1933.44","53","","1192.50","120.84","4149.90","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3100.80","85","","750.00","75.00","750.00","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3648.00","100","","657.00","121.50","1971.00","14","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3648.00","100","","75.00","75.00","75.00","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3648.00","100","","366.00","144.00","1971.00","45","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2663.04","73","","667.50","667.50","667.50","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1621.54","44.45","","123.77","123.77","123.77","1 through 10","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","both","","","3648.00","2736.00","WELLPOINT [1015]","HB CH WELLPOINT","2842.16","77.91","","483.51","229.32","1316.08","96","1621.54","3648","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3648.00","2736.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2163.26","59.3","","439.50","225.34","1872.27","197","1824","2861.86","percent of total billed charges",""
"TOE WEDGE 20X10MM TRIAL BIOFOAM EVANS TITANIUM FIXATION","SUP-ITM-10057078","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3648.00","2736.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2861.86","78.45","","385.32","55.36","1815.62","58","1824","2861.86","percent of total billed charges",""
"Total Iodine","PX-30002115","CDM","83789","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","18.62","121.6","percent of total billed charges",""
"Toxic Effects Of Non-Medicinal Substances,MAJOR","816","DRG","","","","","","","","inpatient","","","50605.84","","MASSHEALTH [3001]","HB BWF MEDICAID","6486.35","","Case rate ($7,171.78). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,601.78, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7170.02","7170.02","7170.02","1 through 10","3774.38","77633.88","case rate",""
"Toxic Effects Of Non-Medicinal Substances,MINOR","816","DRG","","","","","","","","inpatient","","","12119.25","","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF MEDICAID","3774.38","","Case rate ($4,173.22). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $46,603.22, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","4172.20","4172.20","4172.20","1 through 10","3774.38","77633.88","case rate",""
"Toxoplasma Antibody","PX-30000999","CDM","86777","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","14.1","88.33","percent of total billed charges",""
"Toxoplasma Antibody Igm","PX-30001001","CDM","86778","CPT","0302","RC","","","","both","","","121.00","90.75","AETNA [1001]","HB CH AETNA HMO / PPO","70.54","58.3","","66.91","66.91","66.91","1 through 10","14.12","88.33","percent of total billed charges",""
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","both","","","4478.00","3358.50","MEDICARE [2001]","HB BWF MEDICARE","6036.49","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","6037.10","5647.41","6037.10","1 through 10","1921.06","12733.05","other","OPPS APC"
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","both","","","4478.00","3358.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","5915.76","","APC Price ($6,036.49). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","5940.24","5940.24","5940.24","1 through 10","1921.06","12733.05","other","OPPS APC"
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","outpatient","","","4478.00","3358.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","4597.72","","Case rate ($4,597.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","6648.30","6648.30","6648.30","1 through 10","2239","7939.38","other","ASC "
"Tprnl Plmt Biodegradable Matrl Periprostatic","PX-33000131","CDM","55874","CPT","0333","RC","","","","outpatient","","","4478.00","3358.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2655.45","59.3","","1749.21","1749.21","1749.21","1 through 10","2239","7939.38","percent of total billed charges",""
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures","004","MS-DRG","","","","","","","","inpatient","","","522523.15","391892.36","MEDICARE [2001]","HB BWF MEDICARE","140069.13","","Case rate ($140,069.13). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $128,083.41, add-ons for qualifying new technology services are included. If operating cost exceeds $173,607.14 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $12,353.17, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 22.4. The base transfer operating payment is the transfer adjustment factor * $129,937.50 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $127,744.17 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $9,792.38. The transfer capital threshold is the transfer adjustment factor * $9,792.38. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","140752.28","140752.28","140752.28","1 through 10","125318.04","140069.13","other","Inpatient DRG"
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","both","","","4610.00","3457.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3365.30","73","","2995.45","2995.45","2995.45","1 through 10","1548.96","3591.65","percent of total billed charges",""
"Transfer Tissue Trunk <10cm","PX-76000154","CDM","14000","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","1548.96","","Case rate ($1,548.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","9100.15","9100.15","13728.09","11","1548.96","4472.66","other","Multiple Surgery"
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","both","","","4610.00","3457.50","AETNA [1001]","HB CH AETNA HMO / PPO","2687.63","58.3","","5471.55","5471.55","5471.55","1 through 10","1548.96","3591.65","percent of total billed charges",""
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2508.19","1252.33","2508.19","1 through 10","1548.96","7178","other","ASC "
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2561.33","2508.19","2561.33","1 through 10","1548.96","7178","other","ASC "
"Transfer Tissue Trunk 10.1-30.0cm","PX-76000155","CDM","14001","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3616.55","78.45","","3453.90","3453.90","3453.90","1 through 10","1548.96","7178","percent of total billed charges",""
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","61.53","61.53","61.53","1 through 10","13.17","84.73","percent of total billed charges",""
"Transferrin","PX-30000707","CDM","84466","CPT","0301","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","80.72","80.72","80.72","1 through 10","13.17","84.73","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","AETNA [1001]","HB CH AETNA HMO / PPO","545.11","58.3","","515.40","515.40","515.40","1 through 10","415.61","1489.48","percent of total billed charges",""
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","both","","","935.00","701.25","MEDICARE [2001]","HB BWF MEDICARE","519.18","","APC Price ($519.18). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","519.18","519.18","519.18","1 through 10","415.61","1489.48","other","OPPS APC"
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","935.00","701.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","437.87","","Case rate ($437.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","633.16","620.02","633.16","1 through 10","437.87","1334.96","other","ASC "
"Transfusion Blood/Comp","PX-39100001","CDM","36430","CPT","0391","RC","","","","outpatient","","","935.00","701.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","554.46","59.3","","909.00","909.00","909.00","1 through 10","437.87","1334.96","percent of total billed charges",""
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","39130.90","29348.17","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","8397.36","","Case rate ($8,397.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,706.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,229.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,125.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,493.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,366.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.72. The transfer capital threshold is the transfer adjustment factor * $564.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","7422.13","7422.13","7422.13","1 through 10","7540.29","8397.36","other","Inpatient DRG"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","39130.90","29348.17","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","7540.29","","Case rate ($7,694.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,706.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,229.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,125.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,790.20 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,366.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.72. The transfer capital threshold is the transfer adjustment factor * $564.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7414.26","7414.26","7414.26","1 through 10","7540.29","8397.36","other","Inpatient DRG"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","39130.90","29348.17","MEDICARE [2001]","HB BWF MEDICARE","8397.36","","Case rate ($8,397.36). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,706.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,229.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,125.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $7,493.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,366.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.72. The transfer capital threshold is the transfer adjustment factor * $564.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8206.94","8153.29","8206.94","1 through 10","7540.29","8397.36","other","Inpatient DRG"
"Transient Ischemia Without Thrombolytic","069","MS-DRG","","","","","","","","inpatient","","","39130.90","29348.17","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7540.29","","Case rate ($7,694.17). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,706.15, add-ons for qualifying new technology services are included. If operating cost exceeds $53,229.88 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,125.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2. The base transfer operating payment is the transfer adjustment factor * $6,790.20 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,366.91 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $564.72. The transfer capital threshold is the transfer adjustment factor * $564.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7400.11","7400.11","7400.11","1 through 10","7540.29","8397.36","other","Inpatient DRG"
"Transient Ischemia,MODERATE","047","DRG","","","","","","","","inpatient","","","41582.45","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","17822.41","","Standard inlier is a Case rate ($17,822.41). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $27,667, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,529.96) for the length of stay and the standard reimbursement.","17822.40","17822.40","17822.40","1 through 10","4704.26","28564.96","case rate",""
"Transurethral Procedures With Cc","669","MS-DRG","","","","","","","","inpatient","","","47142.02","35356.51","MEDICARE [2001]","HB BWF MEDICARE","15995.48","","Case rate ($15,995.48). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,652.52, add-ons for qualifying new technology services are included. If operating cost exceeds $60,176.25 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,657.98, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $14,559.03 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $14,313.28 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,097.20. The transfer capital threshold is the transfer adjustment factor * $1,097.20. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","15534.91","15534.91","15534.91","1 through 10","14336.65","15995.48","other","Inpatient DRG"
"Transurethral Prostatectomy With Cc/McC","713","MS-DRG","","","","","","","","inpatient","","","56939.17","42704.38","HUMANA [1012]","HB BWF MEDICARE","14181.74","","Case rate ($14,181.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,204.30, add-ons for qualifying new technology services are included. If operating cost exceeds $59,728.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,623.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $12,779.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,865.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.84. The transfer capital threshold is the transfer adjustment factor * $1,062.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13103.92","13103.92","13103.92","1 through 10","13898.11","14607.19","other","Inpatient Replacement Plans DRG"
"Transurethral Prostatectomy With Cc/McC","713","MS-DRG","","","","","","","","inpatient","","","56939.17","42704.38","MEDICARE [2001]","HB BWF MEDICARE","14181.74","","Case rate ($14,181.74). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,204.30, add-ons for qualifying new technology services are included. If operating cost exceeds $59,728.03 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,623.62, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $12,779.66 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,865.07 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,062.84. The transfer capital threshold is the transfer adjustment factor * $1,062.84. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","13898.11","14607.19","other","Inpatient Replacement Plans DRG"
"Transurethral Prostatectomy,MINOR","482","DRG","","","","","","","","inpatient","","","19251.75","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","12313.4519","","Fee schedule rate ($12,313.45). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","12313.4519","12899.75","12899.75","1 through 10","5848.91","27201.04","case rate",""
"Transurethral Prostatectomy,MODERATE","482","DRG","","","","","","","","inpatient","","","56939.17","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","7255.17","","Case rate ($8,021.83). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,451.83, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8019.86","8019.86","8019.86","1 through 10","5848.91","27201.04","case rate",""
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","44787.22","33590.41","HUMANA [1012]","HB BWF MEDICARE","15189.47","","Case rate ($15,189.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,915.64, add-ons for qualifying new technology services are included. If operating cost exceeds $59,439.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,601.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,809.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,576.40 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,040.72. The transfer capital threshold is the transfer adjustment factor * $1,040.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13488.92","13488.92","13488.92","1 through 10","13615.69","15189.47","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","44787.22","33590.41","MEDICARE [2001]","HB BWF MEDICARE","15189.47","","Case rate ($15,189.47). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,915.64, add-ons for qualifying new technology services are included. If operating cost exceeds $59,439.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,601.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $13,809.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,576.40 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,040.72. The transfer capital threshold is the transfer adjustment factor * $1,040.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14924.55","14924.55","14924.55","1 through 10","13615.69","15189.47","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast With McC","604","MS-DRG","","","","","","","","inpatient","","","44787.22","33590.41","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13615.69","","Case rate ($13,893.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,915.64, add-ons for qualifying new technology services are included. If operating cost exceeds $59,439.37 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,601.50, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,513.60 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,576.40 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,040.72. The transfer capital threshold is the transfer adjustment factor * $1,040.72. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13494.30","13494.30","13494.30","1 through 10","13615.69","15189.47","other","Inpatient DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","27552.11","20664.08","MEDICARE [2001]","HB BWF MEDICARE","8773.28","","Case rate ($8,773.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,787.03, add-ons for qualifying new technology services are included. If operating cost exceeds $54,310.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,208.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,786.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,447.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.58. The transfer capital threshold is the transfer adjustment factor * $647.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","9374.00","1126.51","9435.95","1 through 10","8597.81","9134.4693","other","Inpatient Replacement Plans DRG"
"Trauma To The Skin, Subcutaneous Tissue And Breast Without McC","605","MS-DRG","","","","","","","","inpatient","","","27552.11","20664.08","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","8597.81","","Case rate ($8,773.28). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,787.03, add-ons for qualifying new technology services are included. If operating cost exceeds $54,310.76 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,208.35, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,786.46 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,447.79 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $647.58. The transfer capital threshold is the transfer adjustment factor * $647.58. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8513.29","8513.29","8513.29","1 through 10","8597.81","9134.4693","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With Cc","086","MS-DRG","","","","","","","","inpatient","","","20038.30","15028.72","MEDICARE [2001]","HB BWF MEDICARE","13480.58","","Case rate ($13,480.58). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,353.35, add-ons for qualifying new technology services are included. If operating cost exceeds $57,877.08 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,481.73, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.9. The base transfer operating payment is the transfer adjustment factor * $12,220.40 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,014.12 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $920.96. The transfer capital threshold is the transfer adjustment factor * $920.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","13205.08","13205.08","13205.08","1 through 10","12087.12","13480.58","other","Inpatient DRG"
"Traumatic Stupor And Coma <1 Hour With McC","085","MS-DRG","","","","","","","","inpatient","","","12860.66","9645.49","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","21257.68","","Case rate ($21,257.68). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $21,291.78, add-ons for qualifying new technology services are included. If operating cost exceeds $66,815.51 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,166.92, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4.6. The base transfer operating payment is the transfer adjustment factor * $19,312.30 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $20,952.54 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,606.14. The transfer capital threshold is the transfer adjustment factor * $1,606.14. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17919.04","17919.04","17919.04","1 through 10","20832.53","22408.474","other","Inpatient Replacement Plans DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","47616.77","35712.58","MEDICARE [2001]","HB BWF MEDICARE","14419.77","","Case rate ($14,419.77). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,211.97, add-ons for qualifying new technology services are included. If operating cost exceeds $58,735.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,547.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $13,093.75 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,872.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $986.77. The transfer capital threshold is the transfer adjustment factor * $986.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14076.56","14076.56","14076.56","1 through 10","12927.21","14419.77","other","Inpatient DRG"
"Traumatic Stupor And Coma >1 Hour With Cc","083","MS-DRG","","","","","","","","inpatient","","","47616.77","35712.58","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","12927.21","","Case rate ($13,191.03). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,211.97, add-ons for qualifying new technology services are included. If operating cost exceeds $58,735.70 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,547.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.2. The base transfer operating payment is the transfer adjustment factor * $11,865.01 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,872.73 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $986.77. The transfer capital threshold is the transfer adjustment factor * $986.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","12648.50","12648.50","12648.50","1 through 10","12927.21","14419.77","other","Inpatient DRG"
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"TRAY 1.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134658","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","AETNA [1001]","HB CH AETNA HMO / PPO","1574.10","58.3","","1634.24","1004.95","1718.99","42","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","2123.89","1900.92","2123.89","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1574.10","58.3","","3729.00","1254.19","3729.00","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1431.00","53","","939.37","939.37","5593.65","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2295.00","85","","2323.25","1864.50","2882.25","16","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2700.00","100","","2909.44","1772.40","10952.08","45","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2700.00","100","","2323.25","2323.25","2323.25","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2700.00","100","","2882.25","1772.40","10169.17","187","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1971.00","73","","1659.41","1659.41","1659.41","1 through 10","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","both","","","2700.00","2025.00","WELLPOINT [1015]","HB CH WELLPOINT","2103.57","77.91","","2050.91","1468.48","2902.83","52","1200.15","2700","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1601.10","59.3","","1548.60","1092.60","3613.79","82","1350","2118.15","percent of total billed charges",""
"TRAY 3.5MM 0.0 REVERSED SHOULDER ASCEND FLEX OFFSET PLUS","SUP-ITM-10134477","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","2700.00","2025.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2118.15","78.45","","2085.51","998.68","6202.11","56","1350","2118.15","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","AETNA [1001]","HB CH AETNA HMO / PPO","2186.25","58.3","","1634.24","1004.95","1718.99","42","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","2123.89","1900.92","2123.89","1 through 10","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2186.25","58.3","","3729.00","1254.19","3729.00","1 through 10","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1987.50","53","","939.37","939.37","5593.65","1 through 10","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3187.50","85","","2323.25","1864.50","2882.25","16","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3750.00","100","","2909.44","1772.40","10952.08","45","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3750.00","100","","2323.25","2323.25","2323.25","1 through 10","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3750.00","100","","2882.25","1772.40","10169.17","187","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2737.50","73","","1659.41","1659.41","1659.41","1 through 10","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","both","","","3750.00","2812.50","WELLPOINT [1015]","HB CH WELLPOINT","2921.63","77.91","","2050.91","1468.48","2902.83","52","1666.88","3750","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2223.75","59.3","","1548.60","1092.60","3613.79","82","1875","2941.88","percent of total billed charges",""
"TRAY ADAPTER HUMERAL SHOULDER REVERSE EQUINOXE PLUS 5","SUP-ITM-10192423","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3750.00","2812.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2941.88","78.45","","2085.51","998.68","6202.11","56","1875","2941.88","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","1634.24","1004.95","1718.99","42","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","2123.89","1900.92","2123.89","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.96","58.3","","3729.00","1254.19","3729.00","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","939.37","939.37","5593.65","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1686.83","85","","2323.25","1864.50","2882.25","16","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1984.50","100","","2909.44","1772.40","10952.08","45","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1984.50","100","","2323.25","2323.25","2323.25","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1984.50","100","","2882.25","1772.40","10169.17","187","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","1659.41","1659.41","1659.41","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","2050.91","1468.48","2902.83","52","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1548.60","1092.60","3613.79","82","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE B TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020262","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","2085.51","998.68","6202.11","56","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","1634.24","1004.95","1718.99","42","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","2123.89","1900.92","2123.89","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.96","58.3","","3729.00","1254.19","3729.00","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","939.37","939.37","5593.65","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1686.83","85","","2323.25","1864.50","2882.25","16","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1984.50","100","","2909.44","1772.40","10952.08","45","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1984.50","100","","2323.25","2323.25","2323.25","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1984.50","100","","2882.25","1772.40","10169.17","187","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","1659.41","1659.41","1659.41","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","2050.91","1468.48","2902.83","52","882.11","1984.5","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1548.60","1092.60","3613.79","82","992.25","1556.84","percent of total billed charges",""
"TRAY IMPLANT KNEE SIZE C TIBIAL MEDIAL OXFORD UNICOMPARTMENTAL LT 13","SUP-ITM-10020266","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","2085.51","998.68","6202.11","56","992.25","1556.84","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","AETNA [1001]","HB CH AETNA HMO / PPO","660.32","58.3","","554.95","91.85","1421.75","94","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","826.81","73","","2490.03","2490.03","2490.03","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","660.32","58.3","","750.00","750.00","750.00","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","600.29","53","","1192.50","120.84","4149.90","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","962.73","85","","750.00","75.00","750.00","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1132.62","100","","657.00","121.50","1971.00","14","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1132.62","100","","75.00","75.00","75.00","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1132.62","100","","366.00","144.00","1971.00","45","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","826.81","73","","667.50","667.50","667.50","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","503.45","44.45","","123.77","123.77","123.77","1 through 10","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","both","","","1132.62","849.46","WELLPOINT [1015]","HB CH WELLPOINT","882.42","77.91","","483.51","229.32","1316.08","96","503.45","1132.62","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.62","849.46","CIGNA [1006]","HB CH CIGNA HMO / PPO","671.64","59.3","","439.50","225.34","1872.27","197","566.31","888.54","percent of total billed charges",""
"TRAY INSTRUMENT 2.5/3MM CCHS CANNULATED SCREW","SUP-ITM-10277519","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1132.62","849.46","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","888.54","78.45","","385.32","55.36","1815.62","58","566.31","888.54","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1634.24","1004.95","1718.99","42","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","2123.89","1900.92","2123.89","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","939.37","939.37","5593.65","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3427.63","85","","2323.25","1864.50","2882.25","16","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4032.50","100","","2909.44","1772.40","10952.08","45","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4032.50","100","","2323.25","2323.25","2323.25","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4032.50","100","","2882.25","1772.40","10169.17","187","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","1659.41","1659.41","1659.41","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","2050.91","1468.48","2902.83","52","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1548.60","1092.60","3613.79","82","2016.25","3163.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY LEFT","SUP-ITM-10126695","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","2085.51","998.68","6202.11","56","2016.25","3163.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1634.24","1004.95","1718.99","42","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","2123.89","1900.92","2123.89","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","939.37","939.37","5593.65","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3427.63","85","","2323.25","1864.50","2882.25","16","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4032.50","100","","2909.44","1772.40","10952.08","45","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4032.50","100","","2323.25","2323.25","2323.25","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4032.50","100","","2882.25","1772.40","10169.17","187","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","1659.41","1659.41","1659.41","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","2050.91","1468.48","2902.83","52","1792.45","4032.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1548.60","1092.60","3613.79","82","2016.25","3163.5","percent of total billed charges",""
"TRAY LONG SIZE 2 TIBIAL INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10120305","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","2085.51","998.68","6202.11","56","2016.25","3163.5","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","AETNA [1001]","HB CH AETNA HMO / PPO","2042.13","58.3","","1634.24","1004.95","1718.99","42","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2557.04","73","","2123.89","1900.92","2123.89","1 through 10","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2042.13","58.3","","3729.00","1254.19","3729.00","1 through 10","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1856.48","53","","939.37","939.37","5593.65","1 through 10","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2977.38","85","","2323.25","1864.50","2882.25","16","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3502.80","100","","2909.44","1772.40","10952.08","45","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3502.80","100","","2323.25","2323.25","2323.25","1 through 10","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3502.80","100","","2882.25","1772.40","10169.17","187","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2557.04","73","","1659.41","1659.41","1659.41","1 through 10","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","both","","","3502.80","2627.10","WELLPOINT [1015]","HB CH WELLPOINT","2729.03","77.91","","2050.91","1468.48","2902.83","52","1556.99","3502.8","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","CIGNA [1006]","HB CH CIGNA HMO / PPO","2077.16","59.3","","1548.60","1092.60","3613.79","82","1751.4","2747.95","percent of total billed charges",""
"TRAY PEG COMPONENT TIBIAL KNEE PERSONA TRABECULAR METAL 2 RT SIZE F","SUP-ITM-10120525","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3502.80","2627.10","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2747.95","78.45","","2085.51","998.68","6202.11","56","1751.4","2747.95","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","AETNA [1001]","HB CH AETNA HMO / PPO","6598.32","58.3","","554.95","91.85","1421.75","94","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8262.05","73","","2490.03","2490.03","2490.03","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6598.32","58.3","","750.00","750.00","750.00","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","5998.48","53","","1192.50","120.84","4149.90","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","9620.20","85","","750.00","75.00","750.00","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11317.88","100","","657.00","121.50","1971.00","14","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11317.88","100","","75.00","75.00","75.00","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11317.88","100","","366.00","144.00","1971.00","45","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8262.05","73","","667.50","667.50","667.50","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","5030.80","44.45","","123.77","123.77","123.77","1 through 10","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","both","","","11317.88","8488.41","WELLPOINT [1015]","HB CH WELLPOINT","8817.76","77.91","","483.51","229.32","1316.08","96","5030.8","11317.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11317.88","8488.41","CIGNA [1006]","HB CH CIGNA HMO / PPO","6711.50","59.3","","439.50","225.34","1872.27","197","5658.94","8878.88","percent of total billed charges",""
"TRAY PLASMA 35X32.5MM MED TIBIAL SALTO TALARIS COBALT TITANIUM COATED","SUP-ITM-10079341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","11317.88","8488.41","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","8878.88","78.45","","385.32","55.36","1815.62","58","5658.94","8878.88","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","AETNA [1001]","HB CH AETNA HMO / PPO","4764.28","58.3","","1634.24","1004.95","1718.99","42","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5965.56","73","","2123.89","1900.92","2123.89","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4764.28","58.3","","3729.00","1254.19","3729.00","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4331.16","53","","939.37","939.37","5593.65","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6946.20","85","","2323.25","1864.50","2882.25","16","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8172.00","100","","2909.44","1772.40","10952.08","45","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8172.00","100","","2323.25","2323.25","2323.25","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8172.00","100","","2882.25","1772.40","10169.17","187","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5965.56","73","","1659.41","1659.41","1659.41","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","WELLPOINT [1015]","HB CH WELLPOINT","6366.81","77.91","","2050.91","1468.48","2902.83","52","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4846.00","59.3","","1548.60","1092.60","3613.79","82","4086","6410.93","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 1 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132218","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6410.93","78.45","","2085.51","998.68","6202.11","56","4086","6410.93","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","AETNA [1001]","HB CH AETNA HMO / PPO","4764.28","58.3","","1634.24","1004.95","1718.99","42","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5965.56","73","","2123.89","1900.92","2123.89","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4764.28","58.3","","3729.00","1254.19","3729.00","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4331.16","53","","939.37","939.37","5593.65","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6946.20","85","","2323.25","1864.50","2882.25","16","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8172.00","100","","2909.44","1772.40","10952.08","45","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8172.00","100","","2323.25","2323.25","2323.25","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8172.00","100","","2882.25","1772.40","10169.17","187","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5965.56","73","","1659.41","1659.41","1659.41","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","WELLPOINT [1015]","HB CH WELLPOINT","6366.81","77.91","","2050.91","1468.48","2902.83","52","3632.45","8172","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4846.00","59.3","","1548.60","1092.60","3613.79","82","4086","6410.93","percent of total billed charges",""
"TRAY PROSTHESIS SIZE 4 INFINITY TOTAL ANKLE TIBIAL","SUP-ITM-10132221","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6410.93","78.45","","2085.51","998.68","6202.11","56","4086","6410.93","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","AETNA [1001]","HB CH AETNA HMO / PPO","4764.28","58.3","","1634.24","1004.95","1718.99","42","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5965.56","73","","2123.89","1900.92","2123.89","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4764.28","58.3","","3729.00","1254.19","3729.00","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","4331.16","53","","939.37","939.37","5593.65","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","6946.20","85","","2323.25","1864.50","2882.25","16","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","8172.00","100","","2909.44","1772.40","10952.08","45","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","8172.00","100","","2323.25","2323.25","2323.25","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","8172.00","100","","2882.25","1772.40","10169.17","187","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5965.56","73","","1659.41","1659.41","1659.41","1 through 10","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","both","","","8172.00","6129.00","WELLPOINT [1015]","HB CH WELLPOINT","6366.81","77.91","","2050.91","1468.48","2902.83","52","3632.45","8172","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4846.00","59.3","","1548.60","1092.60","3613.79","82","4086","6410.93","percent of total billed charges",""
"TRAY TIBIAL 26X38 5.0MM SIZE 2 ANKLE INFINITY TOTAL TITANIUM ALLOY STANDARD","SUP-ITM-10132219","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","8172.00","6129.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","6410.93","78.45","","2085.51","998.68","6202.11","56","4086","6410.93","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","AETNA [1001]","HB CH AETNA HMO / PPO","6902.72","58.3","","1634.24","1004.95","1718.99","42","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","8643.20","73","","2123.89","1900.92","2123.89","1 through 10","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","6902.72","58.3","","3729.00","1254.19","3729.00","1 through 10","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","6275.20","53","","939.37","939.37","5593.65","1 through 10","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","10064.00","85","","2323.25","1864.50","2882.25","16","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","11840.00","100","","2909.44","1772.40","10952.08","45","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","11840.00","100","","2323.25","2323.25","2323.25","1 through 10","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","11840.00","100","","2882.25","1772.40","10169.17","187","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","8643.20","73","","1659.41","1659.41","1659.41","1 through 10","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","both","","","11840.00","8880.00","WELLPOINT [1015]","HB CH WELLPOINT","9224.54","77.91","","2050.91","1468.48","2902.83","52","5262.88","11840","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11840.00","8880.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","7021.12","59.3","","1548.60","1092.60","3613.79","82","5920","9288.48","percent of total billed charges",""
"TRAY TIBIAL 4MM SHORT SZ INVISION + +4 UNIVERSAL","SUP-ITM-10193762","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","11840.00","8880.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","9288.48","78.45","","2085.51","998.68","6202.11","56","5920","9288.48","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","AETNA [1001]","HB CH AETNA HMO / PPO","1156.96","58.3","","1634.24","1004.95","1718.99","42","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","2123.89","1900.92","2123.89","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1156.96","58.3","","3729.00","1254.19","3729.00","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1051.79","53","","939.37","939.37","5593.65","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1686.83","85","","2323.25","1864.50","2882.25","16","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1984.50","100","","2909.44","1772.40","10952.08","45","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1984.50","100","","2323.25","2323.25","2323.25","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1984.50","100","","2882.25","1772.40","10169.17","187","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1448.69","73","","1659.41","1659.41","1659.41","1 through 10","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","both","","","1984.50","1488.37","WELLPOINT [1015]","HB CH WELLPOINT","1546.12","77.91","","2050.91","1468.48","2902.83","52","882.11","1984.5","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1176.81","59.3","","1548.60","1092.60","3613.79","82","992.25","1556.84","percent of total billed charges",""
"TRAY TIBIAL KNEE OXFORD COBALT ALLOY RT MEDIAL SIZE A","SUP-ITM-10021776","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1984.50","1488.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1556.84","78.45","","2085.51","998.68","6202.11","56","992.25","1556.84","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","AETNA [1001]","HB CH AETNA HMO / PPO","2350.95","58.3","","1634.24","1004.95","1718.99","42","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","2123.89","1900.92","2123.89","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2350.95","58.3","","3729.00","1254.19","3729.00","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2137.23","53","","939.37","939.37","5593.65","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3427.63","85","","2323.25","1864.50","2882.25","16","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4032.50","100","","2909.44","1772.40","10952.08","45","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4032.50","100","","2323.25","2323.25","2323.25","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4032.50","100","","2882.25","1772.40","10169.17","187","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2943.73","73","","1659.41","1659.41","1659.41","1 through 10","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","both","","","4032.50","3024.37","WELLPOINT [1015]","HB CH WELLPOINT","3141.72","77.91","","2050.91","1468.48","2902.83","52","1792.45","4032.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","2391.27","59.3","","1548.60","1092.60","3613.79","82","2016.25","3163.5","percent of total billed charges",""
"TRAY TIBIAL LONG SIZE 4 INBONE II TITANIUM ALLOY RIGHT","SUP-ITM-10131997","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","4032.50","3024.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3163.50","78.45","","2085.51","998.68","6202.11","56","2016.25","3163.5","percent of total billed charges",""
"Treatment Room Procedure","PX-76001357","CDM","57295","CPT","0761","RC","","","","outpatient","","","8940.00","6705.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","4386.86","49.07","","3818.15","3818.15","3818.15","1 through 10","3576","7013.43","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","AETNA [1001]","HB CH AETNA HMO / PPO","89.78","58.3","","85.05","85.05","85.05","48","12.98","112.42","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","112.42","73","","18.54","18.54","18.54","1 through 10","12.98","112.42","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","both","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.45","44.45","","115.32","68.34","115.32","1 through 10","12.98","112.42","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","154.00","115.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.32","59.3","","87.90","87.90","87.90","49","13.65","120.81","percent of total billed charges",""
"Treponema Pallidum Antibody","PX-30001003","CDM","86780","CPT","0302","RC","","","","outpatient","","","154.00","115.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.81","78.45","","115.32","68.34","115.32","45","13.65","120.81","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","AETNA [1001]","HB CH AETNA HMO / PPO","1931.19","58.3","","1634.24","1004.95","1718.99","42","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2418.13","73","","2123.89","1900.92","2123.89","1 through 10","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1931.19","58.3","","3729.00","1254.19","3729.00","1 through 10","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1755.63","53","","939.37","939.37","5593.65","1 through 10","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2815.63","85","","2323.25","1864.50","2882.25","16","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3312.50","100","","2909.44","1772.40","10952.08","45","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3312.50","100","","2323.25","2323.25","2323.25","1 through 10","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3312.50","100","","2882.25","1772.40","10169.17","187","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2418.13","73","","1659.41","1659.41","1659.41","1 through 10","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","both","","","3312.50","2484.37","WELLPOINT [1015]","HB CH WELLPOINT","2580.77","77.91","","2050.91","1468.48","2902.83","52","1472.41","3312.5","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","1964.31","59.3","","1548.60","1092.60","3613.79","82","1656.25","2598.66","percent of total billed charges",""
"TRIAL IMPLANT 8MM SMALL KNEE TIBIAL COMPONENT ALL POLY DURATION KRH ONC 05","SUP-ITM-10024455","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","3312.50","2484.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2598.66","78.45","","2085.51","998.68","6202.11","56","1656.25","2598.66","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","AETNA [1001]","HB CH AETNA HMO / PPO","514.21","58.3","","1634.24","1004.95","1718.99","42","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","643.86","73","","2123.89","1900.92","2123.89","1 through 10","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","514.21","58.3","","3729.00","1254.19","3729.00","1 through 10","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","467.46","53","","939.37","939.37","5593.65","1 through 10","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","749.70","85","","2323.25","1864.50","2882.25","16","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","882.00","100","","2909.44","1772.40","10952.08","45","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","882.00","100","","2323.25","2323.25","2323.25","1 through 10","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","882.00","100","","2882.25","1772.40","10169.17","187","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","643.86","73","","1659.41","1659.41","1659.41","1 through 10","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","both","","","882.00","661.50","WELLPOINT [1015]","HB CH WELLPOINT","687.17","77.91","","2050.91","1468.48","2902.83","52","392.05","882","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","523.03","59.3","","1548.60","1092.60","3613.79","82","441","691.93","percent of total billed charges",""
"TRIAL KNEE 26MM PATELLA COMPONENT SCORPIO RECESSED POLYETHYLENE","SUP-ITM-10036095","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","882.00","661.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","691.93","78.45","","2085.51","998.68","6202.11","56","441","691.93","percent of total billed charges",""
"Triamcinolone Ace Inj","PX-63600364","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.57","6.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.00","58.3","","1.76","1.76","1.76","1 through 10","2.84","6.26","percent of total billed charges",""
"Triamcinolone Ace Inj 10mg","PX-63600188","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.87","6.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.17","58.3","","1.76","1.76","1.76","1 through 10","2.84","6.48","percent of total billed charges",""
"Triamcinolone Ace Vl 40mg/Ml 1ml","PX-63600331","CDM","J3301","HCPCS","0636","RC","","","","both","","","8.87","6.65","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","5.17","58.3","","1.76","1.76","1.76","1 through 10","2.84","6.48","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","AETNA [1001]","HB CH AETNA HMO / PPO","130.01","58.3","","123.04","123.04","123.04","24","34.39","207.04","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","99.12","44.45","","98.87","98.87","98.87","1 through 10","34.39","207.04","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","both","","","223.00","167.25","WELLPOINT [1015]","HB CH WELLPOINT","173.74","77.91","","289.00","170.91","604.91","28","34.39","207.04","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","223.00","167.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","132.24","59.3","","127.16","127.16","665.22","42","26.86","174.94","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","223.00","167.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","132.24","59.3","","124.12","124.12","124.12","1 through 10","26.86","174.94","percent of total billed charges",""
"Trichomonas Vaginalis Amplif","PX-30002753","CDM","87661","CPT","0300","RC","","","","outpatient","","","223.00","167.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","174.94","78.45","","166.83","98.87","166.83","22","26.86","174.94","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","142.00","106.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","84.21","59.3","","80.87","80.87","80.87","1 through 10","17.47","111.4","percent of total billed charges",""
"Triiodothyronine (T-3) Free","PX-30000712","CDM","84481","CPT","0301","RC","","","","outpatient","","","142.00","106.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","111.40","78.45","","106.09","106.09","106.09","1 through 10","17.47","111.4","percent of total billed charges",""
"Triiodothyronine (T-3) Reverse","PX-30000713","CDM","84482","CPT","0301","RC","","","","outpatient","","","175.00","131.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.29","78.45","","130.70","130.70","130.70","1 through 10","15.7","137.29","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0300","RC","","","","inpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.31","70.6","","88.41","88.41","88.41","1 through 10","66.08","83.31","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","both","","","118.00","88.50","AETNA [1001]","HB CH AETNA HMO / PPO","68.79","58.3","","65.21","65.21","65.21","1 through 10","13.9","86.14","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","118.00","88.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","69.97","59.3","","67.39","57.50","67.39","1 through 10","14.61","92.57","percent of total billed charges",""
"Triiodothyronine (T-3) Total","PX-30000711","CDM","84480","CPT","0301","RC","","","","outpatient","","","118.00","88.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","92.57","78.45","","88.41","52.39","88.41","1 through 10","14.61","92.57","percent of total billed charges",""
"Trlml Balo Angiop Open/Perq Img S&I 1st Art","PX-36000416","CDM","37246","CPT","0361","RC","","","","both","","","8544.00","6408.00","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6974.02","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6967.26","6967.26","6967.26","1 through 10","4210.68","15281.41","other","OPPS APC"
"Trlml Balo Angiop Open/Perq Img S&I 1st Art","PX-36000416","CDM","37246","CPT","0361","RC","","","","both","","","8544.00","6408.00","MEDICARE [2001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","18714.63","6238.21","18714.63","1 through 10","4210.68","15281.41","other","OPPS APC"
"Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein","PX-36000418","CDM","37248","CPT","0361","RC","","","","both","","","7350.00","5512.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","6974.02","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","6967.26","6967.26","6967.26","1 through 10","3267.08","15281.41","other","OPPS APC"
"Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein","PX-36000418","CDM","37248","CPT","0361","RC","","","","both","","","7350.00","5512.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","6635.48","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6635.48","6113.45","6635.48","1 through 10","3267.08","15281.41","other","OPPS APC"
"Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein","PX-36000418","CDM","37248","CPT","0361","RC","","","","both","","","7350.00","5512.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4285.05","58.3","","4052.35","4052.35","4052.35","1 through 10","3267.08","15281.41","percent of total billed charges",""
"Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein","PX-36000418","CDM","37248","CPT","0361","RC","","","","both","","","7350.00","5512.50","MEDICARE [2001]","HB BWF MEDICARE","6770.90","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","20312.70","6238.21","20312.70","44","3267.08","15281.41","other","OPPS APC"
"Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein","PX-36000418","CDM","37248","CPT","0361","RC","","","","both","","","7350.00","5512.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","6635.48","","APC Price ($6,770.90). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","6113.45","6113.45","6113.45","1 through 10","3267.08","15281.41","other","OPPS APC"
"Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I","PX-36000413","CDM","36907","CPT","0361","RC","","","","both","","","2989.00","2241.75","AETNA [1001]","HB CH AETNA HMO / PPO","1742.59","58.3","","1647.70","1647.70","1647.70","1 through 10","1328.61","2989","percent of total billed charges",""
"Trluml Balo Angiop Ctr Dialysis Seg W/Img S&I","PX-36000413","CDM","36907","CPT","0361","RC","","","","both","","","2989.00","2241.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1584.17","53","","1540.18","1540.18","1540.18","1 through 10","1328.61","2989","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","4477.60","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","4473.70","4473.70","4473.70","1 through 10","2766.13","5919.6","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","AETNA [1001]","HB CH AETNA HMO / PPO","4429.63","58.3","","4602.91","4602.91","4602.91","1 through 10","2766.13","5919.6","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","4260.24","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","4278.06","4278.06","4278.06","1 through 10","2766.13","5919.6","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","FALLON HEALTH [1008]","HB BWF MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","4266.17","4266.17","4266.17","1 through 10","2766.13","5919.6","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4429.63","58.3","","5080.89","5080.89","5080.89","1 through 10","2766.13","5919.6","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","MEDICARE [2001]","HB BWF MEDICARE","4347.18","","APC Price ($4,347.18). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3915.62","3915.62","3915.62","1 through 10","2766.13","5919.6","other","OPPS APC"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,310). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","1065.00","1065.00","1065.00","1 through 10","2766.13","5919.6","per diem",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","both","","","7598.00","5698.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","2766.13","5919.6","per diem",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2283.85","2236.41","2283.85","1 through 10","2766.13","7939.38","other","ASC "
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","3163.23","","Case rate ($3,163.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2287.02","2239.57","4574.03","15","2766.13","7939.38","other","ASC "
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","4505.61","59.3","","4877.28","4877.28","4877.28","1 through 10","2766.13","7939.38","percent of total billed charges",""
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 235 procedures at 0%, 117.5 procedures at 0%.","10416.00","8837.79","14618.41","1 through 10","2766.13","7939.38","other","Multiple Surgery"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","2766.13","","Case rate ($2,766.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 247%, 123.5 procedures at 0%.","15162.00","15162.00","15162.00","1 through 10","2766.13","7939.38","other","Multiple Surgery"
"Trnsf Tissue Any Area 30.1-60 Sqcm","PX-76000162","CDM","14301","CPT","0761","RC","","","","outpatient","","","7598.00","5698.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5960.63","78.45","","2331.31","2331.31","2331.31","1 through 10","2766.13","7939.38","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1250.00","937.50","AETNA [1001]","HB CH AETNA HMO / PPO","728.75","58.3","","4602.91","4602.91","4602.91","1 through 10","536.25","973.88","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1250.00","937.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","728.75","58.3","","5080.89","5080.89","5080.89","1 through 10","536.25","973.88","percent of total billed charges",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1250.00","937.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,310). Procedure 2, Per diem ($1,065). Procedures 3 - 9999, Per diem ($532.50).","532.50","532.50","532.50","1 through 10","536.25","973.88","per diem",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","both","","","1250.00","937.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","554.00","554.00","554.00","1 through 10","536.25","973.88","per diem",""
"Trnsf Tissue Any Area Ea Addl 30","PX-76000163","CDM","14302","CPT","0761","RC","","","","outpatient","","","1250.00","937.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","741.25","59.3","","4877.28","4877.28","4877.28","1 through 10","373.2","980.63","percent of total billed charges",""
"Trnsf Tissue Eye/Nose/Ear/Lip <10cm","PX-76000160","CDM","14060","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1280.66","1280.66","1280.66","1 through 10","1548.96","7178","other","ASC "
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","2172.10","","APC Price ($2,172.10). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","2134.87","2134.87","2134.87","1 through 10","1548.96","3591.65","other","OPPS APC"
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","both","","","4610.00","3457.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1548.96","3591.65","per diem",""
"Trnsf Tissue Head/Hand/Foot <10cm","PX-76000158","CDM","14040","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","1254.10","1254.10","1254.10","1 through 10","1548.96","4472.66","other","ASC "
"Trnsf Tissue Sclp/Arm/Lg <10cm","PX-76000156","CDM","14020","CPT","0761","RC","","","","outpatient","","","4610.00","3457.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1771.32","","Case rate ($1,771.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","1278.90","1278.90","1278.90","1 through 10","1548.96","7178","other","ASC "
"TROCAR BALLOON 10MM STRUCTURAL SPACEMAKER LF STERILE DISP BX/5EA","SUP-ITM-10002678","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","445.94","334.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","349.84","78.45","","2644.76","2644.76","2644.76","1 through 10","222.97","349.84","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0300","RC","","","","inpatient","","","110.00","82.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","61.60","56","","61.21","61.21","61.21","1 through 10","61.6","77.66","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0300","RC","","","","inpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","77.66","70.6","","164.52","164.52","164.52","1 through 10","61.6","77.66","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","110.00","82.50","AETNA [1001]","HB CH AETNA HMO / PPO","64.13","58.3","","60.67","60.67","60.67","41","12.22","80.3","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","both","","","110.00","82.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","80.30","73","","78.11","78.11","78.11","1 through 10","12.22","80.3","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","110.00","82.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","65.23","59.3","","62.70","62.70","320.27","28","10.14","86.3","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","110.00","82.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","86.30","78.45","","164.52","164.52","164.52","1 through 10","10.14","86.3","percent of total billed charges",""
"Troponin Qn","PX-30000714","CDM","84484","CPT","0301","RC","","","","outpatient","","","110.00","82.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","86.30","78.45","","48.75","30.95","97.50","1 through 10","10.14","86.3","percent of total billed charges",""
"Trurl Dstrj Prst8 Tiss Rf Wv Thermotherapy","PX-76002577","CDM","53854","CPT","0761","RC","","","","both","","","2159.00","1619.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2159.00","100","","5970.00","5970.00","5970.00","1 through 10","926.21","2159","percent of total billed charges",""
"Trurl Dstrj Prst8 Tiss Rf Wv Thermotherapy","PX-76002577","CDM","53854","CPT","0761","RC","","","","outpatient","","","2159.00","1619.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1081.66","50.1","","2947.05","2885.91","2947.05","1 through 10","863.6","1693.74","percent of total billed charges",""
"Trurl Dstrj Prst8 Tiss Rf Wv Thermotherapy","PX-76002577","CDM","53854","CPT","0761","RC","","","","outpatient","","","2159.00","1619.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1280.29","59.3","","4845.05","4845.05","4845.05","1 through 10","863.6","1693.74","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Tryptase","PX-30003578","CDM","83520","CPT","0301","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"TUBE EUSTACHIAN 6X16MM AERA BALLOON DILATION PK/5EA","SUP-ITM-10185058","CDM","C1726","HCPCS","0272","RC","","","","outpatient","","","4125.00","3093.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3236.06","78.45","","2644.76","2644.76","2644.76","1 through 10","2062.5","3236.06","percent of total billed charges",""
"TUNNELER SUBCUTANEOUS","SUP-ITM-10283217","CDM","C1894","HCPCS","0272","RC","","","","both","","","912.45","684.34","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","483.60","53","","69.13","15.86","85.00","1 through 10","405.58","912.45","percent of total billed charges",""
"TUNNELER SUBCUTANEOUS","SUP-ITM-10283217","CDM","C1894","HCPCS","0272","RC","","","","both","","","912.45","684.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","775.58","85","","29.94","29.94","29.94","1 through 10","405.58","912.45","percent of total billed charges",""
"TUNNELER SUBCUTANEOUS","SUP-ITM-10283217","CDM","C1894","HCPCS","0272","RC","","","","both","","","912.45","684.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","912.45","100","","60.23","29.94","60.23","12","405.58","912.45","percent of total billed charges",""
"TUNNELER SUBCUTANEOUS","SUP-ITM-10283217","CDM","C1894","HCPCS","0272","RC","","","","both","","","912.45","684.34","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","912.45","100","","65.22","29.94","360.69","1 through 10","405.58","912.45","percent of total billed charges",""
"TUNNELER SUBCUTANEOUS","SUP-ITM-10283217","CDM","C1894","HCPCS","0272","RC","","","","both","","","912.45","684.34","WELLPOINT [1015]","HB CH WELLPOINT","710.89","77.91","","51.37","51.37","284.08","1 through 10","405.58","912.45","percent of total billed charges",""
"TUNNELER SUBCUTANEOUS","SUP-ITM-10283217","CDM","C1894","HCPCS","0272","RC","","","","outpatient","","","912.45","684.34","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","715.82","78.45","","123.30","23.02","333.57","1 through 10","456.23","715.82","percent of total billed charges",""
"Tx Fx Radial Dist Extra-Artic Opn|BILATERAL PROCEDURE","PX-76000461","CDM","25607","CPT","0761","RC","","","50","outpatient","","","18101.00","13575.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9776.72","","Case rate ($9,776.72). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","13843.84","13843.84","13843.84","1 through 10","9776.72","23663.91","other","ASC "
"Tx Fx Radial Distal 3+ Frag Open","PX-76000463","CDM","25609","CPT","0761","RC","","","","both","","","4936.00","3702.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8903.33","","APC Price ($9,085.03). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","8321.84","8321.84","8321.84","1 through 10","2117.54","9357.58","other","OPPS APC"
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","AETNA [1001]","HB CH AETNA HMO / PPO","4041.36","58.3","","1830.28","315.58","1830.28","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5060.36","73","","4170.85","4170.85","4170.85","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","3081.27","44.45","","649.55","649.55","649.55","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","WELLPOINT [1015]","HB CH WELLPOINT","5400.72","77.91","","8998.38","2542.37","8998.38","20","3081.27","6932","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6932.00","5199.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4110.68","59.3","","1891.61","1609.14","3664.18","25","3466","5438.15","percent of total billed charges",""
"ULNA COMPONENT 3X75MM DISCOVERY LEFT WITH E PLUS BEARING","SUP-ITM-10276256","CDM","C1889","HCPCS","0278","RC","","","","outpatient","","","6932.00","5199.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5438.15","78.45","","1470.68","1310.06","2481.69","19","3466","5438.15","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","AETNA [1001]","HB CH AETNA HMO / PPO","1030.16","58.3","","1634.24","1004.95","1718.99","42","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1289.91","73","","2123.89","1900.92","2123.89","1 through 10","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1030.16","58.3","","3729.00","1254.19","3729.00","1 through 10","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","936.51","53","","939.37","939.37","5593.65","1 through 10","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1501.95","85","","2323.25","1864.50","2882.25","16","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1767.00","100","","2909.44","1772.40","10952.08","45","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1767.00","100","","2323.25","2323.25","2323.25","1 through 10","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1767.00","100","","2882.25","1772.40","10169.17","187","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1289.91","73","","1659.41","1659.41","1659.41","1 through 10","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","both","","","1767.00","1325.25","WELLPOINT [1015]","HB CH WELLPOINT","1376.67","77.91","","2050.91","1468.48","2902.83","52","785.43","1767","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1767.00","1325.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1047.83","59.3","","1548.60","1092.60","3613.79","82","883.5","1386.21","percent of total billed charges",""
"ULNA KIT XSM ELBOW BEARING DSCVRY REVISION 04","SUP-ITM-10113701","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","1767.00","1325.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1386.21","78.45","","2085.51","998.68","6202.11","56","883.5","1386.21","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","AETNA [1001]","HB CH AETNA HMO / PPO","1526.88","58.3","","554.95","91.85","1421.75","94","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1911.87","73","","2490.03","2490.03","2490.03","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1526.88","58.3","","750.00","750.00","750.00","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1388.07","53","","1192.50","120.84","4149.90","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2226.15","85","","750.00","75.00","750.00","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2619.00","100","","657.00","121.50","1971.00","14","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2619.00","100","","75.00","75.00","75.00","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2619.00","100","","366.00","144.00","1971.00","45","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1911.87","73","","667.50","667.50","667.50","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1164.15","44.45","","123.77","123.77","123.77","1 through 10","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","both","","","2619.00","1964.25","WELLPOINT [1015]","HB CH WELLPOINT","2040.46","77.91","","483.51","229.32","1316.08","96","1164.15","2619","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2619.00","1964.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1553.07","59.3","","439.50","225.34","1872.27","197","1309.5","2054.61","percent of total billed charges",""
"ULNA PLATE 2.7MM 3.5 6 HOLE RAYHACK SS LOCKING LOW PROFILE SHORTENING STANDARD","SUP-ITM-10050572","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2619.00","1964.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2054.61","78.45","","385.32","55.36","1815.62","58","1309.5","2054.61","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","AETNA [1001]","HB CH AETNA HMO / PPO","1687.79","58.3","","554.95","91.85","1421.75","94","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2113.35","73","","2490.03","2490.03","2490.03","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1687.79","58.3","","750.00","750.00","750.00","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1534.35","53","","1192.50","120.84","4149.90","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2460.75","85","","750.00","75.00","750.00","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2895.00","100","","657.00","121.50","1971.00","14","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2895.00","100","","75.00","75.00","75.00","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2895.00","100","","366.00","144.00","1971.00","45","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2113.35","73","","667.50","667.50","667.50","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1286.83","44.45","","123.77","123.77","123.77","1 through 10","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","both","","","2895.00","2171.25","WELLPOINT [1015]","HB CH WELLPOINT","2255.49","77.91","","483.51","229.32","1316.08","96","1286.83","2895","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.00","2171.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1716.74","59.3","","439.50","225.34","1872.27","197","1447.5","2271.13","percent of total billed charges",""
"ULNA PLATE BONE ARM RAYHACK TITANIUM LOCKING LOW PROFILE SHORTENING","SUP-ITM-10051723","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2895.00","2171.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2271.13","78.45","","385.32","55.36","1815.62","58","1447.5","2271.13","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","AETNA [1001]","HB CH AETNA HMO / PPO","1474.32","58.3","","554.95","91.85","1421.75","94","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","1846.06","73","","2490.03","2490.03","2490.03","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1474.32","58.3","","750.00","750.00","750.00","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1340.29","53","","1192.50","120.84","4149.90","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2149.52","85","","750.00","75.00","750.00","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2528.85","100","","657.00","121.50","1971.00","14","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2528.85","100","","75.00","75.00","75.00","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2528.85","100","","366.00","144.00","1971.00","45","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","1846.06","73","","667.50","667.50","667.50","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1124.07","44.45","","123.77","123.77","123.77","1 through 10","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","both","","","2528.85","1896.64","WELLPOINT [1015]","HB CH WELLPOINT","1970.23","77.91","","483.51","229.32","1316.08","96","1124.07","2528.85","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2528.85","1896.64","CIGNA [1006]","HB CH CIGNA HMO / PPO","1499.61","59.3","","439.50","225.34","1872.27","197","1264.43","1983.88","percent of total billed charges",""
"ULNA PLATE BONE DVR LOW PROFILE DISTAL BILATERAL","SUP-ITM-10175573","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2528.85","1896.64","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1983.88","78.45","","385.32","55.36","1815.62","58","1264.43","1983.88","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","AETNA [1001]","HB CH AETNA HMO / PPO","1897.67","58.3","","554.95","91.85","1421.75","94","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2376.15","73","","2490.03","2490.03","2490.03","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1897.67","58.3","","750.00","750.00","750.00","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1725.15","53","","1192.50","120.84","4149.90","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2766.75","85","","750.00","75.00","750.00","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3255.00","100","","657.00","121.50","1971.00","14","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3255.00","100","","75.00","75.00","75.00","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3255.00","100","","366.00","144.00","1971.00","45","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2376.15","73","","667.50","667.50","667.50","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1446.85","44.45","","123.77","123.77","123.77","1 through 10","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","both","","","3255.00","2441.25","WELLPOINT [1015]","HB CH WELLPOINT","2535.97","77.91","","483.51","229.32","1316.08","96","1446.85","3255","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1930.22","59.3","","439.50","225.34","1872.27","197","1627.5","2553.55","percent of total billed charges",""
"ULNA PLATE DISTAL FRAGMENT","SUP-ITM-10157785","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3255.00","2441.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2553.55","78.45","","385.32","55.36","1815.62","58","1627.5","2553.55","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","AETNA [1001]","HB CH AETNA HMO / PPO","2162.93","58.3","","554.95","91.85","1421.75","94","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2708.30","73","","2490.03","2490.03","2490.03","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2162.93","58.3","","750.00","750.00","750.00","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1966.30","53","","1192.50","120.84","4149.90","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3153.50","85","","750.00","75.00","750.00","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3710.00","100","","657.00","121.50","1971.00","14","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3710.00","100","","75.00","75.00","75.00","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3710.00","100","","366.00","144.00","1971.00","45","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2708.30","73","","667.50","667.50","667.50","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1649.10","44.45","","123.77","123.77","123.77","1 through 10","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","both","","","3710.00","2782.50","WELLPOINT [1015]","HB CH WELLPOINT","2890.46","77.91","","483.51","229.32","1316.08","96","1649.1","3710","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3710.00","2782.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","2200.03","59.3","","439.50","225.34","1872.27","197","1855","2910.5","percent of total billed charges",""
"ULNA PLATE PROXIMAL SHORTENING","SUP-ITM-10281665","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3710.00","2782.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2910.50","78.45","","385.32","55.36","1815.62","58","1855","2910.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","AETNA [1001]","HB CH AETNA HMO / PPO","2062.36","58.3","","554.95","91.85","1421.75","94","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2582.38","73","","2490.03","2490.03","2490.03","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2062.36","58.3","","750.00","750.00","750.00","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1874.88","53","","1192.50","120.84","4149.90","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3006.88","85","","750.00","75.00","750.00","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3537.50","100","","657.00","121.50","1971.00","14","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3537.50","100","","75.00","75.00","75.00","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3537.50","100","","366.00","144.00","1971.00","45","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2582.38","73","","667.50","667.50","667.50","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1572.42","44.45","","123.77","123.77","123.77","1 through 10","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","both","","","3537.50","2653.12","WELLPOINT [1015]","HB CH WELLPOINT","2756.07","77.91","","483.51","229.32","1316.08","96","1572.42","3537.5","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3537.50","2653.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","2097.74","59.3","","439.50","225.34","1872.27","197","1768.75","2775.17","percent of total billed charges",""
"ULNA PLATE PROXIMALIMAL 6 HOLE RIGHT","SUP-ITM-10198216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3537.50","2653.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2775.17","78.45","","385.32","55.36","1815.62","58","1768.75","2775.17","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","AETNA [1001]","HB CH AETNA HMO / PPO","4041.36","58.3","","1634.24","1004.95","1718.99","42","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5060.36","73","","2123.89","1900.92","2123.89","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4041.36","58.3","","3729.00","1254.19","3729.00","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3673.96","53","","939.37","939.37","5593.65","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5892.20","85","","2323.25","1864.50","2882.25","16","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6932.00","100","","2909.44","1772.40","10952.08","45","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6932.00","100","","2323.25","2323.25","2323.25","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6932.00","100","","2882.25","1772.40","10169.17","187","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5060.36","73","","1659.41","1659.41","1659.41","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","WELLPOINT [1015]","HB CH WELLPOINT","5400.72","77.91","","2050.91","1468.48","2902.83","52","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6932.00","5199.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4110.68","59.3","","1548.60","1092.60","3613.79","82","3466","5438.15","percent of total billed charges",""
"ULNAR COMPONENT 75X3MM DISCOVERY ELBOW RT E PLUS BEARING","SUP-ITM-10277328","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6932.00","5199.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5438.15","78.45","","2085.51","998.68","6202.11","56","3466","5438.15","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","AETNA [1001]","HB CH AETNA HMO / PPO","4041.36","58.3","","1634.24","1004.95","1718.99","42","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","5060.36","73","","2123.89","1900.92","2123.89","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","4041.36","58.3","","3729.00","1254.19","3729.00","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3673.96","53","","939.37","939.37","5593.65","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","5892.20","85","","2323.25","1864.50","2882.25","16","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","6932.00","100","","2909.44","1772.40","10952.08","45","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","6932.00","100","","2323.25","2323.25","2323.25","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","6932.00","100","","2882.25","1772.40","10169.17","187","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","5060.36","73","","1659.41","1659.41","1659.41","1 through 10","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","both","","","6932.00","5199.00","WELLPOINT [1015]","HB CH WELLPOINT","5400.72","77.91","","2050.91","1468.48","2902.83","52","3081.27","6932","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6932.00","5199.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","4110.68","59.3","","1548.60","1092.60","3613.79","82","3466","5438.15","percent of total billed charges",""
"ULNAR COMPONENT 75X4MM DISCOVERY ELBOW LT E PLUS BEARING","SUP-ITM-10277335","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","6932.00","5199.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5438.15","78.45","","2085.51","998.68","6202.11","56","3466","5438.15","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","AETNA [1001]","HB CH AETNA HMO / PPO","3290.45","58.3","","1634.24","1004.95","1718.99","42","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","4120.12","73","","2123.89","1900.92","2123.89","1 through 10","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","3290.45","58.3","","3729.00","1254.19","3729.00","1 through 10","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2991.32","53","","939.37","939.37","5593.65","1 through 10","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","4797.40","85","","2323.25","1864.50","2882.25","16","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","5644.00","100","","2909.44","1772.40","10952.08","45","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","5644.00","100","","2323.25","2323.25","2323.25","1 through 10","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","5644.00","100","","2882.25","1772.40","10169.17","187","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","4120.12","73","","1659.41","1659.41","1659.41","1 through 10","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","both","","","5644.00","4233.00","WELLPOINT [1015]","HB CH WELLPOINT","4397.24","77.91","","2050.91","1468.48","2902.83","52","2508.76","5644","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","3346.89","59.3","","1548.60","1092.60","3613.79","82","2822","4427.72","percent of total billed charges",""
"ULNAR STEM 3X115MM DISCOVERY ORTHO COMPONENT PROXIMALIMAL BEARING LEFT","SUP-ITM-10008629","CDM","C1776","HCPCS","0278","RC","","","","outpatient","","","5644.00","4233.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","4427.72","78.45","","2085.51","998.68","6202.11","56","2822","4427.72","percent of total billed charges",""
"Ultrasound Guided IR Drain Injection of TPA.","PX-76002888","CDM","49999","CPT","0761","RC","","","","both","","","1680.00","1260.00","WELLPOINT [1015]","HB CH WELLPOINT","1308.89","77.91","","3449.15","3449.15","3449.15","1 through 10","720.72","1597.68","percent of total billed charges",""
"Uncomplicated Peptic Ulcer With McC","383","MS-DRG","","","","","","","","inpatient","","","37375.85","28031.89","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","13443.55","","Case rate ($13,051.99). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,072.71, add-ons for qualifying new technology services are included. If operating cost exceeds $58,596.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,536.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $11,736.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,733.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $976.10. The transfer capital threshold is the transfer adjustment factor * $976.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","12142.52","12142.52","12142.52","1 through 10","12501.6738","14267.44","other","Inpatient DRG"
"Uncomplicated Peptic Ulcer With McC","383","MS-DRG","","","","","","","","inpatient","","","37375.85","28031.89","MEDICARE [2001]","HB BWF MEDICARE","14267.44","","Case rate ($14,267.44). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $13,072.71, add-ons for qualifying new technology services are included. If operating cost exceeds $58,596.44 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,536.88, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.9. The base transfer operating payment is the transfer adjustment factor * $12,952.10 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,733.47 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $976.10. The transfer capital threshold is the transfer adjustment factor * $976.10. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","12736.92","12736.92","12736.92","1 through 10","12501.6738","14267.44","other","Inpatient DRG"
"Uncomplicated Peptic Ulcer Without McC","384","MS-DRG","","","","","","","","inpatient","","","26570.82","19928.11","MEDICARE [2001]","HB BWF MEDICARE","8209.79","","Case rate ($8,209.79). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,222.61, add-ons for qualifying new technology services are included. If operating cost exceeds $53,746.34 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,165.09, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.4. The base transfer operating payment is the transfer adjustment factor * $7,266.23 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,883.37 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $604.31. The transfer capital threshold is the transfer adjustment factor * $604.31. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8898.00","8898.00","8898.00","1 through 10","8045.59","8599.4744","other","Inpatient Replacement Plans DRG"
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","both","","","33.00","24.75","AETNA [1001]","HB CH AETNA HMO / PPO","19.24","58.3","","18.14","18.14","18.14","1 through 10","3.87","25.91","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","33.00","24.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","19.57","59.3","","18.75","18.30","18.75","1 through 10","4.07","25.89","percent of total billed charges",""
"Urea Nitrogen Quantitative","PX-30000721","CDM","84520","CPT","0301","RC","","","","outpatient","","","33.00","24.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","25.89","78.45","","24.60","24.60","24.60","1 through 10","4.07","25.89","percent of total billed charges",""
"Urea Nitrogen Urine","PX-30000723","CDM","84540","CPT","0301","RC","","","","outpatient","","","50.00","37.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","39.23","78.45","","1.62","1.62","1.62","1 through 10","4.89","39.23","percent of total billed charges",""
"Urethral And Transurethral Procedures,MODERATE","446","DRG","","","","","","","","inpatient","","","29090.60","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","13118.5446","","Fee schedule rate ($15,782.12). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","13118.5446","15782.12","15782.12","1 through 10","7718.97","26040.25","case rate",""
"Urethral And Transurethral Procedures,MODERATE","446","DRG","","","","","","","","inpatient","","","29090.60","","MASSHEALTH [3001]","HB BWF MEDICAID","7718.97","","Case rate ($8,534.65). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $50,964.65, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","8532.55","8532.55","8532.55","1 through 10","7718.97","26040.25","case rate",""
"Urethral Stricture","697","MS-DRG","","","","","","","","inpatient","","","84709.92","63532.44","MEDICARE [2001]","HB BWF MEDICARE","11211.85","","Case rate ($11,211.85). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $10,279.22, add-ons for qualifying new technology services are included. If operating cost exceeds $55,802.95 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,322.74, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.6. The base transfer operating payment is the transfer adjustment factor * $10,110.65 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $9,939.98 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $761.96. The transfer capital threshold is the transfer adjustment factor * $761.96. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","9906.8002","11211.85","other","Inpatient DRG"
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","both","","","56.00","42.00","AETNA [1001]","HB CH AETNA HMO / PPO","32.65","58.3","","30.62","30.62","30.62","14","4.43","40.88","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","56.00","42.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","33.21","59.3","","31.64","31.64","31.64","16","4.65","43.93","percent of total billed charges",""
"Uric Acid Blood","PX-30000725","CDM","84550","CPT","0301","RC","","","","outpatient","","","56.00","42.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","43.93","78.45","","41.52","24.60","41.52","12","4.65","43.93","percent of total billed charges",""
"Uric Acid Other Source","PX-30000726","CDM","84560","CPT","0301","RC","","","","outpatient","","","44.00","33.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","26.09","59.3","","25.19","25.19","25.19","1 through 10","4.89","34.52","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","AETNA [1001]","HB CH AETNA HMO / PPO","21.57","58.3","","20.41","20.41","20.41","52","3.11","27.01","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","27.01","73","","20.41","20.41","20.41","1 through 10","3.11","27.01","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","both","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","16.45","44.45","","27.68","27.68","27.68","1 through 10","3.11","27.01","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","21.94","59.3","","21.10","21.10","21.10","38","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","27.68","27.68","27.68","1 through 10","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/Micro","PX-30001374","CDM","81001","CPT","0307","RC","","","","outpatient","","","37.00","27.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","29.03","78.45","","27.68","16.40","27.68","26","3.27","29.03","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","AETNA [1001]","HB CH AETNA HMO / PPO","18.07","58.3","","17.01","17.01","17.01","53","2.21","22.63","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","16.43","53","","15.90","15.90","15.90","1 through 10","2.21","22.63","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","22.63","73","","17.16","17.16","17.16","1 through 10","2.21","22.63","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","both","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","13.78","44.45","","23.06","23.06","23.06","1 through 10","2.21","22.63","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","31.00","23.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","18.38","59.3","","17.58","17.58","17.58","61","2.31","24.32","percent of total billed charges",""
"Urinalysis Auto W/O Micro","PX-30001376","CDM","81003","CPT","0307","RC","","","","outpatient","","","31.00","23.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","24.32","78.45","","23.06","13.67","23.06","58","2.31","24.32","percent of total billed charges",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","49622.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","24090.89","","Standard inlier is a Case rate ($24,090.89). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,419.80) for the length of stay and the standard reimbursement.","24090.89","24090.89","24090.89","1 through 10","4561.47","68276.67","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MAJOR","465","DRG","","","","","","","","inpatient","","","49622.81","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","25878.42","","Standard inlier is a Case rate ($25,878.42). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $36,362, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,673.33) for the length of stay and the standard reimbursement.","24702.12","24702.12","24702.12","1 through 10","4561.47","68276.67","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","23458.40","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","15637.13","","Standard inlier is a Case rate ($15,637.13). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $26,581, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,219.62) for the length of stay and the standard reimbursement.","15637.12","15637.12","15637.12","1 through 10","4561.47","68276.67","case rate",""
"Urinary Stones And Acquired Upper Urinary Tract Obstruction,MODERATE","465","DRG","","","","","","","","inpatient","","","23458.40","","MASSHEALTH [3001]","HB BWF MEDICAID","4561.47","","Case rate ($5,043.49). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $47,473.49, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","5042.25","5042.25","5042.25","1 through 10","4561.47","68276.67","case rate",""
"Urinary Stones With McC","693","MS-DRG","","","","","","","","inpatient","","","19880.16","14910.12","MEDICARE [2001]","HB BWF MEDICARE","13902.24","","Case rate ($13,902.24). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $12,738.85, add-ons for qualifying new technology services are included. If operating cost exceeds $58,262.58 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,511.28, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 3.7. The base transfer operating payment is the transfer adjustment factor * $12,612.51 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $12,399.62 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $950.51. The transfer capital threshold is the transfer adjustment factor * $950.51. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14773.43","0.03","14773.43","1 through 10","12464.29","13902.24","other","Inpatient DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","24135.49","18101.62","MEDICARE [2001]","HB BWF MEDICARE","8224.86","","Case rate ($8,224.86). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,548.45, add-ons for qualifying new technology services are included. If operating cost exceeds $53,072.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,113.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $7,332.99 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,209.21 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $552.63. The transfer capital threshold is the transfer adjustment factor * $552.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8020.98","7968.60","8020.98","1 through 10","7385.99","8224.86","other","Inpatient DRG"
"Urinary Stones Without McC","694","MS-DRG","","","","","","","","inpatient","","","24135.49","18101.62","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","7385.99","","Case rate ($7,536.72). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $7,548.45, add-ons for qualifying new technology services are included. If operating cost exceeds $53,072.18 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,113.41, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.1. The base transfer operating payment is the transfer adjustment factor * $6,644.85 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $7,209.21 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $552.63. The transfer capital threshold is the transfer adjustment factor * $552.63. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","7213.98","7213.98","7213.98","1 through 10","7385.99","8224.86","other","Inpatient DRG"
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","AETNA [1001]","HB CH AETNA HMO / PPO","42.56","58.3","","40.26","40.26","40.26","51","8.44","53.29","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","42.56","58.3","","40.26","35.50","40.26","1 through 10","8.44","53.29","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","38.69","53","","37.63","37.63","37.63","15","8.44","53.29","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","53.29","73","","40.26","40.25","40.26","1 through 10","8.44","53.29","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.45","44.45","","54.58","32.35","54.58","1 through 10","8.44","53.29","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","both","","","73.00","54.75","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","32.45","44.45","","32.35","32.35","32.35","1 through 10","8.44","53.29","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","73.00","54.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","43.29","59.3","","124.83","41.61","124.83","98","6.52","57.27","percent of total billed charges",""
"Urine Pregnancy Visual","PX-30001381","CDM","81025","CPT","0307","RC","","","","outpatient","","","73.00","54.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","57.27","78.45","","54.58","32.35","54.58","41","6.52","57.27","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","423.04","423.04","423.04","1 through 10","112.51","602.98","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","268.90","282.40","1 through 10","112.51","602.98","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","124.52","126.29","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","146","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","119.09","125.26","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","602.98","other","Tricare OPPS"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","91.81","125.76","1 through 10","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","367.16","44.45","","617.35","617.35","617.35","1 through 10","112.51","602.98","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","both","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","126.29","54","112.51","602.98","other","OPPS APC"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","56","112.51","648","other","Multiple Imaging"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","95","112.51","648","other","Multiple Imaging"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","489.82","59.3","","470.56","470.56","1411.68","14","112.51","648","percent of total billed charges",""
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","38","112.51","648","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","134.45","268.90","1 through 10","112.51","648","other","Multiple Radiology"
"US Abdomen Cmpl","PX-40000032","CDM","76700","CPT","0402","RC","","","","outpatient","","","826.00","619.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","648.00","78.45","","617.35","365.85","617.35","16","112.51","648","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","118.07","118.07","118.07","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","320.65","1 through 10","112.51","486.91","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","363.99","19","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","486.91","other","Tricare OPPS"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.55","123.76","125.76","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","296.48","44.45","","498.95","498.95","498.95","1 through 10","112.51","486.91","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","both","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","118.07","126.29","18","112.51","486.91","other","OPPS APC"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","523.26","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","99.71","199.42","17","112.51","523.26","other","Multiple Imaging"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","395.53","59.3","","380.31","380.31","380.31","1 through 10","112.51","523.26","percent of total billed charges",""
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","13","112.51","523.26","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","523.26","other","Multiple Radiology"
"US Abdomen Ltd","PX-40000033","CDM","76705","CPT","0402","RC","","","","outpatient","","","667.00","500.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","523.26","78.45","","498.95","295.68","498.95","1 through 10","112.51","523.26","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","357.02","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","20","112.51","357.02","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","123.76","1 through 10","112.51","357.02","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","117.59","117.59","117.59","1 through 10","112.51","357.02","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.76","123.77","1 through 10","112.51","357.02","other","OPPS APC"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","both","","","383.00","287.25","WELLPOINT [1015]","HB CH WELLPOINT","298.40","77.91","","292.99","292.99","292.99","1 through 10","112.51","357.02","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","436.15","other","Multiple Imaging"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","99.71","199.42","1 through 10","112.51","436.15","other","Multiple Imaging"
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","227.12","59.3","","217.99","217.99","217.99","1 through 10","112.51","436.15","percent of total billed charges",""
"US Abdominal Aorta Real Time Screen Study Aaa","PX-40000148","CDM","76706","CPT","0402","RC","","","","outpatient","","","383.00","287.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","118.07","118.07","118.07","1 through 10","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","320.65","1 through 10","53.78","360.14","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.52","124.52","124.52","1 through 10","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","363.99","19","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","53.78","360.14","other","Tricare OPPS"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.55","123.76","125.76","1 through 10","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","53.78","44.45","","498.95","498.95","498.95","1 through 10","53.78","360.14","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","both","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","118.07","126.29","18","53.78","360.14","other","OPPS APC"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","60.5","436.15","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","99.71","199.42","17","60.5","436.15","other","Multiple Imaging"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","71.75","59.3","","380.31","380.31","380.31","1 through 10","60.5","436.15","percent of total billed charges",""
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","13","60.5","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","60.5","436.15","other","Multiple Radiology"
"US Abdominal Real Time W/Image Limited","PX-98301180","CDM","76705","CPT","0983","RC","","","","outpatient","","","121.00","90.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.92","78.45","","498.95","295.68","498.95","1 through 10","60.5","436.15","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","AETNA [1001]","HB CH AETNA HMO / PPO","181.31","58.3","","171.23","171.23","171.23","1 through 10","62.3","231.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","ELDER SERVICES [1037]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","62.3","231.74","other","OPPS APC"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","156.37","150.14","312.74","13","62.3","231.74","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","138.24","44.45","","209.00","209.00","209.00","1 through 10","62.3","231.74","percent of total billed charges",""
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","both","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","102.89","33","62.3","231.74","other","OPPS APC"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","213.06","213.06","213.06","1 through 10","62.3","283.67","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","62.30","","Case rate ($62.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","417.55","143.29","478.06","1 through 10","62.3","283.67","other","Multiple Radiology"
"US Breast Uni Real Time With Image Limited","PX-40000140","CDM","76642","CPT","0402","RC","","","","outpatient","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","243.98","78.45","","464.36","175.12","464.36","1 through 10","62.3","283.67","percent of total billed charges",""
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","112.51","360.14","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","125.76","125.76","1 through 10","112.51","360.14","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","both","","","423.00","317.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","63.15","63.15","63.15","1 through 10","112.51","360.14","other","OPPS APC"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","331.84","other","Multiple Imaging"
"US Chest","PX-40000030","CDM","76604","CPT","0402","RC","","","","outpatient","","","423.00","317.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","331.84","other","Multiple Radiology"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","AETNA [1001]","HB CH AETNA HMO / PPO","304.91","58.3","","288.60","288.60","288.60","1 through 10","119.97","423.04","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","423.04","other","Tricare OPPS"
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","both","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","232.47","44.45","","391.32","391.32","391.32","1 through 10","119.97","423.04","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","523.00","392.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","310.14","59.3","","298.27","298.27","298.27","11","199.42","436.15","percent of total billed charges",""
"US Fetal Biophysical Profile W/O","PX-40000050","CDM","76819","CPT","0402","RC","","","","outpatient","","","523.00","392.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","410.29","78.45","","391.32","231.90","391.32","13","199.42","436.15","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","533.00","399.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","316.07","59.3","","303.55","303.55","303.55","1 through 10","199.42","418.14","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","236.92","44.45","","398.24","398.24","398.24","1 through 10","199.42","418.14","percent of total billed charges",""
"US Fetal Doppler Velocimerty Umbil","PX-40000051","CDM","76820","CPT","0402","RC","","","","outpatient","","","533.00","399.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.14","78.45","","398.24","398.24","398.24","1 through 10","199.42","418.14","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","both","","","422.00","316.50","AETNA [1001]","HB CH AETNA HMO / PPO","246.03","58.3","","232.47","232.47","232.47","1 through 10","223.66","422","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","422.00","316.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","250.25","59.3","","480.52","240.26","480.52","1 through 10","187.58","331.06","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","187.58","44.45","","315.21","315.21","315.21","1 through 10","187.58","331.06","percent of total billed charges",""
"US Guidance Intraoperative","PX-40000085","CDM","76998","CPT","0402","RC","","","","outpatient","","","422.00","316.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","331.06","78.45","","315.21","186.80","315.21","1 through 10","187.58","331.06","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","726.00","544.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","617.10","85","","83.21","83.21","83.21","1 through 10","261.88","726","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","both","","","726.00","544.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","726.00","100","","106.95","106.95","106.95","1 through 10","261.88","726","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","726.00","544.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","430.52","59.3","","1441.57","1441.57","1441.57","1 through 10","363","569.55","percent of total billed charges",""
"US Guided Needle Placement","PX-40000074","CDM","76942","CPT","0402","RC","","","","outpatient","","","726.00","544.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","569.55","78.45","","542.77","321.65","542.77","1 through 10","363","569.55","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","124.02","53","","120.84","120.84","120.84","1 through 10","104.01","234","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","198.90","85","","72.39","72.39","72.39","1 through 10","104.01","234","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","both","","","234.00","175.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","234.00","100","","70.28","70.28","70.28","1 through 10","104.01","234","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","234.00","175.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","138.76","59.3","","133.61","133.61","133.61","1 through 10","117","183.57","percent of total billed charges",""
"US Guided Vascular Access","PX-40000071","CDM","76937","CPT","0402","RC","","","","outpatient","","","234.00","175.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","183.57","78.45","","175.29","175.29","175.29","1 through 10","117","183.57","percent of total billed charges",""
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","782.00","586.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","570.86","other","OPPS APC"
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","both","","","782.00","586.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","570.86","other","OPPS APC"
"US Kidney Transplant With Doppler","PX-40000036","CDM","76776","CPT","0402","RC","","","","outpatient","","","782.00","586.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","613.48","other","Multiple Imaging"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","318.00","238.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"US Lmtd Jt/Fcl Eval Nonvasc Xtr Strux R-T W/Img","PX-40000065","CDM","76882","CPT","0402","RC","","","","both","","","318.00","238.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","123.97","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.37","125.37","125.37","1 through 10","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","423.04","1 through 10","112.51","557.72","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","141.20","141.20","282.40","1 through 10","112.51","557.72","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","404.92","53","","382.13","382.13","382.13","1 through 10","112.51","557.72","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","68","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","557.72","other","Tricare OPPS"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","both","","","764.00","573.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","126.24","24","112.51","557.72","other","OPPS APC"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","95","112.51","599.36","other","Multiple Imaging"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","142","112.51","599.36","other","Multiple Imaging"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","453.05","59.3","","435.40","435.40","2224.02","22","112.51","599.36","percent of total billed charges",""
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","128.26","128.26","256.52","1 through 10","112.51","599.36","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","134.45","134.45","134.45","1 through 10","112.51","599.36","other","Multiple Radiology"
"US Pelvis Non OB","PX-40000055","CDM","76856","CPT","0402","RC","","","","outpatient","","","764.00","573.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","599.36","78.45","","571.22","338.51","571.22","16","112.51","599.36","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","125.76","125.76","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","both","","","650.00","487.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.67","124.67","124.67","1 through 10","112.51","474.5","other","OPPS APC"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","509.93","other","Multiple Imaging"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","385.45","59.3","","370.35","370.35","370.35","1 through 10","112.51","509.93","percent of total billed charges",""
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","246.40","246.40","246.40","1 through 10","112.51","509.93","other","Multiple Radiology"
"US Pelvis Non OB Ltd","PX-40000056","CDM","76857","CPT","0402","RC","","","","outpatient","","","650.00","487.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","268.90","1 through 10","112.51","509.93","other","Multiple Radiology"
"US Pregnancy <14 Weeks Ea Add","PX-40000039","CDM","76802","CPT","0402","RC","","","","both","","","271.00","203.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","230.35","85","","61.85","61.85","61.85","1 through 10","135.5","271","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","AETNA [1001]","HB CH AETNA HMO / PPO","437.83","58.3","","413.91","413.91","413.91","1 through 10","112.51","548.23","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","271.15","141.20","282.40","1 through 10","112.51","548.23","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","both","","","751.00","563.25","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","548.23","other","Tricare OPPS"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","28","112.51","589.16","other","Multiple Imaging"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","48","112.51","589.16","other","Multiple Imaging"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","445.34","59.3","","427.78","427.78","427.78","1 through 10","112.51","589.16","percent of total billed charges",""
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","14","112.51","589.16","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","320.65","1 through 10","112.51","589.16","other","Multiple Radiology"
"US Pregnancy <14 Weeks Single","PX-40000038","CDM","76801","CPT","0402","RC","","","","outpatient","","","751.00","563.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","589.16","78.45","","561.22","332.59","561.22","1 through 10","112.51","589.16","percent of total billed charges",""
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","688.01","other","Multiple Imaging"
"US Pregnancy >14 Weeks Single","PX-40000040","CDM","76805","CPT","0402","RC","","","","outpatient","","","877.00","657.75","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","1 through 10","112.51","688.01","other","Multiple Imaging"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","AETNA [1001]","HB CH AETNA HMO / PPO","413.93","58.3","","391.23","391.23","391.23","1 through 10","112.51","518.3","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","423.04","1 through 10","112.51","518.3","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","1 through 10","112.51","518.3","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","both","","","710.00","532.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","315.60","44.45","","530.47","530.47","530.47","1 through 10","112.51","518.3","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","421.03","59.3","","404.34","404.34","1384.72","24","112.51","557","percent of total billed charges",""
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.53","256.52","769.56","29","112.51","557","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","134.45","320.65","16","112.51","557","other","Multiple Radiology"
"US Pregnancy Followup per Fetus","PX-40000047","CDM","76816","CPT","0402","RC","","","","outpatient","","","710.00","532.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","557.00","78.45","","530.47","314.36","530.47","16","112.51","557","percent of total billed charges",""
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","1 through 10","112.51","418.92","other","Multiple Radiology"
"US Pregnancy Ltd","PX-40000046","CDM","76815","CPT","0402","RC","","","","outpatient","","","534.00","400.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","418.92","78.45","","399.01","399.01","399.01","1 through 10","112.51","418.92","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","both","","","719.00","539.25","AETNA [1001]","HB CH AETNA HMO / PPO","419.18","58.3","","396.33","396.33","396.33","1 through 10","119.97","524.87","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","719.00","539.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","426.37","59.3","","409.61","409.61","409.61","1 through 10","199.42","564.06","percent of total billed charges",""
"US Pregnancy Nuchal Meas Sgl/1st","PX-40000044","CDM","76813","CPT","0402","RC","","","","outpatient","","","719.00","539.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","564.06","78.45","","537.39","318.46","537.39","11","199.42","564.06","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","both","","","602.00","451.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","439.46","other","Multiple Radiology"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","99.71","99.71","99.71","1 through 10","112.51","472.27","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","99.71","199.42","1 through 10","112.51","472.27","other","Multiple Imaging"
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","356.99","59.3","","342.81","342.81","342.81","1 through 10","112.51","472.27","percent of total billed charges",""
"US Pregnancy Transvaginal","PX-40000048","CDM","76817","CPT","0402","RC","","","","outpatient","","","602.00","451.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","160.33","134.45","160.33","1 through 10","112.51","472.27","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","21","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","308.28","320.65","1 through 10","112.51","580.35","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","1 through 10","112.51","580.35","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","235","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","119.09","125.26","1 through 10","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","252.58","1 through 10","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","580.35","other","Tricare OPPS"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","85.54","125.76","1 through 10","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","353.38","44.45","","594.28","352.18","594.28","1 through 10","112.51","580.35","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","both","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","119.99","126.29","60","112.51","580.35","other","OPPS APC"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","438.29","438.29","438.29","1 through 10","112.51","623.68","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","51","112.51","623.68","other","Multiple Imaging"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","80","112.51","623.68","other","Multiple Imaging"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","471.44","59.3","","452.98","452.98","452.98","13","112.51","623.68","percent of total billed charges",""
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","513.04","49","112.51","623.68","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","320.65","13","112.51","623.68","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","258.77","258.77","258.77","1 through 10","112.51","623.68","other","Multiple Radiology"
"US Retroperitioneal Cmpl","PX-40000034","CDM","76770","CPT","0402","RC","","","","outpatient","","","795.00","596.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","623.68","78.45","","594.28","352.18","1041.90","18","112.51","623.68","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","548.96","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","548.96","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","282.40","282.40","1 through 10","112.51","548.96","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","548.96","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","119.09","119.09","119.09","1 through 10","112.51","548.96","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","both","","","752.00","564.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","125.76","125.76","1 through 10","112.51","548.96","other","OPPS APC"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","AETNA [1001]","HB CH AETNA HMO / PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, 58.3% of billed. Procedures 2 - 9999, 29.15% of billed.","414.48","414.48","414.48","1 through 10","112.51","589.94","percent of total billed charges"," standard_charge|negotiated_dollar calculated as 0;"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","17","112.51","589.94","other","Multiple Imaging"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","35","112.51","589.94","other","Multiple Imaging"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","445.94","59.3","","428.37","428.37","428.37","1 through 10","112.51","589.94","percent of total billed charges",""
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","11","112.51","589.94","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","160.33","268.90","1 through 10","112.51","589.94","other","Multiple Radiology"
"US Scrotum","PX-40000057","CDM","76870","CPT","0402","RC","","","","outpatient","","","752.00","564.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","589.94","78.45","","561.99","561.99","561.99","1 through 10","112.51","589.94","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0400","RC","","","","inpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","497.02","70.6","","526.63","526.63","526.63","1 through 10","394.24","497.02","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","AETNA [1001]","HB CH AETNA HMO / PPO","410.43","58.3","","388.40","388.40","388.40","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","118.07","125.72","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","320.65","320.65","320.65","1 through 10","112.51","513.92","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","271.15","282.40","11","112.51","513.92","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","373.12","53","","363.05","363.05","363.05","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","MARTIN'S POINT [160007]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.14","124.14","124.14","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","194","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","125.26","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","751.68","250.74","751.68","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","513.92","other","Tricare OPPS"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","125.76","125.76","1 through 10","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","312.93","44.45","","526.63","526.63","526.63","1 through 10","112.51","513.92","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","both","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","119.99","126.29","66","112.51","513.92","other","OPPS APC"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","70","112.51","552.29","other","Multiple Imaging"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","199.42","199.42","199.42","133","112.51","552.29","other","Multiple Imaging"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","417.47","59.3","","401.41","401.41","738.46","22","112.51","552.29","percent of total billed charges",""
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","256.52","256.52","40","112.51","552.29","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","268.90","806.70","17","112.51","552.29","other","Multiple Radiology"
"US Soft Tissue Head/Neck","PX-40000029","CDM","76536","CPT","0402","RC","","","","outpatient","","","704.00","528.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","552.29","78.45","","526.63","312.09","526.63","15","112.51","552.29","percent of total billed charges",""
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2105.00","2105.00","2105.00","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","MEDICARE [2001]","HB BWF MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Complete","PX-92000183","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","29.95","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","2105.00","2105.00","2105.00","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","MEDICARE [2001]","HB BWF MEDICARE","29.08","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","29.08","29.08","29.08","1 through 10","27.63","1686.75","other","OPPS APC"
"US Temporal Artery Limited","PX-92000184","CDM","93998","CPT","0921","RC","","","","both","","","2165.00","1623.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","28.50","","APC Price ($29.08). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","28.50","28.50","28.50","1 through 10","27.63","1686.75","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 285%, 142.5 procedures at 0%.","160.33","160.33","211.52","1 through 10","112.51","419.02","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 251%, 125.5 procedures at 0%.","282.40","141.20","282.40","1 through 10","112.51","419.02","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","304.22","53","","287.26","287.26","287.26","1 through 10","112.51","419.02","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","70","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","125.26","125.26","125.26","1 through 10","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","112.51","419.02","other","Tricare OPPS"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","125.76","125.76","125.76","1 through 10","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","both","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","126.29","24","112.51","419.02","other","OPPS APC"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","99.71","99.71","99.71","102","112.51","450.3","other","Multiple Imaging"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","199.42","","Case rate ($199.42). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 50 procedures at 0%.","99.71","99.71","99.71","152","112.51","450.3","other","Multiple Imaging"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","340.38","59.3","","326.99","326.99","1670.26","23","112.51","450.3","percent of total billed charges",""
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 228%, 114 procedures at 0%.","256.52","246.40","256.52","59","112.51","450.3","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","112.51","","Case rate ($112.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 239%, 119.5 procedures at 0%.","268.90","258.77","268.90","13","112.51","450.3","other","Multiple Radiology"
"US Transvaginal","PX-40000053","CDM","76830","CPT","0402","RC","","","","outpatient","","","574.00","430.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","450.30","78.45","","428.99","254.22","428.99","17","112.51","450.3","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","both","","","221.00","165.75","AETNA [1001]","HB CH AETNA HMO / PPO","128.84","58.3","","121.91","121.91","121.91","1 through 10","18.27","161.33","percent of total billed charges",""
"Ustekinumab Drug Level","PX-30003524","CDM","80299","CPT","0301","RC","","","","outpatient","","","221.00","165.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","173.37","78.45","","165.29","165.29","165.29","1 through 10","14.12","173.37","percent of total billed charges",""
"Vancomycin","PX-30000192","CDM","80202","CPT","0301","RC","","","","both","","","149.00","111.75","AETNA [1001]","HB CH AETNA HMO / PPO","86.87","58.3","","82.22","82.22","82.22","1 through 10","13.27","108.77","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","151.00","113.25","AETNA [1001]","HB CH AETNA HMO / PPO","88.03","58.3","","83.35","83.35","83.35","22","12.62","110.23","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","both","","","151.00","113.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","110.23","73","","124.95","124.95","124.95","1 through 10","12.62","110.23","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","151.00","113.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","89.54","59.3","","86.14","86.14","258.42","21","13.29","118.46","percent of total billed charges",""
"Varicella-Zoster Antibody","PX-30001005","CDM","86787","CPT","0302","RC","","","","outpatient","","","151.00","113.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","118.46","78.45","","113.01","66.97","234.12","18","13.29","118.46","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","AETNA [1001]","HB CH AETNA HMO / PPO","90.37","58.3","","85.62","85.62","171.24","103","16.92","113.15","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","82.15","53","","80.03","80.03","80.03","1 through 10","16.92","113.15","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","both","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.90","44.45","","67.80","67.80","67.80","1 through 10","16.92","113.15","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","inpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","109.43","70.6","","232.18","232.18","232.18","1 through 10","86.8","109.43","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","353.95","74","13.35","121.6","percent of total billed charges",""
"Vasc Endthl Grwth Factr 83520","PX-30003304","CDM","83520","CPT","0300","RC","","","","outpatient","","","155.00","116.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","121.60","78.45","","116.09","66.39","116.09","106","13.35","121.6","percent of total billed charges",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","both","","","4872.00","3654.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","","","Payment is accumulated by procedure count, in order of descending billed amounts. Procedure 1, Per diem ($2,216). Procedure 2, Per diem ($1,108). Procedures 3 - 9999, Per diem ($554).","2216.00","2216.00","2216.00","1 through 10","1565.78","3795.78","per diem",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","both","","","4872.00","3654.00","WELLPOINT [1015]","HB CH WELLPOINT","3795.78","77.91","","6511.88","6511.88","6511.88","1 through 10","1565.78","3795.78","percent of total billed charges",""
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","4872.00","3654.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.4%, 72.2 procedures at 0%.","2872.84","2872.84","2872.84","1 through 10","1565.78","3822.08","other","ASC "
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","4872.00","3654.00","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","1989.50","","Case rate ($1,989.50). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 144.6%, 72.3 procedures at 0%.","2817.13","2817.13","2817.13","1 through 10","1565.78","3822.08","other","ASC "
"Vasectomy Semen Exam Postop","PX-76001320","CDM","55250","CPT","0761","RC","","","","outpatient","","","4872.00","3654.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3822.08","78.45","","8123.14","3766.90","8123.14","1 through 10","1565.78","3822.08","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","both","","","355.00","266.25","AETNA [1001]","HB CH AETNA HMO / PPO","206.97","58.3","","121.91","121.91","121.91","1 through 10","18.27","259.15","percent of total billed charges",""
"Vedolizumab Level","PX-31000867","CDM","80299","CPT","0301","RC","","","","outpatient","","","355.00","266.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","278.50","78.45","","165.29","165.29","165.29","1 through 10","14.12","278.5","percent of total billed charges",""
"Veeg by Tech 2-12 Hours Unmonitored","PX-74000064","CDM","95711","CPT","0740","RC","","","","both","","","2715.00","2036.25","AETNA [1001]","HB CH AETNA HMO / PPO","1582.85","58.3","","1496.88","1496.88","1496.88","1 through 10","351.32","2115.26","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","3171.00","2378.25","AETNA [1001]","HB CH AETNA HMO / PPO","1848.69","58.3","","1748.06","1748.06","1748.06","1 through 10","598.61","2470.53","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","3171.00","2378.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","617.52","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","620.04","620.04","620.04","1 through 10","598.61","2470.53","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","3171.00","2378.25","MEDICARE [2001]","HB BWF MEDICARE","630.12","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","630.12","584.98","630.12","20","598.61","2470.53","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","3171.00","2378.25","TRICARE [160005]","HB BWF TRICARE","598.61","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","598.61","598.61","598.61","1 through 10","598.61","2470.53","other","Tricare OPPS"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","3171.00","2378.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","617.52","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","620.04","620.04","620.04","1 through 10","598.61","2470.53","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","both","","","3171.00","2378.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","617.52","","APC Price ($630.12). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","620.04","620.04","620.04","1 through 10","598.61","2470.53","other","OPPS APC"
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","outpatient","","","3171.00","2378.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1880.40","59.3","","1806.64","1806.64","1806.64","1 through 10","768.5","2487.65","percent of total billed charges",""
"Veeg by Tech Ea Incr 12-26 Hr Unmonitored","PX-74000067","CDM","95714","CPT","0740","RC","","","","outpatient","","","3171.00","2378.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2487.65","78.45","","2370.21","1404.61","2370.21","1 through 10","768.5","2487.65","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","AETNA [1001]","HB CH AETNA HMO / PPO","9.33","58.3","","9.07","9.07","9.07","82","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","11.68","73","","11.68","11.68","11.68","1 through 10","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","9.33","58.3","","9.07","9.07","9.07","1 through 10","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","8.48","53","","8.48","8.48","8.48","1 through 10","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","11.68","73","","9.15","9.07","11.68","1 through 10","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.11","44.45","","12.30","7.18","12.30","14","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","both","","","16.00","12.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","7.11","44.45","","7.29","7.29","7.29","1 through 10","7.11","11.68","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","9.49","59.3","","9.38","9.34","9.38","22","8","12.75","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","12.55","78.45","","12.30","12.14","12.30","1 through 10","8","12.75","percent of total billed charges",""
"Venipuncture","PX-30000003","CDM","36415","CPT","0300","RC","","","","outpatient","","","16.00","12.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","12.55","78.45","","12.30","7.29","12.30","503","8","12.75","percent of total billed charges",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MAJOR","310","DRG","","","","","","","","inpatient","","","40521.79","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","46975.24","","Fee schedule rate ($46,975.24). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","46975.24","46975.24","46975.24","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","26584.07","","Standard inlier is a Case rate ($26,584.07). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($3,773.71) for the length of stay and the standard reimbursement.","25376.04","25376.04","25376.04","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","28556.59","","Standard inlier is a Case rate ($28,556.59). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($4,053.49) for the length of stay and the standard reimbursement.","28556.58","28556.58","28556.58","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16573.5702","","Fee schedule rate ($16,573.57). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16573.5702","16573.58","16573.58","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","17402.1639","","Fee schedule rate ($17,402.16). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","17402.1639","16731.32","16731.32","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","18230.76","","Fee schedule rate ($18,230.76). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","18230.76","18230.76","18230.76","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","28376.48","","Fee schedule rate ($28,376.48). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","28376.48","28376.48","28376.48","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MINOR","310","DRG","","","","","","","","inpatient","","","37007.47","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","9727.25","","Case rate ($10,755.14). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $53,185.14, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","10752.50","10752.50","10752.50","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","32512.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","35840.93","","Standard inlier is a Case rate ($35,840.93). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $38,920, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,087.76) for the length of stay and the standard reimbursement.","35840.93","35840.93","35840.93","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","32512.54","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","38500.31","","Standard inlier is a Case rate ($38,500.31). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $48,416, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($5,464.96) for the length of stay and the standard reimbursement.","36750.29","36750.29","36750.29","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","32512.54","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","16573.5702","","Fee schedule rate ($23,774.80). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","16573.5702","23774.80","23774.80","1 through 10","9727.25","72439.37","case rate",""
"Vertebral And Intervertebral Spinal Procedures Including Disc Procedures,MODERATE","310","DRG","","","","","","","","inpatient","","","32512.54","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","13916.30","","Case rate ($15,386.86). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $57,816.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","15383.09","15383.09","15383.09","1 through 10","9727.25","72439.37","case rate",""
"Vertigo And Other Labyrinth Disorders,MAJOR","111","DRG","","","","","","","","inpatient","","","25629.28","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","18141.10","","Standard inlier is a Case rate ($18,141.10). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,257, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,575.20) for the length of stay and the standard reimbursement.","18141.10","18141.10","18141.10","1 through 10","4681.42","23709.01","case rate",""
"Vertigo And Other Labyrinth Disorders,MAJOR","111","DRG","","","","","","","","inpatient","","","25629.28","","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","19287.85","","Fee schedule rate ($19,287.85). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($51,248), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","6779.00","6779.00","6779.00","1 through 10","4681.42","23709.01","case rate",""
"Vertigo And Other Labyrinth Disorders,MAJOR","111","DRG","","","","","","","","inpatient","","","25629.28","","MGB HEALTH PLAN [150001]","HB BWF MGBHP MEDICAID","6842.77","","Case rate ($7,565.86). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,995.86, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","7564.00","7564.00","7564.00","1 through 10","4681.42","23709.01","case rate",""
"Vfc Admin Hepatitis B Vaccine","PX-77100026","CDM","G0010","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","51.85","51.85","51.85","1 through 10","9.87","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","56.44","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","53.35","53.35","53.35","1 through 10","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","50.81","50.81","50.81","1 through 10","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWF MEDICARE","54.79","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.70","54.79","207.40","16","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","161.07","53.69","161.07","1 through 10","10.22","147.35","other","OPPS APC"
"Vfc Admin Influenza Virus Vac","PX-77100024","CDM","G0008","HCPCS","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","53.70","","APC Price ($54.79). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","53.69","50.82","54.79","1 through 10","10.22","147.35","other","OPPS APC"
"Vfc Admin Pneumococcal Vaccine","PX-77100025","CDM","G0009","HCPCS","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","60.44","","APC Price ($58.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","56.38","56.38","56.38","1 through 10","9.87","147.35","other","OPPS APC"
"Vfc Im Admn Sarscov2 Vaccine Sngl Dose","PX-77100076","CDM","90480","CPT","0771","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","48.32","","APC Price ($49.30). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","46.61","46.61","46.61","1 through 10","9.87","145.84","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","18.14","18.14","18.14","1 through 10","10.22","232.43","percent of total billed charges",""
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","40.90","40.90","40.90","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Imadm Prq ID Subq/Im Njxs 1 Vaccine","PX-77100020","CDM","90471","CPT","0771","RC","","","","outpatient","","","23.00","17.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.64","59.3","","73.20","36.60","73.20","1 through 10","11.5","154.78","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","87.05","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.","87.33","79.12","87.33","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","AETNA [1001]","HB CH AETNA HMO / PPO","13.41","58.3","","125.31","125.31","250.62","1 through 10","10.22","232.43","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","83.17","83.17","83.17","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.00","25.00","25.00","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","83.17","75.35","83.17","22","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","ELDER SERVICES [1037]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","10.79","10.79","10.79","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MEDICARE [2001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","84.52","76.89","253.56","525","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","84.52","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","82.83","82.83","82.83","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","TRICARE [160005]","HB BWF TRICARE","80.29","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","80.29","80.29","80.29","1 through 10","10.22","232.43","other","Tricare OPPS"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","82.83","21.58","82.83","1 through 10","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","both","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","82.83","","APC Price ($84.52). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","84.52","75.66","84.52","67","10.22","232.43","other","OPPS APC"
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","13.64","59.3","","129.51","129.51","129.51","1 through 10","11.5","204.65","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","13.64","59.3","","129.48","129.48","129.48","1 through 10","11.5","204.65","percent of total billed charges",""
"Vfc Therapeutic Prophylactic/Diagnostic Inj Sc/Im","PX-26000023","CDM","96372","CPT","0260","RC","","","","outpatient","","","23.00","17.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","18.04","78.45","","169.90","100.69","169.90","12","11.5","204.65","percent of total billed charges",""
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","25367.34","19025.50","AETNA [1001]","HB BWF AETNA MEDICARE REPLACEMENT","14558.82","","Case rate ($14,134.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,157.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,681.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,620.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,736.31 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,818.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.24. The transfer capital threshold is the transfer adjustment factor * $1,059.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 103%.","14108.81","14108.81","14108.81","1 through 10","13852.08","15453.75","other","Inpatient DRG"
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","25367.34","19025.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","13852.08","","Case rate ($14,134.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,157.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,681.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,620.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,736.31 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,818.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.24. The transfer capital threshold is the transfer adjustment factor * $1,059.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13406.90","13406.90","13406.90","1 through 10","13852.08","15453.75","other","Inpatient DRG"
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","25367.34","19025.50","MEDICARE [2001]","HB BWF MEDICARE","15453.75","","Case rate ($15,453.75). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,157.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,681.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,620.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $14,055.28 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,818.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.24. The transfer capital threshold is the transfer adjustment factor * $1,059.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","14827.74","14827.74","14926.72","1 through 10","13852.08","15453.75","other","Inpatient DRG"
"Viral Illness With McC","865","MS-DRG","","","","","","","","inpatient","","","25367.34","19025.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","13852.08","","Case rate ($14,134.78). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $14,157.27, add-ons for qualifying new technology services are included. If operating cost exceeds $59,681.00 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,620.01, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 4. The base transfer operating payment is the transfer adjustment factor * $12,736.31 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $13,818.03 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,059.24. The transfer capital threshold is the transfer adjustment factor * $1,059.24. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","13369.79","13369.79","13369.79","1 through 10","13852.08","15453.75","other","Inpatient DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","28994.23","21745.67","MEDICARE [2001]","HB BWF MEDICARE","8346.06","","Case rate ($8,346.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,359.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,882.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,175.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,392.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,019.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.77. The transfer capital threshold is the transfer adjustment factor * $614.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","8989.81","8989.81","9049.15","1 through 10","8179.14","8749.7872","other","Inpatient Replacement Plans DRG"
"Viral Illness Without McC","866","MS-DRG","","","","","","","","inpatient","","","28994.23","21745.67","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","8179.14","","Case rate ($8,346.06). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $8,359.10, add-ons for qualifying new technology services are included. If operating cost exceeds $53,882.83 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,175.56, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 2.7. The base transfer operating payment is the transfer adjustment factor * $7,392.04 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $8,019.86 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $614.77. The transfer capital threshold is the transfer adjustment factor * $614.77. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","8147.28","8147.28","8147.28","1 through 10","8179.14","8749.7872","other","Inpatient DRG"
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","29453.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8680.7615","","Standard inlier is a Case rate ($18,584.82). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,714, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,638.19) for the length of stay and the standard reimbursement.","8680.7615","18584.82","18584.82","1 through 10","6031.69","44642.65","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","29453.47","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS PPO","9324.8694","","Standard inlier is a Case rate ($19,963.81). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $30,714, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($2,833.78) for the length of stay and the standard reimbursement.","9324.8694","19963.80","19963.80","1 through 10","6031.69","44642.65","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","29453.47","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","8414.7852","","Fee schedule rate ($18,840.44). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","8414.7852","18840.44","18840.44","1 through 10","6031.69","44642.65","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","29453.47","","MASSHEALTH [3001]","HB BWF MEDICAID","8685.41","","Case rate ($9,603.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,033.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9600.86","9600.86","9600.86","1 through 10","6031.69","44642.65","case rate",""
"Viral Illness,MAJOR","723","DRG","","","","","","","","inpatient","","","29453.47","","WELLSENSE [1003]","HB BWF WELLSENSE MCO","8685.41","","Case rate ($9,603.21). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $52,033.21, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","9600.86","9600.86","9600.86","1 through 10","6031.69","44642.65","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","22520.44","","BLUE CROSS BLUE SHIELD [110001]","HB CH BLUE CROSS HMO","8680.7615","","Standard inlier is a Case rate ($12,384.98). If the cost, defined as total billed multiplied by the cost-to-charge ratio of 0.2802, exceeds the outlier threshold of $20,554, the excess is included in the final reimbursement as an outlier payment. For transfer scenarios, the final reimbursement is the lesser of the Per diem ($1,758.10) for the length of stay and the standard reimbursement.","8680.7615","12384.97","12384.97","1 through 10","6031.69","44642.65","case rate",""
"Viral Illness,MODERATE","723","DRG","","","","","","","","inpatient","","","22520.44","","MASSHEALTH [3001]","HB BWF MEDICAID","6031.69","","Case rate ($6,669.07). If cost, defined as total billed times cost-to-charge ratio (0.4262), exceeds outlier threshold $49,099.07, an outlier payment of 60% of the excess amount is included. For transfer scenarios, reimbursement is the lesser of a per diem of $0.00 and the sum of the standard inlier and any outlier amount.","6667.43","6667.43","6667.43","1 through 10","6031.69","44642.65","case rate",""
"Viral Meningitis With Cc/McC","075","MS-DRG","","","","","","","","inpatient","","","43053.84","32290.38","MEDICARE [2001]","HB BWF MEDICARE","17994.56","","Case rate ($17,994.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,023.33, add-ons for qualifying new technology services are included. If operating cost exceeds $63,547.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,916.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $16,299.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,684.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,355.60. The transfer capital threshold is the transfer adjustment factor * $1,355.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","17262.28","17262.28","17262.28","1 through 10","17032.8136","18534.4","other","Inpatient Replacement Plans DRG"
"Viral Meningitis With Cc/McC","075","MS-DRG","","","","","","","","inpatient","","","43053.84","32290.38","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","17634.67","","Case rate ($17,994.56). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $18,023.33, add-ons for qualifying new technology services are included. If operating cost exceeds $63,547.06 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $3,916.38, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $16,299.72 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $17,684.09 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $1,355.60. The transfer capital threshold is the transfer adjustment factor * $1,355.60. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","18212.80","18212.80","18212.80","1 through 10","17032.8136","18534.4","other","Inpatient DRG"
"Viral Meningitis,MAJOR","051","DRG","","","","","","","","inpatient","","","24627.78","","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","11830.7268","","Fee schedule rate ($22,732.15). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.736), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($93,140), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","11830.7268","81934.68","81934.68","1 through 10","6436.55","37507.85","case rate",""
"Viral Meningitis,MODERATE","051","DRG","","","","","","","","inpatient","","","61215.10","","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","7950.64","","Fee schedule rate ($7,950.64). If the estimated cost, defined as the billed amount multiplied by the cost-to-charge ratio (0.2688), exceeds an outlier threshold, defined as the inlier reimbursement plus a stop loss amount ($25,246), then an outlier payment applies. The outlier payment equals the excess of the estimated cost over the outlier threshold, multiplied by the marginal cost factor (1). Otherwise, no outlier payment applies.","7950.64","7950.64","7950.64","1 through 10","6436.55","37507.85","case rate",""
"Virus Not Elsewhere Specified","PX-30001009","CDM","86790","CPT","0302","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","75.99","percent of total billed charges",""
"Virus Not Elsewhere Specified","PX-30001446","CDM","86790","CPT","0302","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","75.99","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","both","","","137.00","102.75","AETNA [1001]","HB CH AETNA HMO / PPO","79.87","58.3","","75.41","75.41","75.41","1 through 10","11.38","100.01","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","137.00","102.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","81.24","59.3","","77.94","77.94","77.94","1 through 10","11.97","107.48","percent of total billed charges",""
"Vitamin A","PX-30000734","CDM","84590","CPT","0301","RC","","","","outpatient","","","137.00","102.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","107.48","78.45","","102.25","102.25","102.25","1 through 10","11.97","107.48","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","AETNA [1001]","HB CH AETNA HMO / PPO","100.86","58.3","","95.26","95.26","95.26","56","14.78","126.29","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.69","53","","89.04","89.04","89.04","1 through 10","14.78","126.29","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.29","73","","95.26","95.26","95.26","1 through 10","14.78","126.29","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","both","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","76.90","44.45","","129.16","75.43","129.16","1 through 10","14.78","126.29","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","173.00","129.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","295.35","59","15.43","135.72","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","173.00","129.75","INTERNATIONAL COMMERCIAL [140001]","HB CH CIGNA HMO / PPO","102.59","59.3","","98.45","98.45","98.45","1 through 10","15.43","135.72","percent of total billed charges",""
"Vitamin B-12 (Cyancobalamin)","PX-30000400","CDM","82607","CPT","0301","RC","","","","outpatient","","","173.00","129.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","135.72","78.45","","129.16","76.54","129.16","64","15.43","135.72","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","both","","","228.00","171.00","AETNA [1001]","HB CH AETNA HMO / PPO","132.92","58.3","","125.87","125.87","125.87","1 through 10","27.54","166.44","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","228.00","171.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","135.20","59.3","","130.09","130.09","130.09","1 through 10","28.01","178.87","percent of total billed charges",""
"Vitamin B-6 (Pyridoxal Phosphate)","PX-30000659","CDM","84207","CPT","0301","RC","","","","outpatient","","","228.00","171.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","178.87","78.45","","170.67","170.67","170.67","1 through 10","28.01","178.87","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","both","","","177.00","132.75","AETNA [1001]","HB CH AETNA HMO / PPO","103.19","58.3","","97.52","97.52","97.52","1 through 10","20.81","129.21","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","177.00","132.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.96","59.3","","100.79","100.79","100.79","1 through 10","21.89","138.86","percent of total billed charges",""
"Vitamin B1 (Thiamine)","PX-30000693","CDM","84425","CPT","0301","RC","","","","outpatient","","","177.00","132.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","138.86","78.45","","132.23","78.36","132.23","1 through 10","21.89","138.86","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","AETNA [1001]","HB CH AETNA HMO / PPO","203.47","58.3","","192.21","192.21","192.21","61","29.01","254.77","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","254.77","73","","247.47","192.21","247.47","1 through 10","29.01","254.77","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","both","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","155.13","44.45","","260.62","260.62","260.62","1 through 10","29.01","254.77","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","349.00","261.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","206.96","59.3","","198.65","198.65","198.65","50","30.54","273.79","percent of total billed charges",""
"Vitamin D 25 Hydroxy Inc Fraction","PX-30000334","CDM","82306","CPT","0301","RC","","","","outpatient","","","349.00","261.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","273.79","78.45","","260.62","154.45","260.62","56","30.54","273.79","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","both","","","120.00","90.00","AETNA [1001]","HB CH AETNA HMO / PPO","69.96","58.3","","66.34","66.34","66.34","1 through 10","13.9","87.6","percent of total billed charges",""
"Vitamin E","PX-30000703","CDM","84446","CPT","0301","RC","","","","outpatient","","","120.00","90.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","94.14","78.45","","53.31","53.31","53.31","1 through 10","14.61","94.14","percent of total billed charges",""
"Vitamin K","PX-30000736","CDM","84597","CPT","0301","RC","","","","outpatient","","","155.00","116.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","91.92","59.3","","88.49","88.49","88.49","1 through 10","14.14","121.6","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","84.48","84.48","84.48","1 through 10","11.81","145.5","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","both","","","153.00","114.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO NON PREFERRED B","110.31","72.1","","112.35","112.35","112.35","1 through 10","11.81","145.5","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","both","","","153.00","114.75","HARVARD PILGRIM ALTERNATE [120002]","HB CH HPHC ALLIANCE PPO PREFERRED B","97.00","63.4","","98.79","98.79","98.79","1 through 10","11.81","145.5","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","66.90","66.90","66.90","1 through 10","11.81","145.5","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","261.93","87.31","261.93","1 through 10","46.42","120.03","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","88.28","57.7","","89.85","89.85","269.55","1 through 10","46.42","120.03","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","153.00","114.75","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","92.57","60.5","","108.03","98.79","108.03","1 through 10","46.42","120.03","percent of total billed charges",""
"Voltage-Gated Calcium Channel Antibody Each","PX-30003773","CDM","86596","CPT","0302","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","114.55","67.88","114.55","1 through 10","46.42","120.03","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","554.95","91.85","1421.75","94","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","210.24","73","","2490.03","2490.03","2490.03","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","167.90","58.3","","750.00","750.00","750.00","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","152.64","53","","1192.50","120.84","4149.90","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","244.80","85","","750.00","75.00","750.00","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","288.00","100","","657.00","121.50","1971.00","14","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","288.00","100","","75.00","75.00","75.00","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","288.00","100","","366.00","144.00","1971.00","45","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","210.24","73","","667.50","667.50","667.50","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.02","44.45","","123.77","123.77","123.77","1 through 10","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","483.51","229.32","1316.08","96","128.02","288","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","439.50","225.34","1872.27","197","144","225.94","percent of total billed charges",""
"WASHER BABY GORILLA","SUP-ITM-10241789","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","385.32","55.36","1815.62","58","144","225.94","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","554.95","91.85","1421.75","94","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","2490.03","2490.03","2490.03","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","750.00","750.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","1192.50","120.84","4149.90","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","224.40","85","","750.00","75.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","264.00","100","","657.00","121.50","1971.00","14","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","264.00","100","","75.00","75.00","75.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","264.00","100","","366.00","144.00","1971.00","45","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","667.50","667.50","667.50","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","123.77","123.77","123.77","1 through 10","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","483.51","229.32","1316.08","96","117.35","264","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","439.50","225.34","1872.27","197","132","207.11","percent of total billed charges",""
"WASHER BONE 5.5MM SCREW CANNULATED THREADED SS PK/5EA","SUP-ITM-10002363","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","385.32","55.36","1815.62","58","132","207.11","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","AETNA [1001]","HB CH AETNA HMO / PPO","35.59","58.3","","554.95","91.85","1421.75","94","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","44.57","73","","2490.03","2490.03","2490.03","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","35.59","58.3","","750.00","750.00","750.00","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.36","53","","1192.50","120.84","4149.90","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","51.89","85","","750.00","75.00","750.00","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","61.05","100","","657.00","121.50","1971.00","14","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","61.05","100","","75.00","75.00","75.00","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","61.05","100","","366.00","144.00","1971.00","45","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","44.57","73","","667.50","667.50","667.50","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.14","44.45","","123.77","123.77","123.77","1 through 10","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.05","45.79","WELLPOINT [1015]","HB CH WELLPOINT","47.56","77.91","","483.51","229.32","1316.08","96","27.14","61.05","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.05","45.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.20","59.3","","439.50","225.34","1872.27","197","30.53","47.89","percent of total billed charges",""
"WASHER BONE 6.5X13MM","SUP-ITM-10004538","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.05","45.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","47.89","78.45","","385.32","55.36","1815.62","58","30.53","47.89","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","AETNA [1001]","HB CH AETNA HMO / PPO","38.18","58.3","","554.95","91.85","1421.75","94","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","47.81","73","","2490.03","2490.03","2490.03","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","38.18","58.3","","750.00","750.00","750.00","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","34.71","53","","1192.50","120.84","4149.90","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","55.67","85","","750.00","75.00","750.00","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","65.49","100","","657.00","121.50","1971.00","14","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","65.49","100","","75.00","75.00","75.00","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","65.49","100","","366.00","144.00","1971.00","45","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","47.81","73","","667.50","667.50","667.50","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","29.11","44.45","","123.77","123.77","123.77","1 through 10","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","both","","","65.49","49.12","WELLPOINT [1015]","HB CH WELLPOINT","51.02","77.91","","483.51","229.32","1316.08","96","29.11","65.49","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","65.49","49.12","CIGNA [1006]","HB CH CIGNA HMO / PPO","38.84","59.3","","439.50","225.34","1872.27","197","32.75","51.38","percent of total billed charges",""
"WASHER BONE 6.5X3MM SCREW CANNULATED SS","SUP-ITM-10002413","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","65.49","49.12","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","51.38","78.45","","385.32","55.36","1815.62","58","32.75","51.38","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","AETNA [1001]","HB CH AETNA HMO / PPO","31.71","58.3","","554.95","91.85","1421.75","94","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","39.70","73","","2490.03","2490.03","2490.03","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","31.71","58.3","","750.00","750.00","750.00","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","28.83","53","","1192.50","120.84","4149.90","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","46.23","85","","750.00","75.00","750.00","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","54.39","100","","657.00","121.50","1971.00","14","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","54.39","100","","75.00","75.00","75.00","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","54.39","100","","366.00","144.00","1971.00","45","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","39.70","73","","667.50","667.50","667.50","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","24.18","44.45","","123.77","123.77","123.77","1 through 10","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","both","","","54.39","40.79","WELLPOINT [1015]","HB CH WELLPOINT","42.38","77.91","","483.51","229.32","1316.08","96","24.18","54.39","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.39","40.79","CIGNA [1006]","HB CH CIGNA HMO / PPO","32.25","59.3","","439.50","225.34","1872.27","197","27.2","42.67","percent of total billed charges",""
"WASHER BONE 7MM SM SCREW CANNULATED SS","SUP-ITM-10004537","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","54.39","40.79","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","42.67","78.45","","385.32","55.36","1815.62","58","27.2","42.67","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","AETNA [1001]","HB CH AETNA HMO / PPO","61.85","58.3","","554.95","91.85","1421.75","94","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","77.45","73","","2490.03","2490.03","2490.03","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.85","58.3","","750.00","750.00","750.00","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","56.23","53","","1192.50","120.84","4149.90","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","90.18","85","","750.00","75.00","750.00","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","106.09","100","","657.00","121.50","1971.00","14","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","106.09","100","","75.00","75.00","75.00","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","106.09","100","","366.00","144.00","1971.00","45","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","77.45","73","","667.50","667.50","667.50","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","47.16","44.45","","123.77","123.77","123.77","1 through 10","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","both","","","106.09","79.57","WELLPOINT [1015]","HB CH WELLPOINT","82.65","77.91","","483.51","229.32","1316.08","96","47.16","106.09","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.09","79.57","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.91","59.3","","439.50","225.34","1872.27","197","53.05","83.23","percent of total billed charges",""
"WASHER CUP 3.5 TO 4.0MM SM TIMAX FRAGMENT SYSTEM SINGLE PK/3EA","SUP-ITM-10077575","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","106.09","79.57","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","83.23","78.45","","385.32","55.36","1815.62","58","53.05","83.23","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","AETNA [1001]","HB CH AETNA HMO / PPO","274.16","58.3","","554.95","91.85","1421.75","94","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","343.28","73","","2490.03","2490.03","2490.03","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","274.16","58.3","","750.00","750.00","750.00","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","249.23","53","","1192.50","120.84","4149.90","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","399.71","85","","750.00","75.00","750.00","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","470.25","100","","657.00","121.50","1971.00","14","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","470.25","100","","75.00","75.00","75.00","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","470.25","100","","366.00","144.00","1971.00","45","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","343.28","73","","667.50","667.50","667.50","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","209.03","44.45","","123.77","123.77","123.77","1 through 10","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","both","","","470.25","352.69","WELLPOINT [1015]","HB CH WELLPOINT","366.37","77.91","","483.51","229.32","1316.08","96","209.03","470.25","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.25","352.69","CIGNA [1006]","HB CH CIGNA HMO / PPO","278.86","59.3","","439.50","225.34","1872.27","197","235.13","368.91","percent of total billed charges",""
"WASHER DOME 7.0MM","SUP-ITM-10243330","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","470.25","352.69","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","368.91","78.45","","385.32","55.36","1815.62","58","235.13","368.91","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","554.95","91.85","1421.75","94","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","2490.03","2490.03","2490.03","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","750.00","750.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","1192.50","120.84","4149.90","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","224.40","85","","750.00","75.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","264.00","100","","657.00","121.50","1971.00","14","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","264.00","100","","75.00","75.00","75.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","264.00","100","","366.00","144.00","1971.00","45","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","667.50","667.50","667.50","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","123.77","123.77","123.77","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","483.51","229.32","1316.08","96","117.35","264","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","439.50","225.34","1872.27","197","132","207.11","percent of total billed charges",""
"WASHER HEADED 2.0MM","SUP-ITM-10243341","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","385.32","55.36","1815.62","58","132","207.11","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","AETNA [1001]","HB CH AETNA HMO / PPO","153.91","58.3","","554.95","91.85","1421.75","94","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","2490.03","2490.03","2490.03","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.91","58.3","","750.00","750.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.92","53","","1192.50","120.84","4149.90","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","224.40","85","","750.00","75.00","750.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","264.00","100","","657.00","121.50","1971.00","14","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","264.00","100","","75.00","75.00","75.00","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","264.00","100","","366.00","144.00","1971.00","45","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","192.72","73","","667.50","667.50","667.50","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","117.35","44.45","","123.77","123.77","123.77","1 through 10","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","both","","","264.00","198.00","WELLPOINT [1015]","HB CH WELLPOINT","205.68","77.91","","483.51","229.32","1316.08","96","117.35","264","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","156.55","59.3","","439.50","225.34","1872.27","197","132","207.11","percent of total billed charges",""
"WASHER HEADED 4.0MM","SUP-ITM-10243337","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","264.00","198.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","207.11","78.45","","385.32","55.36","1815.62","58","132","207.11","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","AETNA [1001]","HB CH AETNA HMO / PPO","106.72","58.3","","554.95","91.85","1421.75","94","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","133.63","73","","2490.03","2490.03","2490.03","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","106.72","58.3","","750.00","750.00","750.00","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","97.02","53","","1192.50","120.84","4149.90","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","155.60","85","","750.00","75.00","750.00","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","183.06","100","","657.00","121.50","1971.00","14","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","183.06","100","","75.00","75.00","75.00","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","183.06","100","","366.00","144.00","1971.00","45","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","133.63","73","","667.50","667.50","667.50","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","81.37","44.45","","123.77","123.77","123.77","1 through 10","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","both","","","183.06","137.29","WELLPOINT [1015]","HB CH WELLPOINT","142.62","77.91","","483.51","229.32","1316.08","96","81.37","183.06","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","CIGNA [1006]","HB CH CIGNA HMO / PPO","108.55","59.3","","439.50","225.34","1872.27","197","91.53","143.61","percent of total billed charges",""
"WASHER ORTHOPEDIC 2.4/2.7/3.5MM T8 T10 SCREW","SUP-ITM-10166605","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","183.06","137.29","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","143.61","78.45","","385.32","55.36","1815.62","58","91.53","143.61","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","AETNA [1001]","HB CH AETNA HMO / PPO","102.32","58.3","","554.95","91.85","1421.75","94","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","128.12","73","","2490.03","2490.03","2490.03","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","102.32","58.3","","750.00","750.00","750.00","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","93.02","53","","1192.50","120.84","4149.90","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","149.18","85","","750.00","75.00","750.00","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","175.50","100","","657.00","121.50","1971.00","14","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","175.50","100","","75.00","75.00","75.00","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","175.50","100","","366.00","144.00","1971.00","45","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","128.12","73","","667.50","667.50","667.50","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","78.01","44.45","","123.77","123.77","123.77","1 through 10","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","both","","","175.50","131.62","WELLPOINT [1015]","HB CH WELLPOINT","136.73","77.91","","483.51","229.32","1316.08","96","78.01","175.5","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.50","131.62","CIGNA [1006]","HB CH CIGNA HMO / PPO","104.07","59.3","","439.50","225.34","1872.27","197","87.75","137.68","percent of total billed charges",""
"WASHER ORTHOPEDIC 6.5MM BONE FLAT 110008351","SUP-ITM-10188933","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","175.50","131.62","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","137.68","78.45","","385.32","55.36","1815.62","58","87.75","137.68","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","AETNA [1001]","HB CH AETNA HMO / PPO","139.92","58.3","","554.95","91.85","1421.75","94","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","2490.03","2490.03","2490.03","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","139.92","58.3","","750.00","750.00","750.00","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","127.20","53","","1192.50","120.84","4149.90","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","204.00","85","","750.00","75.00","750.00","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","240.00","100","","657.00","121.50","1971.00","14","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","240.00","100","","75.00","75.00","75.00","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","240.00","100","","366.00","144.00","1971.00","45","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","175.20","73","","667.50","667.50","667.50","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","106.68","44.45","","123.77","123.77","123.77","1 through 10","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","both","","","240.00","180.00","WELLPOINT [1015]","HB CH WELLPOINT","186.98","77.91","","483.51","229.32","1316.08","96","106.68","240","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","142.32","59.3","","439.50","225.34","1872.27","197","120","188.28","percent of total billed charges",""
"WASHER SCREW 13MM TITANIUM","SUP-ITM-10080582","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","240.00","180.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","188.28","78.45","","385.32","55.36","1815.62","58","120","188.28","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","AETNA [1001]","HB CH AETNA HMO / PPO","36.03","58.3","","554.95","91.85","1421.75","94","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","45.11","73","","2490.03","2490.03","2490.03","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","36.03","58.3","","750.00","750.00","750.00","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","32.75","53","","1192.50","120.84","4149.90","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","52.53","85","","750.00","75.00","750.00","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","61.80","100","","657.00","121.50","1971.00","14","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","61.80","100","","75.00","75.00","75.00","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","61.80","100","","366.00","144.00","1971.00","45","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","45.11","73","","667.50","667.50","667.50","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","27.47","44.45","","123.77","123.77","123.77","1 through 10","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","both","","","61.80","46.35","WELLPOINT [1015]","HB CH WELLPOINT","48.15","77.91","","483.51","229.32","1316.08","96","27.47","61.8","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.80","46.35","CIGNA [1006]","HB CH CIGNA HMO / PPO","36.65","59.3","","439.50","225.34","1872.27","197","30.9","48.48","percent of total billed charges",""
"WASHER SCREW 2.5MM BONE HAND ALPS THREADED","SUP-ITM-10056551","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","61.80","46.35","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","48.48","78.45","","385.32","55.36","1815.62","58","30.9","48.48","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","AETNA [1001]","HB CH AETNA HMO / PPO","91.87","58.3","","554.95","91.85","1421.75","94","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","115.04","73","","2490.03","2490.03","2490.03","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","91.87","58.3","","750.00","750.00","750.00","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","83.52","53","","1192.50","120.84","4149.90","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","133.95","85","","750.00","75.00","750.00","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","157.59","100","","657.00","121.50","1971.00","14","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","157.59","100","","75.00","75.00","75.00","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","157.59","100","","366.00","144.00","1971.00","45","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","115.04","73","","667.50","667.50","667.50","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","70.05","44.45","","123.77","123.77","123.77","1 through 10","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","both","","","157.59","118.19","WELLPOINT [1015]","HB CH WELLPOINT","122.78","77.91","","483.51","229.32","1316.08","96","70.05","157.59","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.59","118.19","CIGNA [1006]","HB CH CIGNA HMO / PPO","93.45","59.3","","439.50","225.34","1872.27","197","78.8","123.63","percent of total billed charges",""
"WASHER SCREW 3.5MM BONE LOW PROFILE","SUP-ITM-10071462","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","157.59","118.19","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","123.63","78.45","","385.32","55.36","1815.62","58","78.8","123.63","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","AETNA [1001]","HB CH AETNA HMO / PPO","87.45","58.3","","554.95","91.85","1421.75","94","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","2490.03","2490.03","2490.03","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","87.45","58.3","","750.00","750.00","750.00","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","79.50","53","","1192.50","120.84","4149.90","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","127.50","85","","750.00","75.00","750.00","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","150.00","100","","657.00","121.50","1971.00","14","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","150.00","100","","75.00","75.00","75.00","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","150.00","100","","366.00","144.00","1971.00","45","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","109.50","73","","667.50","667.50","667.50","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","66.68","44.45","","123.77","123.77","123.77","1 through 10","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","both","","","150.00","112.50","WELLPOINT [1015]","HB CH WELLPOINT","116.87","77.91","","483.51","229.32","1316.08","96","66.68","150","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","88.95","59.3","","439.50","225.34","1872.27","197","75","117.68","percent of total billed charges",""
"WASHER SCREW 3.75MM TITANIUM NON-STERILE DISP","SUP-ITM-10135508","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","150.00","112.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","117.68","78.45","","385.32","55.36","1815.62","58","75","117.68","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","AETNA [1001]","HB CH AETNA HMO / PPO","61.22","58.3","","554.95","91.85","1421.75","94","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","2490.03","2490.03","2490.03","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","61.22","58.3","","750.00","750.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","55.65","53","","1192.50","120.84","4149.90","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","89.25","85","","750.00","75.00","750.00","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","105.00","100","","657.00","121.50","1971.00","14","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","105.00","100","","75.00","75.00","75.00","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","105.00","100","","366.00","144.00","1971.00","45","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","76.65","73","","667.50","667.50","667.50","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","46.67","44.45","","123.77","123.77","123.77","1 through 10","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","both","","","105.00","78.75","WELLPOINT [1015]","HB CH WELLPOINT","81.81","77.91","","483.51","229.32","1316.08","96","46.67","105","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","62.27","59.3","","439.50","225.34","1872.27","197","52.5","82.37","percent of total billed charges",""
"WASHER SCREW 3.75X7MM BONE FRACTURE PLATE TITANIUM QUICKFIX RING","SUP-ITM-10154055","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","105.00","78.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","82.37","78.45","","385.32","55.36","1815.62","58","52.5","82.37","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","AETNA [1001]","HB CH AETNA HMO / PPO","167.90","58.3","","554.95","91.85","1421.75","94","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","210.24","73","","2490.03","2490.03","2490.03","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","167.90","58.3","","750.00","750.00","750.00","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","152.64","53","","1192.50","120.84","4149.90","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","244.80","85","","750.00","75.00","750.00","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","288.00","100","","657.00","121.50","1971.00","14","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","288.00","100","","75.00","75.00","75.00","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","288.00","100","","366.00","144.00","1971.00","45","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","210.24","73","","667.50","667.50","667.50","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","128.02","44.45","","123.77","123.77","123.77","1 through 10","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","both","","","288.00","216.00","WELLPOINT [1015]","HB CH WELLPOINT","224.38","77.91","","483.51","229.32","1316.08","96","128.02","288","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.00","216.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","170.78","59.3","","439.50","225.34","1872.27","197","144","225.94","percent of total billed charges",""
"WASHER SCREW 4.2MM BONE GORILLA","SUP-ITM-10212042","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","288.00","216.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","225.94","78.45","","385.32","55.36","1815.62","58","144","225.94","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","AETNA [1001]","HB CH AETNA HMO / PPO","30.22","58.3","","554.95","91.85","1421.75","94","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","37.84","73","","2490.03","2490.03","2490.03","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","30.22","58.3","","750.00","750.00","750.00","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","27.48","53","","1192.50","120.84","4149.90","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","44.06","85","","750.00","75.00","750.00","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","51.84","100","","657.00","121.50","1971.00","14","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","51.84","100","","75.00","75.00","75.00","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","51.84","100","","366.00","144.00","1971.00","45","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","37.84","73","","667.50","667.50","667.50","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","23.04","44.45","","123.77","123.77","123.77","1 through 10","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","both","","","51.84","38.88","WELLPOINT [1015]","HB CH WELLPOINT","40.39","77.91","","483.51","229.32","1316.08","96","23.04","51.84","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.84","38.88","CIGNA [1006]","HB CH CIGNA HMO / PPO","30.74","59.3","","439.50","225.34","1872.27","197","25.92","40.67","percent of total billed charges",""
"WASHER SCREW 4.5MM 10 BONE CANNULATED STAINLESS BX/4EA","SUP-ITM-10004539","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","51.84","38.88","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","40.67","78.45","","385.32","55.36","1815.62","58","25.92","40.67","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","AETNA [1001]","HB CH AETNA HMO / PPO","101.11","58.3","","554.95","91.85","1421.75","94","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","126.60","73","","2490.03","2490.03","2490.03","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","101.11","58.3","","750.00","750.00","750.00","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","91.92","53","","1192.50","120.84","4149.90","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","147.42","85","","750.00","75.00","750.00","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","173.43","100","","657.00","121.50","1971.00","14","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","173.43","100","","75.00","75.00","75.00","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","173.43","100","","366.00","144.00","1971.00","45","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","126.60","73","","667.50","667.50","667.50","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","77.09","44.45","","123.77","123.77","123.77","1 through 10","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","both","","","173.43","130.07","WELLPOINT [1015]","HB CH WELLPOINT","135.12","77.91","","483.51","229.32","1316.08","96","77.09","173.43","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","CIGNA [1006]","HB CH CIGNA HMO / PPO","102.84","59.3","","439.50","225.34","1872.27","197","86.72","136.06","percent of total billed charges",""
"WASHER SCREW 6.5X9MM BONE ASNIS III SS CANNULATED","SUP-ITM-10094919","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","173.43","130.07","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","136.06","78.45","","385.32","55.36","1815.62","58","86.72","136.06","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","AETNA [1001]","HB CH AETNA HMO / PPO","62.96","58.3","","554.95","91.85","1421.75","94","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","78.84","73","","2490.03","2490.03","2490.03","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","62.96","58.3","","750.00","750.00","750.00","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","57.24","53","","1192.50","120.84","4149.90","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","91.80","85","","750.00","75.00","750.00","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","108.00","100","","657.00","121.50","1971.00","14","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","108.00","100","","75.00","75.00","75.00","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","108.00","100","","366.00","144.00","1971.00","45","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","78.84","73","","667.50","667.50","667.50","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","48.01","44.45","","123.77","123.77","123.77","1 through 10","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","both","","","108.00","81.00","WELLPOINT [1015]","HB CH WELLPOINT","84.14","77.91","","483.51","229.32","1316.08","96","48.01","108","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.00","81.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","64.04","59.3","","439.50","225.34","1872.27","197","54","84.73","percent of total billed charges",""
"WASHER SCREW 7.0MM BONE TIMAX TITANIUM MINI FRAGMENT ROUND","SUP-ITM-10072015","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","108.00","81.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","84.73","78.45","","385.32","55.36","1815.62","58","54","84.73","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","AETNA [1001]","HB CH AETNA HMO / PPO","56.14","58.3","","554.95","91.85","1421.75","94","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","70.30","73","","2490.03","2490.03","2490.03","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","56.14","58.3","","750.00","750.00","750.00","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","51.04","53","","1192.50","120.84","4149.90","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","81.86","85","","750.00","75.00","750.00","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","96.30","100","","657.00","121.50","1971.00","14","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","96.30","100","","75.00","75.00","75.00","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","96.30","100","","366.00","144.00","1971.00","45","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","70.30","73","","667.50","667.50","667.50","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","42.81","44.45","","123.77","123.77","123.77","1 through 10","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","both","","","96.30","72.22","WELLPOINT [1015]","HB CH WELLPOINT","75.03","77.91","","483.51","229.32","1316.08","96","42.81","96.3","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.30","72.22","CIGNA [1006]","HB CH CIGNA HMO / PPO","57.11","59.3","","439.50","225.34","1872.27","197","48.15","75.55","percent of total billed charges",""
"WASHER SCREW 7.0MM SM BONE SS ANKLE FRACTURE","SUP-ITM-10076901","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","96.30","72.22","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","75.55","78.45","","385.32","55.36","1815.62","58","48.15","75.55","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","AETNA [1001]","HB CH AETNA HMO / PPO","398.77","58.3","","554.95","91.85","1421.75","94","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","499.32","73","","2490.03","2490.03","2490.03","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","398.77","58.3","","750.00","750.00","750.00","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","362.52","53","","1192.50","120.84","4149.90","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","581.40","85","","750.00","75.00","750.00","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","684.00","100","","657.00","121.50","1971.00","14","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","684.00","100","","75.00","75.00","75.00","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","684.00","100","","366.00","144.00","1971.00","45","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","499.32","73","","667.50","667.50","667.50","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","304.04","44.45","","123.77","123.77","123.77","1 through 10","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","both","","","684.00","513.00","WELLPOINT [1015]","HB CH WELLPOINT","532.90","77.91","","483.51","229.32","1316.08","96","304.04","684","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","405.61","59.3","","439.50","225.34","1872.27","197","342","536.6","percent of total billed charges",""
"WASHER SCREW BONE TIMAX FLAT","SUP-ITM-10028060","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","684.00","513.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","536.60","78.45","","385.32","55.36","1815.62","58","342","536.6","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","AETNA [1001]","HB CH AETNA HMO / PPO","89.20","58.3","","554.95","91.85","1421.75","94","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","2490.03","2490.03","2490.03","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","89.20","58.3","","750.00","750.00","750.00","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","81.09","53","","1192.50","120.84","4149.90","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","130.05","85","","750.00","75.00","750.00","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","153.00","100","","657.00","121.50","1971.00","14","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","153.00","100","","75.00","75.00","75.00","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","153.00","100","","366.00","144.00","1971.00","45","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","111.69","73","","667.50","667.50","667.50","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","68.01","44.45","","123.77","123.77","123.77","1 through 10","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","both","","","153.00","114.75","WELLPOINT [1015]","HB CH WELLPOINT","119.20","77.91","","483.51","229.32","1316.08","96","68.01","153","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","90.73","59.3","","439.50","225.34","1872.27","197","76.5","120.03","percent of total billed charges",""
"WASHER SURGICAL 2.7MM ID 5MM OD GEMINUS","SUP-ITM-10130613","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","153.00","114.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","120.03","78.45","","385.32","55.36","1815.62","58","76.5","120.03","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","AETNA [1001]","HB CH AETNA HMO / PPO","94.45","58.3","","554.95","91.85","1421.75","94","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","2490.03","2490.03","2490.03","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","94.45","58.3","","750.00","750.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","85.86","53","","1192.50","120.84","4149.90","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","137.70","85","","750.00","75.00","750.00","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","162.00","100","","657.00","121.50","1971.00","14","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","162.00","100","","75.00","75.00","75.00","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","162.00","100","","366.00","144.00","1971.00","45","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","118.26","73","","667.50","667.50","667.50","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","72.01","44.45","","123.77","123.77","123.77","1 through 10","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","both","","","162.00","121.50","WELLPOINT [1015]","HB CH WELLPOINT","126.21","77.91","","483.51","229.32","1316.08","96","72.01","162","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","96.07","59.3","","439.50","225.34","1872.27","197","81","127.09","percent of total billed charges",""
"WASHER TROCHANTER 60X45MM S-ROM TITANIUM","SUP-ITM-10119851","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","162.00","121.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","127.09","78.45","","385.32","55.36","1815.62","58","81","127.09","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","AETNA [1001]","HB CH AETNA HMO / PPO","2530.22","58.3","","554.95","91.85","1421.75","94","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","2490.03","2490.03","2490.03","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2530.22","58.3","","750.00","750.00","750.00","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2300.20","53","","1192.50","120.84","4149.90","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3689.00","85","","750.00","75.00","750.00","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","4340.00","100","","657.00","121.50","1971.00","14","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","4340.00","100","","75.00","75.00","75.00","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","4340.00","100","","366.00","144.00","1971.00","45","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","3168.20","73","","667.50","667.50","667.50","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1929.13","44.45","","123.77","123.77","123.77","1 through 10","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","both","","","4340.00","3255.00","WELLPOINT [1015]","HB CH WELLPOINT","3381.29","77.91","","483.51","229.32","1316.08","96","1929.13","4340","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","2573.62","59.3","","439.50","225.34","1872.27","197","2170","3404.73","percent of total billed charges",""
"WEDGE TOE 6.5X14X20MM BIOFOAM COTTON","SUP-ITM-10114308","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","4340.00","3255.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","3404.73","78.45","","385.32","55.36","1815.62","58","2170","3404.73","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","both","","","47.97","35.98","WELLPOINT [1015]","HB CH WELLPOINT","37.37","77.91","","37.78","37.78","37.78","1 through 10","21.32","1362.89","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","47.97","35.98","CIGNA [1006]","HB CH CIGNA HMO / PPO","28.45","59.3","","28.11","28.11","28.11","1 through 10","23.99","957.19","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","47.97","35.98","HARVARD PILGRIM [120001]","HB CH HPHC HMO / POS","27.68","57.7","","86.79","28.93","86.79","1 through 10","23.99","957.19","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","47.97","35.98","HARVARD PILGRIM [120001]","HB CH HPHC PPO / PREFERRED A","29.02","60.5","","30.37","30.37","30.37","1 through 10","23.99","957.19","percent of total billed charges",""
"Whfo, Rigid W/O Joints","PX-27000491","CDM","L3808","HCPCS","0274","RC","","","","outpatient","","","47.97","35.98","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","37.63","78.45","","36.88","36.88","36.88","1 through 10","23.99","957.19","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","AETNA [1001]","HB CH AETNA HMO / PPO","157.41","58.3","","161.55","62.25","161.55","1 through 10","120.02","270","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","143.10","53","","52.44","22.90","505.57","1 through 10","120.02","270","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","229.50","85","","68.52","68.52","68.52","1 through 10","120.02","270","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","270.00","100","","62.20","62.19","81.17","14","120.02","270","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","270.00","100","","43.22","31.95","953.91","1 through 10","120.02","270","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","both","","","270.00","202.50","WELLPOINT [1015]","HB CH WELLPOINT","210.36","77.91","","63.92","25.16","245.73","18","120.02","270","percent of total billed charges",""
"WIRE BONE 1.6MMX15CM SUTUREPLATE TITANIUM BALL TIP PROXIMALIMAL HUMERAL","SUP-ITM-10115031","CDM","C1769","HCPCS","0272","RC","","","","outpatient","","","270.00","202.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","211.82","78.45","","97.25","24.56","207.80","18","135","211.82","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","AETNA [1001]","HB CH AETNA HMO / PPO","113.06","58.3","","554.95","91.85","1421.75","94","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","141.56","73","","2490.03","2490.03","2490.03","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","113.06","58.3","","750.00","750.00","750.00","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","102.78","53","","1192.50","120.84","4149.90","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","164.83","85","","750.00","75.00","750.00","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","193.92","100","","657.00","121.50","1971.00","14","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","193.92","100","","75.00","75.00","75.00","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","193.92","100","","366.00","144.00","1971.00","45","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","141.56","73","","667.50","667.50","667.50","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","86.20","44.45","","123.77","123.77","123.77","1 through 10","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","both","","","193.92","145.44","WELLPOINT [1015]","HB CH WELLPOINT","151.08","77.91","","483.51","229.32","1316.08","96","86.2","193.92","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.92","145.44","CIGNA [1006]","HB CH CIGNA HMO / PPO","114.99","59.3","","439.50","225.34","1872.27","197","96.96","152.13","percent of total billed charges",""
"WIRE GUIDE 150MM 300X2.8 BONE SS FLUTED CALIBRATED","SUP-ITM-10014597","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","193.92","145.44","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","152.13","78.45","","385.32","55.36","1815.62","58","96.96","152.13","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","AETNA [1001]","HB CH AETNA HMO / PPO","50.72","58.3","","554.95","91.85","1421.75","94","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","63.51","73","","2490.03","2490.03","2490.03","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","50.72","58.3","","750.00","750.00","750.00","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","46.11","53","","1192.50","120.84","4149.90","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","73.95","85","","750.00","75.00","750.00","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","87.00","100","","657.00","121.50","1971.00","14","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","87.00","100","","75.00","75.00","75.00","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","87.00","100","","366.00","144.00","1971.00","45","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","63.51","73","","667.50","667.50","667.50","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","38.67","44.45","","123.77","123.77","123.77","1 through 10","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","both","","","87.00","65.25","WELLPOINT [1015]","HB CH WELLPOINT","67.78","77.91","","483.51","229.32","1316.08","96","38.67","87","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.00","65.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","51.59","59.3","","439.50","225.34","1872.27","197","43.5","68.25","percent of total billed charges",""
"WIRE K 165X1.4MM 15DEG STANDARD TIP SS","SUP-ITM-10157798","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","87.00","65.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","68.25","78.45","","385.32","55.36","1815.62","58","43.5","68.25","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","554.95","91.85","1421.75","94","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","2490.03","2490.03","2490.03","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.53","58.3","","750.00","750.00","750.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","1192.50","120.84","4149.90","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","238.43","85","","750.00","75.00","750.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","280.50","100","","657.00","121.50","1971.00","14","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","280.50","100","","75.00","75.00","75.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","280.50","100","","366.00","144.00","1971.00","45","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","667.50","667.50","667.50","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.68","44.45","","123.77","123.77","123.77","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","483.51","229.32","1316.08","96","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.34","59.3","","439.50","225.34","1872.27","197","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.3MM SMOOTH","SUP-ITM-10241224","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","385.32","55.36","1815.62","58","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","554.95","91.85","1421.75","94","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","2490.03","2490.03","2490.03","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.53","58.3","","750.00","750.00","750.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","1192.50","120.84","4149.90","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","238.43","85","","750.00","75.00","750.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","280.50","100","","657.00","121.50","1971.00","14","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","280.50","100","","75.00","75.00","75.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","280.50","100","","366.00","144.00","1971.00","45","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","667.50","667.50","667.50","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.68","44.45","","123.77","123.77","123.77","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","483.51","229.32","1316.08","96","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.34","59.3","","439.50","225.34","1872.27","197","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.6X80MM SMOOTH TOWER WIRE STANDARD","SUP-ITM-10241216","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","385.32","55.36","1815.62","58","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","AETNA [1001]","HB CH AETNA HMO / PPO","163.53","58.3","","554.95","91.85","1421.75","94","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","2490.03","2490.03","2490.03","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","163.53","58.3","","750.00","750.00","750.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","148.67","53","","1192.50","120.84","4149.90","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","238.43","85","","750.00","75.00","750.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","280.50","100","","657.00","121.50","1971.00","14","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","280.50","100","","75.00","75.00","75.00","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","280.50","100","","366.00","144.00","1971.00","45","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","204.77","73","","667.50","667.50","667.50","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","124.68","44.45","","123.77","123.77","123.77","1 through 10","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","both","","","280.50","210.37","WELLPOINT [1015]","HB CH WELLPOINT","218.54","77.91","","483.51","229.32","1316.08","96","124.68","280.5","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","CIGNA [1006]","HB CH CIGNA HMO / PPO","166.34","59.3","","439.50","225.34","1872.27","197","140.25","220.05","percent of total billed charges",""
"WIRE OLIVE 1.8MM SMOOTH SHORT TIP","SUP-ITM-10241219","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","280.50","210.37","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","220.05","78.45","","385.32","55.36","1815.62","58","140.25","220.05","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","AETNA [1001]","HB CH AETNA HMO / PPO","743.33","58.3","","554.95","91.85","1421.75","94","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","2490.03","2490.03","2490.03","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","743.33","58.3","","750.00","750.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","675.75","53","","1192.50","120.84","4149.90","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","1083.75","85","","750.00","75.00","750.00","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","1275.00","100","","657.00","121.50","1971.00","14","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","1275.00","100","","75.00","75.00","75.00","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","1275.00","100","","366.00","144.00","1971.00","45","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","930.75","73","","667.50","667.50","667.50","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","566.74","44.45","","123.77","123.77","123.77","1 through 10","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","both","","","1275.00","956.25","WELLPOINT [1015]","HB CH WELLPOINT","993.35","77.91","","483.51","229.32","1316.08","96","566.74","1275","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","756.08","59.3","","439.50","225.34","1872.27","197","637.5","1000.24","percent of total billed charges",""
"WIRE SUTURE TRACTION FIXATION TIGHTROPE UHMWPE BONE TENDON","SUP-ITM-10118169","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","1275.00","956.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1000.24","78.45","","385.32","55.36","1815.62","58","637.5","1000.24","percent of total billed charges",""
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","61872.44","46404.33","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","29017.73","","Case rate ($29,017.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $29,064.47, add-ons for qualifying new technology services are included. If operating cost exceeds $74,588.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,762.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $26,476.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $28,725.24 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,201.97. The transfer capital threshold is the transfer adjustment factor * $2,201.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","19424.12","19424.12","19424.12","1 through 10","28437.38","29888.26","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","61872.44","46404.33","MEDICARE [2001]","HB BWF MEDICARE","29017.73","","Case rate ($29,017.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $29,064.47, add-ons for qualifying new technology services are included. If operating cost exceeds $74,588.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,762.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $26,476.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $28,725.24 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,201.97. The transfer capital threshold is the transfer adjustment factor * $2,201.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program.","0.03","0.03","0.03","1 through 10","28437.38","29888.26","other","Inpatient Replacement Plans DRG"
"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc","464","MS-DRG","","","","","","","","inpatient","","","61872.44","46404.33","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","28437.38","","Case rate ($29,017.73). If operating cost, defined as billed amount less exclusions * an operating cost-to-charge ratio of 0.302, exceeds $29,064.47, add-ons for qualifying new technology services are included. If operating cost exceeds $74,588.20 plus the cost of any qualifying new technology services, the stay qualifies for an operating outlier of 80% of the excess amount. If capital cost, defined as billed amount less exclusions * a capital cost-to-charge ratio of 0.017, exceeds $4,762.75, the stay qualifies for a capital outlier of 80% of the excess amount. For transfer cases, the transfer adjustment factor is defined as (length of stay + 1) / 5.5. The base transfer operating payment is the transfer adjustment factor * $26,476.53 + an uncompensated DSH payment of $339.24. The transfer operating threshold is the transfer adjustment factor * $28,725.24 + an uncompensated DSH payment of $339.24. If operating cost exceeds the transfer operating threshold, add-ons for qualifying new technology services are included. If operating cost exceeds the transfer operating threshold + the cost of any qualifying new technology services, the stay qualifies for a transfer operating outlier of 80% of the excess amount. The base transfer capital payment is the transfer adjustment factor * $2,201.97. The transfer capital threshold is the transfer adjustment factor * $2,201.97. If the capital cost exceeds the transfer capital threshold, the stay qualifies for a transfer capital outlier of 80% of the excess amount. Reimbursement is multiplied by 99% as per the Hospital Acquired Conditions (HAC) program. Final payment is multiplied by 98%.","24081.69","24081.69","24081.69","1 through 10","28437.38","29888.26","other","Inpatient DRG"
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","AETNA [1001]","HB CH AETNA HMO / PPO","1920.40","58.3","","554.95","91.85","1421.75","94","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2404.62","73","","2490.03","2490.03","2490.03","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1920.40","58.3","","750.00","750.00","750.00","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1745.82","53","","1192.50","120.84","4149.90","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2799.90","85","","750.00","75.00","750.00","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3294.00","100","","657.00","121.50","1971.00","14","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3294.00","100","","75.00","75.00","75.00","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3294.00","100","","366.00","144.00","1971.00","45","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2404.62","73","","667.50","667.50","667.50","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1464.18","44.45","","123.77","123.77","123.77","1 through 10","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","both","","","3294.00","2470.50","WELLPOINT [1015]","HB CH WELLPOINT","2566.36","77.91","","483.51","229.32","1316.08","96","1464.18","3294","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3294.00","2470.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","1953.34","59.3","","439.50","225.34","1872.27","197","1647","2584.14","percent of total billed charges",""
"WRIST PLATE 10HOLE BONE HUBCAP TITANIUM LIMITED FUSION","SUP-ITM-10017510","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3294.00","2470.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2584.14","78.45","","385.32","55.36","1815.62","58","1647","2584.14","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","AETNA [1001]","HB CH AETNA HMO / PPO","2213.18","58.3","","554.95","91.85","1421.75","94","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2771.23","73","","2490.03","2490.03","2490.03","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2213.18","58.3","","750.00","750.00","750.00","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","2011.99","53","","1192.50","120.84","4149.90","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3226.77","85","","750.00","75.00","750.00","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3796.20","100","","657.00","121.50","1971.00","14","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3796.20","100","","75.00","75.00","75.00","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3796.20","100","","366.00","144.00","1971.00","45","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2771.23","73","","667.50","667.50","667.50","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1687.41","44.45","","123.77","123.77","123.77","1 through 10","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","both","","","3796.20","2847.15","WELLPOINT [1015]","HB CH WELLPOINT","2957.62","77.91","","483.51","229.32","1316.08","96","1687.41","3796.2","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3796.20","2847.15","CIGNA [1006]","HB CH CIGNA HMO / PPO","2251.15","59.3","","439.50","225.34","1872.27","197","1898.1","2978.12","percent of total billed charges",""
"WRIST PLATE 112MM LCP SS FUSION STRAIGHT","SUP-ITM-10042996","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3796.20","2847.15","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2978.12","78.45","","385.32","55.36","1815.62","58","1898.1","2978.12","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","AETNA [1001]","HB CH AETNA HMO / PPO","2028.22","58.3","","554.95","91.85","1421.75","94","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2539.62","73","","2490.03","2490.03","2490.03","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2028.22","58.3","","750.00","750.00","750.00","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1843.83","53","","1192.50","120.84","4149.90","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2957.09","85","","750.00","75.00","750.00","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3478.93","100","","657.00","121.50","1971.00","14","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3478.93","100","","75.00","75.00","75.00","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3478.93","100","","366.00","144.00","1971.00","45","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2539.62","73","","667.50","667.50","667.50","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1546.38","44.45","","123.77","123.77","123.77","1 through 10","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","both","","","3478.93","2609.20","WELLPOINT [1015]","HB CH WELLPOINT","2710.43","77.91","","483.51","229.32","1316.08","96","1546.38","3478.93","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3478.93","2609.20","CIGNA [1006]","HB CH CIGNA HMO / PPO","2063.01","59.3","","439.50","225.34","1872.27","197","1739.47","2729.22","percent of total billed charges",""
"WRIST PLATE 118MM FUSION LCP TITANIUM SHORT BEND","SUP-ITM-10095923","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3478.93","2609.20","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2729.22","78.45","","385.32","55.36","1815.62","58","1739.47","2729.22","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","AETNA [1001]","HB CH AETNA HMO / PPO","2067.58","58.3","","554.95","91.85","1421.75","94","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2588.91","73","","2490.03","2490.03","2490.03","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","2067.58","58.3","","750.00","750.00","750.00","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1879.62","53","","1192.50","120.84","4149.90","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","3014.48","85","","750.00","75.00","750.00","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3546.45","100","","657.00","121.50","1971.00","14","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3546.45","100","","75.00","75.00","75.00","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3546.45","100","","366.00","144.00","1971.00","45","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2588.91","73","","667.50","667.50","667.50","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1576.40","44.45","","123.77","123.77","123.77","1 through 10","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","both","","","3546.45","2659.84","WELLPOINT [1015]","HB CH WELLPOINT","2763.04","77.91","","483.51","229.32","1316.08","96","1576.4","3546.45","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3546.45","2659.84","CIGNA [1006]","HB CH CIGNA HMO / PPO","2103.04","59.3","","439.50","225.34","1872.27","197","1773.23","2782.19","percent of total billed charges",""
"WRIST PLATE 2.4MM 170 STAINLESS LOCKING COMPRESSION STRAIGHT","SUP-ITM-10111817","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3546.45","2659.84","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2782.19","78.45","","385.32","55.36","1815.62","58","1773.23","2782.19","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","AETNA [1001]","HB CH AETNA HMO / PPO","153.12","58.3","","554.95","91.85","1421.75","94","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","191.73","73","","2490.03","2490.03","2490.03","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","153.12","58.3","","750.00","750.00","750.00","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","139.20","53","","1192.50","120.84","4149.90","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","223.25","85","","750.00","75.00","750.00","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","262.65","100","","657.00","121.50","1971.00","14","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","262.65","100","","75.00","75.00","75.00","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","262.65","100","","366.00","144.00","1971.00","45","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","191.73","73","","667.50","667.50","667.50","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","116.75","44.45","","123.77","123.77","123.77","1 through 10","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","both","","","262.65","196.99","WELLPOINT [1015]","HB CH WELLPOINT","204.63","77.91","","483.51","229.32","1316.08","96","116.75","262.65","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.65","196.99","CIGNA [1006]","HB CH CIGNA HMO / PPO","155.75","59.3","","439.50","225.34","1872.27","197","131.33","206.05","percent of total billed charges",""
"WRIST PLATE 3.5X121MM 10 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10028068","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","262.65","196.99","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","206.05","78.45","","385.32","55.36","1815.62","58","131.33","206.05","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","AETNA [1001]","HB CH AETNA HMO / PPO","108.09","58.3","","554.95","91.85","1421.75","94","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","135.34","73","","2490.03","2490.03","2490.03","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","108.09","58.3","","750.00","750.00","750.00","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","98.26","53","","1192.50","120.84","4149.90","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","157.59","85","","750.00","75.00","750.00","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","185.40","100","","657.00","121.50","1971.00","14","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","185.40","100","","75.00","75.00","75.00","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","185.40","100","","366.00","144.00","1971.00","45","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","135.34","73","","667.50","667.50","667.50","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","82.41","44.45","","123.77","123.77","123.77","1 through 10","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","both","","","185.40","139.05","WELLPOINT [1015]","HB CH WELLPOINT","144.45","77.91","","483.51","229.32","1316.08","96","82.41","185.4","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.40","139.05","CIGNA [1006]","HB CH CIGNA HMO / PPO","109.94","59.3","","439.50","225.34","1872.27","197","92.7","145.45","percent of total billed charges",""
"WRIST PLATE 3.5X61MM 5 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10021691","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","185.40","139.05","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","145.45","78.45","","385.32","55.36","1815.62","58","92.7","145.45","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","AETNA [1001]","HB CH AETNA HMO / PPO","138.71","58.3","","554.95","91.85","1421.75","94","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","173.69","73","","2490.03","2490.03","2490.03","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","138.71","58.3","","750.00","750.00","750.00","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","126.10","53","","1192.50","120.84","4149.90","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","202.24","85","","750.00","75.00","750.00","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","237.93","100","","657.00","121.50","1971.00","14","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","237.93","100","","75.00","75.00","75.00","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","237.93","100","","366.00","144.00","1971.00","45","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","173.69","73","","667.50","667.50","667.50","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","105.76","44.45","","123.77","123.77","123.77","1 through 10","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","both","","","237.93","178.45","WELLPOINT [1015]","HB CH WELLPOINT","185.37","77.91","","483.51","229.32","1316.08","96","105.76","237.93","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","CIGNA [1006]","HB CH CIGNA HMO / PPO","141.09","59.3","","439.50","225.34","1872.27","197","118.97","186.66","percent of total billed charges",""
"WRIST PLATE 3.5X85MM 7 HOLE 100DEG BONE A.L.P.S. TITANIUM TUBULAR","SUP-ITM-10017863","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","237.93","178.45","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","186.66","78.45","","385.32","55.36","1815.62","58","118.97","186.66","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","AETNA [1001]","HB CH AETNA HMO / PPO","1619.52","58.3","","554.95","91.85","1421.75","94","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2027.87","73","","2490.03","2490.03","2490.03","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1619.52","58.3","","750.00","750.00","750.00","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1472.29","53","","1192.50","120.84","4149.90","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2361.22","85","","750.00","75.00","750.00","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","2777.91","100","","657.00","121.50","1971.00","14","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","2777.91","100","","75.00","75.00","75.00","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","2777.91","100","","366.00","144.00","1971.00","45","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2027.87","73","","667.50","667.50","667.50","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1234.78","44.45","","123.77","123.77","123.77","1 through 10","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","both","","","2777.91","2083.43","WELLPOINT [1015]","HB CH WELLPOINT","2164.27","77.91","","483.51","229.32","1316.08","96","1234.78","2777.91","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2777.91","2083.43","CIGNA [1006]","HB CH CIGNA HMO / PPO","1647.30","59.3","","439.50","225.34","1872.27","197","1388.96","2179.27","percent of total billed charges",""
"WRIST PLATE DORSAL DVR RIGHT","SUP-ITM-10188735","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","2777.91","2083.43","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2179.27","78.45","","385.32","55.36","1815.62","58","1388.96","2179.27","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","AETNA [1001]","HB CH AETNA HMO / PPO","1810.22","58.3","","554.95","91.85","1421.75","94","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","2266.65","73","","2490.03","2490.03","2490.03","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","1810.22","58.3","","750.00","750.00","750.00","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1645.65","53","","1192.50","120.84","4149.90","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","2639.25","85","","750.00","75.00","750.00","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","3105.00","100","","657.00","121.50","1971.00","14","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","3105.00","100","","75.00","75.00","75.00","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","3105.00","100","","366.00","144.00","1971.00","45","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","2266.65","73","","667.50","667.50","667.50","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","1380.17","44.45","","123.77","123.77","123.77","1 through 10","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","both","","","3105.00","2328.75","WELLPOINT [1015]","HB CH WELLPOINT","2419.11","77.91","","483.51","229.32","1316.08","96","1380.17","3105","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3105.00","2328.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1841.27","59.3","","439.50","225.34","1872.27","197","1552.5","2435.87","percent of total billed charges",""
"WRIST PLATE FUSION STRAIGHT","SUP-ITM-10310320","CDM","C1713","HCPCS","0278","RC","","","","outpatient","","","3105.00","2328.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","2435.87","78.45","","385.32","55.36","1815.62","58","1552.5","2435.87","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","523.60","85","","45.90","45.90","45.90","1 through 10","273.81","616","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","616.00","100","","53.99","53.99","53.99","1 through 10","273.81","616","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL PPO","616.00","100","","56.73","55.07","56.73","1 through 10","273.81","616","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","616.00","100","","59.00","59.00","59.00","35","273.81","616","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","both","","","616.00","462.00","WELLPOINT [1015]","HB CH WELLPOINT","479.93","77.91","","471.77","471.77","471.77","1 through 10","273.81","616","percent of total billed charges",""
"Xr 3d Rend W/Interp W/O Ind Post PR","PX-32000254","CDM","76376","CPT","0320","RC","","","","outpatient","","","616.00","462.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","483.25","78.45","","460.51","272.90","460.51","11","308","483.25","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","800.00","600.00","AETNA [1001]","HB CH AETNA HMO / PPO","466.40","58.3","","441.13","441.13","441.13","1 through 10","424","800","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","800.00","600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","800.00","100","","140.29","140.29","140.29","1 through 10","424","800","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","800.00","600.00","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","800.00","100","","153.31","153.31","153.31","1 through 10","424","800","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","both","","","800.00","600.00","WELLPOINT [1015]","HB CH WELLPOINT","623.28","77.91","","612.75","612.75","612.75","1 through 10","424","800","percent of total billed charges",""
"Xr 3d Rndr W/Postprocess","PX-32000255","CDM","76377","CPT","0320","RC","","","","outpatient","","","800.00","600.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","627.60","78.45","","598.13","598.13","598.13","1 through 10","355.6","627.6","percent of total billed charges",""
"Xr Angio Extremity Uni","PX-32000332","CDM","75710","CPT","0323","RC","","","","both","","","7232.00","5424.00","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","3832.96","53","","3726.96","3726.96","3726.96","1 through 10","3550.95","9932.12","percent of total billed charges",""
"Xr Angio Extremity Uni","PX-32000332","CDM","75710","CPT","0323","RC","","","","both","","","7232.00","5424.00","MEDICARE [2001]","HB BWF MEDICARE","3737.85","","APC Price ($3,737.85). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","3550.95","9932.12","other","OPPS APC"
"Xr Angio Extremity Uni","PX-32000332","CDM","75710","CPT","0323","RC","","","","outpatient","","","7232.00","5424.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","5673.50","78.45","","5406.20","5406.20","5406.20","1 through 10","3214.62","9725.48","percent of total billed charges",""
"Xr Ankle 2 Views|REDUCED SERVICES|UNUSUAL SEPARATE SERVICE","PX-32000174","CDM","73600","CPT","0320","RC","","","52|XU","both","","","267.00","200.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","51.73","51.73","51.73","1 through 10","99.34","107.69","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","419.00","314.25","AETNA [1001]","HB CH AETNA HMO / PPO","244.28","58.3","","461.54","230.77","461.54","1 through 10","99.34","305.87","percent of total billed charges",""
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","419.00","314.25","ELDER SERVICES [1037]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","99.18","99.18","99.18","1 through 10","99.34","305.87","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","both","","","419.00","314.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","26","99.34","305.87","other","OPPS APC"
"Xr Ankle 3+ Views","PX-32000177","CDM","73610","CPT","0320","RC","","","","outpatient","","","419.00","314.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","328.71","78.45","","625.80","625.80","625.80","1 through 10","110.42","328.71","percent of total billed charges",""
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","45","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","102.47","102.47","1 through 10","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","both","","","334.00","250.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","102.47","14","99.34","243.82","other","OPPS APC"
"Xr Bone Density Appendicular","PX-32000279","CDM","77081","CPT","0320","RC","","","","outpatient","","","334.00","250.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","198.06","59.3","","190.45","190.45","190.45","1 through 10","110.42","262.02","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","AETNA [1001]","HB CH AETNA HMO / PPO","329.40","58.3","","311.28","311.28","311.28","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","52","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","ELDER SERVICES [1037]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","674","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","117.59","123.76","28","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.05","250.05","250.05","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","412.45","73","","311.28","176.80","311.28","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","119.98","119.98","1 through 10","119.97","423.04","other","Tricare OPPS"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","33","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","both","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","119.99","126.29","186","119.97","423.04","other","OPPS APC"
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","565.00","423.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","335.05","59.3","","321.71","321.71","321.71","29","199.42","443.24","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","251.14","44.45","","250.12","250.12","422.07","1 through 10","199.42","443.24","percent of total billed charges",""
"Xr Bone Density Axial","PX-32000278","CDM","77080","CPT","0320","RC","","","","outpatient","","","565.00","423.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","443.24","78.45","","422.07","250.12","422.07","33","199.42","443.24","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","39","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","117.59","117.59","117.59","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","both","","","330.00","247.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","258.89","78.45","","246.78","246.78","246.78","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Bone Length Study","PX-32000273","CDM","77073","CPT","0320","RC","","","","outpatient","","","330.00","247.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","195.69","59.3","","188.11","188.11","188.11","1 through 10","146.69","311.62","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","104.56","11","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.89","102.89","102.89","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","HUMANA [1012]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","103.10","103.10","103.10","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","MARTIN'S POINT [160007]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.78","102.78","102.78","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","99.18","104.56","149","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.47","97.50","102.77","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","TRICARE [160005]","HB BWF TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","99.33","99.33","99.33","1 through 10","99.34","360.62","other","Tricare OPPS"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","102.47","102.89","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","104.56","104.56","104.56","1 through 10","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","219.58","44.45","","218.69","218.69","218.69","1 through 10","99.34","360.62","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","both","","","494.00","370.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.47","97.20","104.56","29","99.34","360.62","other","OPPS APC"
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","494.00","370.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","292.94","59.3","","281.28","275.70","281.28","1 through 10","110.42","387.54","percent of total billed charges",""
"Xr C-Spine 2 or 3 Views","PX-32000056","CDM","72040","CPT","0320","RC","","","","outpatient","","","494.00","370.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","387.54","78.45","","369.02","218.69","369.03","14","110.42","387.54","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","20","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","124.06","124.06","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","MOLINA [1014]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","250.56","250.56","250.56","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","372.48","123.76","372.48","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","both","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.76","124.07","1 through 10","119.97","504.43","other","OPPS APC"
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","691.00","518.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","409.76","59.3","","393.79","393.79","393.79","1 through 10","199.42","542.09","percent of total billed charges",""
"Xr C-Spine 4 or 5 Views","PX-32000057","CDM","72050","CPT","0320","RC","","","","outpatient","","","691.00","518.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","542.09","78.45","","516.63","516.63","516.64","1 through 10","199.42","542.09","percent of total billed charges",""
"Xr C-Spine 6 or More Views","PX-32000058","CDM","72052","CPT","0320","RC","","","","outpatient","","","874.00","655.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","685.65","78.45","","653.48","653.48","653.48","1 through 10","199.42","685.65","percent of total billed charges",""
"Xr Calcaneus 2+ Views","PX-32000189","CDM","73650","CPT","0320","RC","","","","both","","","258.00","193.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.77","102.77","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","both","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.20","102.97","1 through 10","99.34","339.45","other","OPPS APC"
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","outpatient","","","465.00","348.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","275.75","59.3","","264.87","264.87","264.87","1 through 10","110.42","364.79","percent of total billed charges",""
"Xr Elbow Cmpl 3+ Views","PX-32000103","CDM","73080","CPT","0320","RC","","","","outpatient","","","465.00","348.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","364.79","78.45","","695.00","695.00","695.00","1 through 10","110.42","364.79","percent of total billed charges",""
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","both","","","1583.00","1187.25","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","211.41","1 through 10","200.84","1155.59","other","OPPS APC"
"Xr Enema Barium W/W/O Kub","PX-32000208","CDM","74270","CPT","0320","RC","","","","outpatient","","","1583.00","1187.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","938.72","59.3","","901.85","901.85","901.85","1 through 10","357.59","1241.86","percent of total billed charges",""
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1215.00","911.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","886.95","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","both","","","1215.00","911.25","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","1 through 10","200.84","886.95","other","OPPS APC"
"Xr Esophagus","PX-32000198","CDM","74220","CPT","0320","RC","","","","outpatient","","","1215.00","911.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","720.50","59.3","","692.07","692.07","692.07","1 through 10","357.59","953.17","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","412.00","309.00","AETNA [1001]","HB CH AETNA HMO / PPO","240.20","58.3","","227.37","227.37","227.37","1 through 10","99.34","300.76","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","412.00","309.00","PHCS MULTIPLAN [1022]","HB CH CLARITEV (PRIMARY PPO)","300.76","73","","340.85","340.85","340.85","1 through 10","99.34","300.76","percent of total billed charges",""
"Xr Finger(S) 2+ Views","PX-32000131","CDM","73140","CPT","0320","RC","","","","both","","","412.00","309.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.20","102.97","23","99.34","300.76","other","OPPS APC"
"Xr Fluoro Cv Access Placement","PX-32000363","CDM","77001","CPT","0320","RC","","","","outpatient","","","906.00","679.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","537.26","59.3","","516.27","516.27","516.27","1 through 10","453","710.76","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL GIC","464.10","85","","263.85","263.85","263.85","1 through 10","242.7","546","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP COMMERCIAL HMO","546.00","100","","310.32","301.32","310.32","1 through 10","242.7","546","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","MGB HEALTH PLAN [150001]","HB BWF MGBHP EMPLOYEE PPO","546.00","100","","339.12","339.12","339.12","25","242.7","546","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","both","","","546.00","409.50","WELLPOINT [1015]","HB CH WELLPOINT","425.39","77.91","","418.22","418.22","418.22","1 through 10","242.7","546","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","546.00","409.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","323.78","59.3","","311.17","311.17","311.17","1 through 10","273","428.34","percent of total billed charges",""
"Xr Fluoro Needle Placement","PX-32000364","CDM","77002","CPT","0320","RC","","","","outpatient","","","546.00","409.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","428.34","78.45","","408.23","408.23","408.23","1 through 10","273","428.34","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","413.00","309.75","AETNA [1001]","HB CH AETNA HMO / PPO","240.78","58.3","","455.87","227.93","455.87","1 through 10","99.34","301.49","percent of total billed charges",""
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","413.00","309.75","TRICARE [160005]","HB BWF TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","99.33","99.33","99.33","1 through 10","99.34","301.49","other","Tricare OPPS"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","both","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.47","102.97","51","99.34","301.49","other","OPPS APC"
"Xr Foot Cmpl 3+ Views","PX-32000186","CDM","73630","CPT","0320","RC","","","","outpatient","","","413.00","309.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.00","78.45","","618.12","146.38","618.12","1 through 10","110.42","324","percent of total billed charges",""
"Xr Forearm 2 Views","PX-32000109","CDM","73090","CPT","0320","RC","","","","both","","","351.00","263.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.97","102.97","1 through 10","99.34","256.23","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","414.00","310.50","AETNA [1001]","HB CH AETNA HMO / PPO","241.36","58.3","","228.50","228.50","228.50","1 through 10","99.34","302.22","percent of total billed charges",""
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","both","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","32","99.34","302.22","other","OPPS APC"
"Xr Hand Cmp 3+V","PX-32000128","CDM","73130","CPT","0320","RC","","","","outpatient","","","414.00","310.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","324.78","78.45","","619.66","619.66","619.66","1 through 10","110.42","324.78","percent of total billed charges",""
"Xr Humerus 2+ Views","PX-32000097","CDM","73060","CPT","0320","RC","","","","both","","","377.00","282.75","GENERIC COMMERCIAL [1009]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","105.19","105.19","105.19","1 through 10","99.34","275.21","other","OPPS APC"
"Xr Humerus 2+ Views","PX-32000097","CDM","73060","CPT","0320","RC","","","","both","","","377.00","282.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","1 through 10","99.34","275.21","other","OPPS APC"
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","both","","","371.00","278.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","196.63","53","","191.33","191.33","191.33","1 through 10","99.34","270.83","percent of total billed charges",""
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","both","","","371.00","278.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","17","99.34","270.83","other","OPPS APC"
"Xr Knee 1-2 Views","PX-32000154","CDM","73560","CPT","0320","RC","","","","outpatient","","","371.00","278.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","220.00","59.3","","211.55","211.55","211.55","1 through 10","110.42","291.05","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","AETNA [1001]","HB CH AETNA HMO / PPO","271.68","58.3","","256.85","256.85","513.70","1 through 10","99.34","340.18","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","ELDER SERVICES [1037]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","32.13","32.13","32.13","1 through 10","99.34","340.18","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","246.98","53","","240.09","240.09","240.09","1 through 10","99.34","340.18","percent of total billed charges",""
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","both","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","20","99.34","340.18","other","OPPS APC"
"Xr Knee 3 Views","PX-32000157","CDM","73562","CPT","0320","RC","","","","outpatient","","","466.00","349.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","365.58","78.45","","696.54","696.54","696.54","1 through 10","110.42","365.58","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","538.00","403.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","both","","","538.00","403.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.07","118.10","124.27","57","119.97","423.04","other","OPPS APC"
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","538.00","403.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","319.03","59.3","","306.48","306.48","306.48","1 through 10","199.42","422.06","percent of total billed charges",""
"Xr Knee Cmpl 4+ Views","PX-32000160","CDM","73564","CPT","0320","RC","","","","outpatient","","","538.00","403.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","422.06","78.45","","268.90","268.90","268.90","1 through 10","199.42","422.06","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","311.00","233.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","102.89","102.89","102.89","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","311.00","233.25","ELDER SERVICES [1037]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","311.00","233.25","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","28","99.34","234.25","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","both","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","102.47","104.56","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","outpatient","","","311.00","233.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","184.42","59.3","","353.94","353.94","353.94","1 through 10","110.42","243.98","percent of total billed charges",""
"Xr Knee Stand Both Knees","PX-32000161","CDM","73565","CPT","0320","RC","","","","outpatient","","","311.00","233.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","243.98","78.45","","232.18","232.18","232.18","1 through 10","110.42","243.98","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","AETNA [1001]","HB CH AETNA HMO / PPO","303.74","58.3","","287.47","287.47","287.47","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","126.29","41","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","CHAMPVA [160001]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","Tricare OPPS"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","21","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","ELDER SERVICES [1037]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","FALLON HEALTH [1008]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","123.76","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","123.76","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","276.13","53","","268.71","268.71","268.71","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","MARTIN'S POINT [160007]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.03","124.03","124.03","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","480","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.96","117.59","124.06","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","TRICARE [160005]","HB BWF TRICARE","119.97","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","119.98","59.99","507.00","1 through 10","119.97","423.04","other","Tricare OPPS"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","117.59","124.36","27","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","231.58","44.45","","389.78","389.78","389.78","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","both","","","521.00","390.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.90","124.27","117","119.97","423.04","other","OPPS APC"
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","521.00","390.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","308.95","59.3","","297.10","297.10","297.10","24","199.42","408.72","percent of total billed charges",""
"Xr L-Spine 2-3 Views","PX-32000065","CDM","72100","CPT","0320","RC","","","","outpatient","","","521.00","390.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","408.72","78.45","","389.78","230.99","389.78","25","199.42","408.72","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","118.07","124.27","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","529.25","73","","514.65","514.65","514.65","1 through 10","119.97","529.25","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","HUMANA [1012]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.76","123.76","123.76","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","52","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","123.96","123.96","123.96","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","123.76","124.83","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","both","","","725.00","543.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.97","123.76","124.27","1 through 10","119.97","529.25","other","OPPS APC"
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","725.00","543.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","429.93","59.3","","413.13","413.13","413.13","1 through 10","199.42","568.76","percent of total billed charges",""
"Xr L-Spine 4+ Views","PX-32000066","CDM","72110","CPT","0320","RC","","","","outpatient","","","725.00","543.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","568.76","78.45","","542.00","542.00","542.00","1 through 10","199.42","568.76","percent of total billed charges",""
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","461.00","345.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","461.00","345.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine Bending Only 2/3 Views","PX-32000068","CDM","72120","CPT","0320","RC","","","","both","","","461.00","345.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.77","123.77","123.77","1 through 10","119.97","423.04","other","OPPS APC"
"Xr L-Spine W/Bending Views, Min 6","PX-32000067","CDM","72114","CPT","0320","RC","","","","both","","","679.00","509.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","495.67","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","HEALTH NEW ENGLAND [1034]","HB CH CLARITEV (PRIMARY PPO)","212.43","73","","206.59","206.59","206.59","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","154.23","53","","149.99","145.75","149.99","1 through 10","119.97","423.04","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","50","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","124.06","124.06","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","both","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","117.90","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","291.00","218.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","172.56","59.3","","333.87","165.84","333.87","1 through 10","145.5","268.9","percent of total billed charges",""
"Xr Pelvis 1-2 Views","PX-32000069","CDM","72170","CPT","0320","RC","","","","outpatient","","","291.00","218.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","228.29","78.45","","217.57","217.57","217.57","13","145.5","268.9","percent of total billed charges",""
"Xr Pelvis 1-2 Views|SEPARATE ORGAN/STRUCTURE","PX-32000069","CDM","72170","CPT","0320","RC","","","XS","both","","","291.00","218.25","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","123.75","130.06","other","OPPS APC"
"Xr Pelvis Cmp 3+ Views","PX-32000070","CDM","72190","CPT","0320","RC","","","","both","","","334.00","250.50","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Peritoneogram","PX-32000323","CDM","74190","CPT","0323","RC","","","","both","","","2612.00","1959.00","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","651.14","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","644.50","651.14","1 through 10","618.58","1906.76","other","OPPS APC"
"Xr Peritoneogram","PX-32000323","CDM","74190","CPT","0323","RC","","","","both","","","2612.00","1959.00","MEDICARE [2001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","602.11","651.14","1 through 10","618.58","1906.76","other","OPPS APC"
"Xr Peritoneogram","PX-32000323","CDM","74190","CPT","0323","RC","","","","outpatient","","","2612.00","1959.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1548.92","59.3","","1488.44","1488.44","1488.44","1 through 10","881.81","2049.11","percent of total billed charges",""
"Xr Remove Cv Pericath Obstruction","PX-32000300","CDM","75901","CPT","0320","RC","","","","outpatient","","","2579.00","1934.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","1529.35","59.3","","1469.69","1469.69","1469.69","1 through 10","1146.37","2023.23","percent of total billed charges",""
"Xr Ribs 2 Views Uni","PX-32000048","CDM","71100","CPT","0324","RC","","","","both","","","415.00","311.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.77","102.97","1 through 10","99.34","302.95","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","522.00","391.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Ribs 3 Views Bilat","PX-32000050","CDM","71110","CPT","0320","RC","","","","both","","","522.00","391.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Ribs W/Cxr 4+ Views Bilat","PX-32000051","CDM","71111","CPT","0324","RC","","","","both","","","686.00","514.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","500.78","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","386.00","289.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","119.99","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","both","","","386.00","289.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","117.59","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","outpatient","","","386.00","289.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","228.90","59.3","","219.75","146.81","219.75","1 through 10","171.58","302.82","percent of total billed charges",""
"Xr Sacroili Jt <3 Views","PX-32000071","CDM","72200","CPT","0320","RC","","","","outpatient","","","386.00","289.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","302.82","78.45","","288.30","170.85","288.30","1 through 10","171.58","302.82","percent of total billed charges",""
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","463.00","347.25","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","both","","","463.00","347.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Sacroili Jt 3+ Views","PX-32000072","CDM","72202","CPT","0320","RC","","","","outpatient","","","463.00","347.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","274.56","59.3","","257.40","257.40","257.40","1 through 10","199.42","363.22","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","198.75","53","","193.45","193.45","193.45","1 through 10","99.34","273.75","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","MEDICARE [2001]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","104.56","104.56","104.56","1 through 10","99.34","273.75","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","TRICARE [160005]","HB BWF TRICARE","99.34","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","365.00","365.00","365.00","1 through 10","99.34","273.75","other","Tricare OPPS"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","both","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.77","97.50","102.97","1 through 10","99.34","273.75","other","OPPS APC"
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","375.00","281.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","222.38","59.3","","213.89","213.89","213.89","1 through 10","110.42","294.19","percent of total billed charges",""
"Xr Sacrum/Coccyx 2+ Views","PX-32000073","CDM","72220","CPT","0320","RC","","","","outpatient","","","375.00","281.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","294.19","78.45","","280.61","280.61","280.61","1 through 10","110.42","294.19","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","384.00","288.00","AETNA [1001]","HB CH AETNA HMO / PPO","223.87","58.3","","211.49","211.49","211.49","1 through 10","99.34","280.32","percent of total billed charges",""
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","384.00","288.00","GENERIC COMMERCIAL [1009]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","96.72","96.72","96.72","1 through 10","99.34","280.32","other","OPPS APC"
"Xr Shoulder Cmp 2+ Views","PX-32000090","CDM","73030","CPT","0320","RC","","","","both","","","384.00","288.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.47","102.97","64","99.34","280.32","other","OPPS APC"
"Xr Sinuses 3+ Views","PX-32000028","CDM","70220","CPT","0320","RC","","","","both","","","492.00","369.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","102.46","","APC Price ($104.55). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.87","102.87","102.87","1 through 10","94.75","359.16","other","OPPS APC"
"Xr Skull Cmpl 4+ Views","PX-32000031","CDM","70260","CPT","0320","RC","","","","both","","","610.00","457.50","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","445.3","other","OPPS APC"
"Xr Skull Ltd <4 Views","PX-32000030","CDM","70250","CPT","0320","RC","","","","both","","","439.00","329.25","MEDICARE [2001]","HB BWF MEDICARE","126.27","","APC Price ($126.27). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Small Intestine","PX-32000206","CDM","74250","CPT","0320","RC","","","","both","","","1469.00","1101.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.16","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","197.32","197.32","197.32","1 through 10","200.84","1072.37","other","OPPS APC"
"Xr Sternum 2+ Views","PX-32000052","CDM","71120","CPT","0324","RC","","","","both","","","306.00","229.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.97","102.97","1 through 10","99.34","234.25","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","AETNA [1001]","HB CH AETNA HMO / PPO","651.79","58.3","","1848.99","616.33","1848.99","1 through 10","170.35","1870.56","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","470.52","296.01","640.72","1 through 10","170.35","1870.56","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","INTERNATIONAL COMMERCIAL [140001]","HB CH AETNA HMO / PPO","651.79","58.3","","616.33","543.50","616.33","1 through 10","170.35","1870.56","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","592.54","53","","576.11","559.15","1118.30","1 through 10","170.35","1870.56","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","MEDICARE [2001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","651.14","651.14","1302.28","11","170.35","1870.56","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","651.14","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","638.32","638.32","638.32","1 through 10","170.35","1870.56","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","638.12","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.72","638.72","638.72","1 through 10","170.35","1870.56","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","UNITED HEALTHCARE [1016]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","496.95","44.45","","495.24","495.24","835.69","1 through 10","170.35","1870.56","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","both","","","1118.00","838.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","638.12","","APC Price ($651.14). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","638.32","638.12","638.32","1 through 10","170.35","1870.56","other","OPPS APC"
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1118.00","838.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","662.97","59.3","","1275.33","636.98","1761.10","129","559","1437.15","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1118.00","838.50","INTERNATIONAL COMMERCIAL [140001]","HB CH UNITED HMO / PPO / INDEMNITY","877.07","78.45","","835.70","835.70","835.70","1 through 10","559","1437.15","percent of total billed charges",""
"Xr Surgical Specimen","PX-32000250","CDM","76098","CPT","0320","RC","","","","outpatient","","","1118.00","838.50","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","877.07","78.45","","835.69","495.24","1671.37","65","559","1437.15","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","16","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","197.32","208.03","1 through 10","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","211.41","634.23","156","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","425.04","425.04","425.04","1 through 10","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","TRICARE [160005]","HB BWF TRICARE","200.84","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.324). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * the adjusted APC rate for the line. The fixed threshold is the sum of the outlier fixed-dollar threshold ($7,175) and the adjusted APC rate for the line. If the cost is greater than the threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 95%.","1348.84","1348.84","1348.84","1 through 10","200.84","862.13","other","Tricare OPPS"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.38","196.52","207.78","1 through 10","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","both","","","1181.00","885.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","196.72","211.41","18","200.84","862.13","other","OPPS APC"
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","outpatient","","","1181.00","885.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","700.33","59.3","","672.73","672.73","672.73","1 through 10","199.42","926.49","percent of total billed charges",""
"Xr Swallow Cine/Video","PX-32000199","CDM","74230","CPT","0320","RC","","","","outpatient","","","1181.00","885.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","926.49","78.45","","882.58","882.58","882.58","1 through 10","199.42","926.49","percent of total billed charges",""
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","118.07","124.79","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","80","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","MGB HEALTH PLAN [150001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","124.06","123.76","124.06","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","123.76","123.76","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","both","","","426.00","319.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","123.76","119.99","124.27","20","119.97","423.04","other","OPPS APC"
"Xr T-Spine 2 Views","PX-32000060","CDM","72070","CPT","0320","RC","","","","outpatient","","","426.00","319.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","252.62","59.3","","242.60","242.60","242.60","1 through 10","199.42","334.2","percent of total billed charges",""
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","MEDICARE [2001]","HB BWF MEDICARE","126.29","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","126.29","126.29","126.29","11","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.16","124.16","124.16","1 through 10","119.97","423.04","other","OPPS APC"
"Xr T-Spine 3 Views","PX-32000061","CDM","72072","CPT","0320","RC","","","","both","","","493.00","369.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","123.76","","APC Price ($126.29). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","124.27","124.27","124.27","1 through 10","119.97","423.04","other","OPPS APC"
"Xr Tibia/Fibula 2 Views","PX-32000167","CDM","73590","CPT","0320","RC","","","","both","","","348.00","261.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.77","102.97","1 through 10","99.34","254.04","other","OPPS APC"
"Xr Tmj Open & Closed Bilat","PX-32000036","CDM","70330","CPT","0320","RC","","","","outpatient","","","631.00","473.25","CIGNA [1006]","HB CH CIGNA HMO / PPO","374.18","59.3","","359.80","359.80","359.80","1 through 10","110.42","495.02","percent of total billed charges",""
"Xr Toe(S) 2+ Views","PX-32000192","CDM","73660","CPT","0320","RC","","","","both","","","392.00","294.00","ELDER SERVICES [1037]","HB BWF MEDICARE","104.56","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","23.14","23.14","23.14","1 through 10","99.34","286.16","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","BLUE CROSS BLUE SHIELD [110001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","208.03","208.03","208.03","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","197.32","208.03","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","211.41","200.53","211.41","22","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","MOLINA [1014]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","419.44","419.44","419.44","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","208.03","208.03","208.03","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.49","196.82","207.69","1 through 10","200.84","1258.52","other","OPPS APC"
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","both","","","1724.00","1293.00","UNITED HEALTHCARE ALTERNATE [1020]","HB AMC CH UNITED NEW BUSINESS DISCOUNT","766.32","44.45","","1288.51","1288.51","1288.51","1 through 10","200.84","1258.52","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","1724.00","1293.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","1022.33","59.3","","982.14","982.14","982.14","1 through 10","357.59","1352.48","percent of total billed charges",""
"Xr Ugi W/Air W/O Kub","PX-32000203","CDM","74246","CPT","0320","RC","","","","outpatient","","","1724.00","1293.00","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1352.48","78.45","","482.16","295.97","506.37","1 through 10","357.59","1352.48","percent of total billed charges",""
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1426.00","1069.50","MEDICARE [2001]","HB BWF MEDICARE","211.41","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","422.82","211.41","422.82","1 through 10","200.84","1040.98","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","both","","","1426.00","1069.50","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","207.18","","APC Price ($211.41). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","207.69","207.69","207.69","1 through 10","200.84","1040.98","other","OPPS APC"
"Xr Ugi W/O Kub","PX-32000200","CDM","74240","CPT","0320","RC","","","","outpatient","","","1426.00","1069.50","CIGNA [1006]","HB CH CIGNA HMO / PPO","845.62","59.3","","812.78","812.78","812.78","1 through 10","357.59","1118.7","percent of total billed charges",""
"Xr Ugi W/O Kub|REDUCED SERVICES","PX-32000200","CDM","74240","CPT","0320","RC","","","52","both","","","1426.00","1069.50","MEDICARE [2001]","HB BWF MEDICARE","211.39","","APC Price ($211.39). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. Discounted by 50%. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","100.27","100.27","100.27","1 through 10","200.84","611.75","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","25.00","25.00","25.00","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.28","1815.28","1815.28","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","ELDER SERVICES [1037]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1712.99","1712.99","1712.99","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","MEDICARE [2001]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1747.95","1844.80","33","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","MOLINA [1014]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3660.08","3660.08","3660.08","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1808.30","1808.30","1808.30","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","TUFTS HEALTH PUBLIC PLANS [1013]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1844.80","1844.80","1844.80","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","both","","","2301.00","1725.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1807.91","","APC Price ($1,844.80). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1807.90","1713.00","1844.80","1 through 10","1219.53","4112.05","other","OPPS APC"
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","outpatient","","","2301.00","1725.75","CIGNA [1006]","HB CH CIGNA HMO / PPO","1364.49","59.3","","1310.88","1310.88","1310.88","1 through 10","1022.79","3157.84","percent of total billed charges",""
"Xr Venogram Extremity Bilat","PX-32000284","CDM","75822","CPT","0320","RC","","","","outpatient","","","2301.00","1725.75","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","1805.13","78.45","","1719.81","1719.81","1719.81","1 through 10","1022.79","3157.84","percent of total billed charges",""
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2045.00","1533.75","CENTERS OF EXCELLENCE [1026]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1807.91","1807.91","1807.91","1 through 10","1083.85","2331.24","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2045.00","1533.75","COMMONWEALTH CARE ALLIANCE [1007]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1815.28","1719.98","1815.28","1 through 10","1083.85","2331.24","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2045.00","1533.75","INTERNATIONAL COMMERCIAL [140001]","HB CH ONE TEAM HEALTH INTERNATIONAL","1083.85","53","","1054.17","1054.17","1054.17","1 through 10","1083.85","2331.24","percent of total billed charges",""
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2045.00","1533.75","MEDICARE [2001]","HB BWF MEDICARE","1844.80","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","1844.80","1844.80","1844.80","26","1083.85","2331.24","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2045.00","1533.75","TUFTS HEALTH PLAN [170001]","HB BWF TUFTS + COMM CARE ALLIANCE MCARE","1807.91","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1807.90","1807.90","1807.90","1 through 10","1083.85","2331.24","other","OPPS APC"
"Xr Venogram Extremity Uni","PX-32000283","CDM","75820","CPT","0320","RC","","","","both","","","2045.00","1533.75","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","1807.91","","APC Price ($1,844.80). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","1807.91","1719.99","1807.91","1 through 10","1083.85","2331.24","other","OPPS APC"
"Xr Venogram Sinus/Jugular","PX-32000290","CDM","75860","CPT","0320","RC","","","","both","","","2894.00","2170.50","MEDICARE [2001]","HB BWF MEDICARE","3737.47","","APC Price ($3,737.47). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.","3737.85","3737.85","3737.85","1 through 10","1241.53","9932.12","other","OPPS APC"
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","475.00","356.25","AETNA [1001]","HB CH AETNA HMO / PPO","276.93","58.3","","141.16","141.16","141.16","1 through 10","99.34","346.75","percent of total billed charges",""
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","both","","","475.00","356.25","UNITED HEALTHCARE [1016]","HB BWF UNITED MEDICARE REPLACEMENT","102.47","","APC Price ($104.56). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.256). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 98%.","102.97","102.47","102.97","24","99.34","346.75","other","OPPS APC"
"Xr Wrist Cmpl 3+ Views","PX-32000119","CDM","73110","CPT","0320","RC","","","","outpatient","","","475.00","356.25","UNITED HEALTHCARE [1016]","HB CH UNITED HMO / PPO / INDEMNITY","372.64","78.45","","710.38","710.38","710.38","1 through 10","110.42","372.64","percent of total billed charges",""
"Zika Virus Mac-Elisa, Igm, S","PX-30003364","CDM","86790","CPT","0301","RC","","","","both","","","83.00","62.25","AETNA [1001]","HB CH AETNA HMO / PPO","48.39","58.3","","45.93","45.93","45.93","1 through 10","12.62","75.99","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","both","","","96.00","72.00","AETNA [1001]","HB CH AETNA HMO / PPO","55.97","58.3","","52.73","52.73","52.73","1 through 10","11.16","70.08","percent of total billed charges",""
"ZINC","PX-30000739","CDM","84630","CPT","0301","RC","","","","outpatient","","","96.00","72.00","CIGNA [1006]","HB CH CIGNA HMO / PPO","56.93","59.3","","54.50","54.50","93.00","1 through 10","11.75","75.31","percent of total billed charges",""